poikiloderma refers to a skin condition clinically consisting of telangiectasia , cutaneous atrophy and macular hypo- and hyperpigmentation .
poikiloderma of civatte ( pc ) , an acquired poikiloderma of the face and neck , is a common benign dermatosis often affecting fair - skinned , middle - aged and elderly people .
it symmetrically involves the sides and v - shaped area of the neck as well as the lateral parts of the face , with sparing of anatomically shaded areas .
even though pc has been described for almost a century , its etiopathogenesis is still under investigation .
chronic sun exposure , estrogen depletion associated with menopause , photoallergic as well as allergic contact reactions to perfumes and cosmetics and genetic susceptibility have been proposed as the major culprits [ 2 , 3 , 4 ] . in the following report ,
contact hypersensitivity to fragrances and a mixture of methylchloroisothiazolinone and methylisothiazolinone ( mci / mi ) , also known as kathon cg , in a post - menopausal woman with pc will be described .
a 54-year - old thai woman , who had entered menopause a few years earlier , presented with gradual progression of erythema and hyperpigmentation on the face and neck for 2 years .
she had never experienced an allergic reaction to medications , food , perfumes or metals .
physical examination showed prominent telangiectasias combined with skin atrophy and mottled brown hyperpigmentation on the upper chest , neck , chin , lateral cheeks and periorbital areas ( fig .
a skin biopsy , performed on the lesion on the neck , revealed mild epidermal atrophy with effacement of rete ridges and irregularly distributed melanin in the basal layer of the epidermis .
solar elastosis , dilated blood vessels , melanophages and superficial perivascular infiltration of lymphocytes were also noticed in the upper dermis . based on physical examination and histopathological findings , the diagnosis of pc was established .
the patient was patch - tested with standard screening series and vehicle - preservative series , and photopatch - tested with scandinavian standard photopatch series , sunscreen series and nsaid series .
photopatch testing showed negative results while patch testing revealed allergic contact reactions to the preservative mci / mi and several fragrance allergens . in detail , the patient exhibited extremely positive reactions ( + + + ) to fragrance mix i and perfume mix , and strong positive reactions ( + + ) to fragrance mix ii and mci / mi . considering the relevance of the positive patch test results , the patient had never encountered typical eczematous changes on the face and neck , but she reported burning and itching sensation after applying some facial creams and sunscreen products .
on examination of the patient 's cosmetics and toiletries , fragrance , mci and mi were found in many products she used on a daily basis , such as skin care creams , shampoos , conditioners and soaps .
interestingly , both fragrance and mi allergens were found in the moisturizing cream she regularly applied to her face and neck .
moreover , the repeated open application test with the mentioned moisturizing cream was performed on the patient 's forearm and it showed a positive reaction within 12 days . in terms of management , the patient was advised to practice adequate strategies for sun protection .
as the contact sensitization to fragrances and preservatives was suspected to be a causative factor for at least the cutaneous symptoms in this patient , it made the rationale for allergen avoidance and immunomodulatory agents .
the patient was also advised to stop using all products containing fragrances and mci / mi , and topical 1% pimecrolimus cream was prescribed for the lesional area . as a result ,
her itching and burning symptoms significantly decreased within 2 months after start of allergen avoidance .
however , for cosmetic reasons the patient requested treatment with vascular lasers to reduce the erythema and telangiectasias on the face .
pc , an acquired poikiloderma of the face and neck , was first described by achille civatte in 1923 .
it is a common chronic dermatosis , particularly in countries where light - skinned people are the majority .
individuals in their fourth to seventh decades are most affected , with a marked female predominance .
clinically , pc manifests as reticulated red to brown patches admixed with telangiectasias , and sometimes cutaneous atrophy , predominantly on the sides and v - shaped area of the neck .
the parotid area of the face and the chin are less often involved [ 1 , 2 , 3 ] .
the symmetrical distribution and sparing of the submental area shaded by the chin are highly characteristic features of the disease .
additionally , up to almost half of patients experience abnormal sensations , described as pruritus , burning or rosacea - like flushing [ 2 , 3 ] . because of the variations in clinical appearance , a pc classification was proposed to categorize the disease into erythemato - telangiectatic type , pigmented type and mixed type , which also assisted in determining the most appropriate treatment .
the most constant features are solar elastosis and dilated blood vessels in the papillary dermis , with the degree of vessel dilatation appearing to depend on the severity of solar elastosis .
the main change is thought to be a degenerative process in the dermal connective tissue , leading to dilatation of adjacent blood vessels due to the loss of vascular support .
less predominantly , irregular distribution of melanin in the lower epidermis and presence of melanophages in the upper dermis are frequently observed .
flattened epidermis with effacement of rete ridges , hyperkeratosis and mild perivascular lymphocytic infiltration are also present to a lesser extent . in some cases , vacuolar degeneration of the basal keratinocytes is evidently noticed . to date , the exact etiology and pathogenesis of pc are still obscure .
many causative factors have been hypothesized to lie behind the development of disease , and pc seems not to be influenced by only one factor .
first of all , both the predilection sites for pc and the presence of solar elastosis indicate a pivotal role of cumulative ultraviolet exposure in pc development
. however , many pc patients have no history of excessive sun exposure and other sun - exposed areas , such as the forehead and forearms , are not commonly affected . the area susceptibility in pc may be due to ( 1 ) the natural photoprotection associated with epidermal thickness , which is thicker in the face and forearm in comparison with the neck area , or ( 2 ) inadequate sun protection measures .
