Disturbances of Pigmentation

1. Disturbances of Pigmentation Boris Ioffe, D.O.

2. Melanin • primary pigment producing brown coloration • Tyrosine – tyrosinase –melanin- this occurs in the melanosomes of melanocytes • Then the melanosomes are transferred from the melanocyte to a group of keratinocytes called the epidermal melanin unit (1:40) • Variations in skin color is related to • number of melanosomes • degree of melanization • distribution of the epidermal melanin unit

3. Pigmentary Demarcation Lines • Group A- outer upper arms with variable extension across the chest • Group B-posteromedial aspect of the lower limb – appear 1st time during pregnancy • Group C-Paired median or paramedian lines on the chest, with midline abdominal extension • Group D-medial, over the spine • Group E-bilaterally symmetrical, obliquely oriented, hypopigmented macules on the chest

4. Normal Pigmentation • Normal skin pigmentation is influenced by: • degree of vascularity • amount & location of melanin • presence of carotene • thickness of the horny layer

5. Melanin Production • The amount produced is dependent on: • Genetics • amount and the wavelengths of ultraviolet light received • amount of melanocyte-stimulating hormone(MSH) secreted • effect of melanocyte stimulating chemicals like furocoumarins (psoralens)

6. Hemosiderin Hyperpigmnetation Pigmentation due to deposits of hemosiderin occurs in: purpura, hemochromatosis, hemorrhagic dzs and stasis ulcers • difficult to distinguish from postinflammatory dermal melanosis clinically

7. Postinflammatory Hyperpigmentation • Any inflammatory condition can cause either hypopigmentation or hyperpigmentation • Also may be a complication of chemical peels, dermabrasion, laser therapy, or liposuction • Histologically, there is melanin in the upper dermis and around upper dermal vessels, located primarily in melanophages

9. Postinflammatory hyperpigmenation • Postinflammatory hyperpigmentation following resolution of lymphocytoma cutis on the cheek of a black child

10. Industrial Hyperpigmentation • Occurs in coal miners, anthracene workers, pitch workers, etc • Pigmentation of the face may occur from the incorporation in cosmetics of derivatives of coal tar, petrolatum, or picric acid, mercury, lead, bismuth, or furocoumarins (psoralens)

11. Systemic Diseases • Syphilis, malaria, pellagra, and diabetes • Addison’s disease- diffuse melanosis pronounced in the axillae and palmar creases, and nipples and genitals, and buccal mucosa • Diabetes produces diffuse bronzing of the skin • ** patients with virilizing adrenal tumors usually develop hyperpigmentation and hypertrichosis

12. Nelson’s syndrome (a pituitary MSH-producing tumor) Pheochromocytoma Hemochromatosis Amyloidosis Scurvy Pregnancy Menopause Porphyria cutanea tarda Vitamin B12 deficiency Kwashiorkor Vitamin A deficiency Primary biliary cirrhosis (triad= hyperpigmentation, pruritis, xanthomas) Systemic Diseases

13. Characterized by: Gray-brown mucocutaneous hyperpigmentation Diabetes mellitus hepatomegaly Usually are present: Cirrhoisis Hypogonadism Liver cirrhosis Hemochromatosis

14. Skin pigmentaion is usually generalized But, more pronounced on face, extensor aspect of the forearms, backs of the hands, and the geniocrural area Iron is deposited in the skin Iron is present as granules around blood vessels and sweat glands and within macrophages The actual pigmentation is caused by increased basal-layer melanin Mucous memebranes are pigmented in up to 20% of patients Koilonychia is present in 50% Localized ichthyosis in 40% Alopecia is common Hemochromatosis

15. Hemochromatosis-tx • Phlebotomy until satisfactory iron levels are obtained • Extracorporeal chelation has also been used successfully • Associated DM requires medical tx • Long-term complications are cirrhosis and then hepatomas

16. Brown patches, sharply demarcated, typically on the malar prominences and forehead The three clinical patterns are: centrofacial, malar, mandibular Increased pigment may simultaneously occur around the nipples and external genitalia Tends to affect the darker-complected It may also be found on the forearms Occurs at pregnancy and at menopause It may also be seen in ovarian disorders and other endocrine disorders Most frequently 90% of the time seen in women, 10% in men Melasma

18. Strong association with the use of OCs or dilantin Discontinuing contraceptives rarely clears the pigmentation, and it may last for years after discontinuing them. Melasma of pregnancy usually clears within a few months of delivery Tx- avoid sunlight, and a complete sun block with broad-spectrum UVA coverage should be used daily Kligman’s formula (Triluma) > then 4% hydroquinone may be needed Side effects of this is ochronosis and satellite pigmentation Melasma

19. Melasma • Jessner’s solution, glycolic acid peels,azelaic acid, kojic acid, and cystamine and buthionine sulfoximine are other options

20. Melasma

21. Melasma

22. AKA acropigmentation A progressive pigmentary disorder first described in a Japanese infant Characterized by diffuse black pigmentation on the dorsum of all the fingers and toes Pigmentation became progressively more widespread and more pigmented By age 4 or 5 the perineum, extremities, and areas of the head and neck were involved Epileptiform seizures occurred History revealed consanguinity Acromelanosis Progressiva

23. Acropigmentation of Dohi Found to affect individuals from Europe, India, Caribbean First described in Japan in 12 patients AKA dyschromatosis symmetrica hereditaria or symmetrical dyschromatosis of the extremities Patients develop progressive pigmented & depigmented macules Often mixed in is a reticulate pattern Many believe this to be a variation of acropigmentation of Kitamura Pigmented Anomalies of the Extremities

24. It begins age 20 to 30 yrs and progresses gradually Unknown etiology AD with variable penetrance and expressivity, and delayed onset Many authors believe it is a spectrum of reticulate acropigmentation of Kitamura Another manifestation of this disorder is familial-rocacea-like dermatitis with warty keratotic plaques on the trunk and limbs There is no treatment Reticular Pigmented Anomaly of the Flexures

25. Histology • Distinctive elongation, tufting, and deep hyperpigmentation of therete ridges, with protrusion of similar tufts even from the sides of the follicles

26. AD Characterized by linear palmar pits and pigmented macules 1-4 mm in diameter on the volar and dorsal aspects of the hands and feet One report of a pt with bony abnormalities consisting of absence of terminal phalanges of the second, third, and fourth toes Some tx success has been reported using axelaic acid ointment Reticulate Acropigmentation of Kitamura

27. Consists of a triad of generalized reticulate hyperpigmentation, noncicatricial alopecia, and onychodystrophy Other associations: adermatoglyphia, hypohidrosis or hyperhidrosis, palmoplantar hyperkeratosis, and nonscarring blisters on dorsa of hands and feet. An autosomal dominant inheritance pattern has been reported. Dermatopathia Pigmentosa Reticularis

28. Dermatopathia Pigmentosa Reticularis

29. Infants develop 2- 3mm macules, pustules, and ruptured pustules at birth, predominantly involving the face Pigmentation may last for weeks or months after the pustules are healed Histologically, there are intracorneal or subcorneal aggregates of predominantly neutrophils, but eosinophils may also be found Dermal inflammation is composed of an admixture of neuts and eos Differential dx: ETN, neonatal acne, & acropustulosis of infancy Transient Neonatal Pustular Melanosis

30. Transient Pustular Neonatal Melanosis

31. Transient Neonatal Pustular Melanosis

32. hyperpigmented macules on the lips and oral mucosa and polyposis of the small intestine Dark brown or black macules appear typically on the lips, especially the lower lip, in infancy or childhood Similar lesions may appear on buccal mucosa, tongue, gingiva, and genital mucosa Associated polyposis involves the small intestine preferencely But, hamartomatous polyps of the stomach and colon may occur Symptoms of hamhartomas of the small intestine may cause repeated bouts of abdominal pain and vomiting, and intussusception Peutz-Jeghers