broad - brimmed hats are needed to provide maximum protection of the face and neck ; nonetheless , a number of people still use just a baseball cap when going outside , leaving the sides of the face and neck exposed to sunlight .
second , the age and sex distribution of pc patients dictates the possible role of hormonal depletion during menopause .
moreover , pc also develops in younger women after iatrogenic premature menopause [ 3 , 6 ] .
as low estrogen levels cause decreased synthesis of collagen and loss of skin elasticity , these changes in dermal connective tissue due to estrogen depletion may be responsible for the development of telangiectasia and cutaneous atrophy in pc patients .
in addition , genetic factors are suspected to be involved in the pathogenesis as pc has been reported in families with an autosomal dominant manner , despite sharing no environmental or hormonal factors .
furthermore , the regional distribution of lesions raises the hypothesis that contact dermatitis is another possible explanation for pc . even though allergic contact dermatitis usually presents with an eczematous lesion , other cutaneous forms , called  non - eczematous eruptions ,
have been described to be a result of delayed - type hypersensitivity as well , including a reaction with only pigmentary changes known as pigmented contact dermatitis .
melanin incontinence , a main histopathological feature of pigmented contact dermatitis , is also found in most cases of pc .
thus , these facts may imply that pc probably develops via type iv hypersensitivity similar to pigmented contact dermatitis , or that contact sensitization possibly contributes to the pigment alteration in pc .
the preferred sites for pc are areas where perfume is frequently atomized and metal jewelry is commonly used , pushing the possibility that fragrances or metal allergens might be crucial sensitizers .
as sparing of anatomically shaded areas is a prominent feature of pc , photocontact sensitization to substances applied to the face and neck may be an additionally suggested mechanism , in combination with the effects of natural photoprotection or inadequate sun protection measures .
with regard to supporting evidence , mci / mi was reported to be a contact sensitizer in a female patient who developed pc in her adolescence , and skin lesions considerably improved after allergen avoidance .
later , a case - control study evaluating the role of contact dermatitis in 32 pc patients documented that a higher rate of positive patch testing to fragrances was found in pc patients compared to age- and sex - matched controls who had a suspected contact dermatitis of the face and/or neck , accounting for 25.0 and 9.27% , respectively ( p < 0.05 ) .
there was no statistically significant difference of positive patch testing to nickel between these two groups .
interestingly , positive patch testing to mci / mi was also shown in one pc patient . on the other hand ,
there are only few data supporting the postulation of pc being a photoallergic contact disease .
photocontact sensitization to 6-methylcoumarin , a fragrance allergen , was reported in a post - menopausal woman with pc who had no history of chronic sun exposure .
however , in the largest study of pc mentioned above , the results of photopatch testing were negative in all tested pc patients .
our patient is a case of symptomatic pc in a post - menopausal woman without an obvious history of sun exposure or family history .
her complaint of burning / itching symptoms appeared to be notable and the skin changes appeared to be beyond the usual locations .
subsequently , contact hypersensitivity to fragrances and mci / mi was demonstrated by showing strong positive patch test reactions whereas typical eczematous lesions had never occurred on the face and neck areas .
the patient denied the use of perfume or cologne ; however , fragrance as well as mci / mi were listed as ingredients in many of her leave - on and rinse - off personal care products .
in fact , both allergens were found in the moisturizing cream she regularly applied only to her face and neck , and it was suspected to be the main culprit causing skin changes on these areas . for pc ,
regarding her symptoms and patch test results , we recommended her to stop using products containing the documented allergens and to apply topical pimecrolimus cream to the atrophic telangiectatic skin lesions .
consequently , the itching and burning sensations considerably decreased and the erythematous change partially improved before the patient elected to initiate additional laser treatment on the face to improve her clinical appearance .
we propose that contact hypersensitivity to fragrances and mci / mi might be a contributing etiology of pc in this patient , in combination with the impact of estrogen decline in her menopause and cumulative sun exposure .
a trial of allergen and sun avoidance should be recommended to patients as it may have some effect on disease improvement .
apart from fragrance allergens , which have been reported as causative agents in pc , mci / mi may probably be another important sensitizer which should be under the radar of investigation .
the reported rate of contact hypersensitivity to mci / mi has constantly risen since 2005 when mi was permitted to be used alone as a preservative at a much higher maximum concentration compared to the maximum allowed concentration of mi when it is combinedly used with mci in mci / mi . as a consequence , mci / mi - induced pc may possibly be seen to occur more often in parallel with the increased prevalence of mci / mi sensitization . in conclusion
, we suggest that patients with pc , particularly those experiencing pruritus or burning sensations with a history of topical applications to their affected areas , should undergo patch and photopatch testing to evaluate the possible causes , as the avoidance of positively identified allergens may benefit the improvement of pc .
the authors declare that there is no conflict of interests regarding the publication of this paper .
 numerous mechanisms have been postulated to play an important role in the pathogenesis of poikiloderma of civatte ( pc ) , including chronic exposure to ultraviolet radiation , menopause - related hormonal changes , contact hypersensitivity and genetic predisposition . 
 herein , we report a case of contact sensitization to fragrances and commonly used preservatives , methylchloroisothiazolinone and methylisothiazolinone , also widely known as kathon cg , in a post - menopausal woman with pc , who denied excessive sun exposure and a family history . after abstaining from the use of her personal care products containing the documented allergens , not only the itching and burning symptoms , but also the cutaneous changes appeared to improve partially . 
 this report underlines the possible influence of contact hypersensitivity in the pathogenesis of pc . 
Introduction
Case Report
Discussion
Disclosure Statement