33. Peutz-Jeghers syndrome • Lip lentigenes in an adolescent with Peutz-Jeghers syndrome

34. P-J syndrome

35. Pathology

36. Photosensitivity, phototoxic dermatitis Begins with pruritis, erythema, and pigmentation, gradually spreads, then becomes stationary Melanosis occurs mostly in women and develops over months Characteristic feature is spotty light to dark brown pigmentation Most intense on the forehead, malar regions, behind the ears, on the sides of the neck, on other sun-exposed areas Also circumscribed telangiectasia and temporary hyperemia Reihl’s Melanosis

37. An occupational dermatosis occurring among tar handlers after years of exposure Severe, widespread itching develops, followed by reticular pigmentation, telangiectases, and a shiny appearance of the skin There is a tendency for hyperhidrosis Small, dark, lichenoid, follicular papules become profuse on the extremities, namely the forearms Bullae are sometimes observed Represents a photosensitivity or phototoxicity induced by tar Tar Melanosis

38. Ruiz-Maldonado reported a case of a Mexican child, born white, who progressively became black Developed pigmentation of the palms, soles, mucous membranes EM showed a negroid pattern in the melanosomes of the epidermal melanocytes and keratinocytes Melanocytes were not increased in number Universal Acquired Melanosis(Carbon Baby)

39. 1.) Familial periorbital melanosis (AD) Usually involves all four eyelids, may extend to involve the eyebrows and cheeks 2.) Erythema dyschromicum perstans is a rare cause 3.) Familial dark circles around the eyes, frequently seen in individuals of Mediterranean ancestry Periorbital Hyperpigmentation

40. Metallic Discolorations • Pigmentation from deposition of fine metallic particles in the skin • Metal may be carried to skin from the blood stream or may permeate into it from surface applications

41. Localized or widespread slate-colored pigmentation Due to silver in the skin Most noticeable in parts exposed to sunlight Tissue silver may stimulate melanocytes Initially discoloration is hardly perceptible, having only a faint blue color, but a slate-gray color develops with time Local tx with a silver-containing product may produce argyria occupational exposure, usually siversmiths In localized exposures, the appearance may be separated by many years from the exposure Argyria

44. Histology • Systemic and localized argyria have the same features • Normal appearing skin under low power • Fine black granules in the basement zone of the sweat glands,blood vessel walls, d-e junction, and arrector pili muscles • Unstained biopsy section by darkfield illumination demonstrates silver granules outlining basement membrane of the epidermis and the eccrine sweat glands

45. Bismuth • Rarely associated with deposition of metallic particles in gums when used IM or orally • Also known as the bismuth line • Presence of stomatitis or peridontitis increased the risk • Generalized cutaneous discoloration, in addition to oral mucous membrane and conjunctival pigmentation resembling argyria has occurred but has not be reported in the last 50 years

46. Lead • Chronic lead poisoning can produce a “lead hue” with lividity and pallor • Deposit of lead in the gums may occur and is known as the “lead line”

47. Iron • In the past, soluble iron compounds were used in the treatment of allergic contact dermatitides • In eroded areas iron was sometimes deposited in the skin, like a tattoo • Use of Monsel’s solution can produce similar tattooing

48. Gold • Chrysiasis may be induced by parenteral administration of gold salts, usually for the treatment of rheumatoid arthritis • More commonly recognized in white patients • A mauve, blue, or slate/gray pigmentation develops initially on the eyelids, spreading to the face, dorsal hands, and other areas • Severity is related to the total dose received, rare < a dose of 20 mg/kg of elemental gold

49. Mercury • Mercurial pigmentation in the skin is rare, especially since the use of mercurials has been strictly controlled • Most common presentation is subcutaneous nodules that result from accidental implantation of elemental mercury from a thermometer into skin

50. Canthaxanthin • Orange-red pigment canthaxanthin is present in many plants ( notably algae and mushrooms) and in bacteria. Crustaceans, sea trout, and feathers • When ingested for the purpose of simulating a tan, its deposition in the panniculus imparts a golden orange hue to the skin • Stools become brick red and the plasma orange, and golden deposits appear in the retina