67 disorders of hyperpigmentation

Question 1

inflammatory mediators that enhance pigment production

Answer 1

prostaglandins E2 and D2

Question 2

flagellate erythema a/w …

Answer 2

bleomycin use, shiitake mushroom ingestion, dermatomyositis, Still disease

Question 3

treatment of PIH

Answer 3

1) hydroquinone +/- Cs +/- topical retinoid
2) azelaic acid, alpha-hydroxy acid, L-ascorbic acid, kojic acid …

laser: Q-switched ruby, alexandrite, and Nd:YAG (for dermal pigment)

Question 4

EDP reported associated triggers

Answer 4

ammonium nitrate (usually in fertilizers and explosives), oral-X ray contrast media, medications (benzos, penicillin); various pesticides, fungicides or toxins; endocrinopathies such as thyroid, infection: whipworm and HIV; presence of HLA-DR4 allele Mexican patients

Question 5

EPD path (active lesions)

Answer 5

vacuolar degeneration of the basal cell layer, perivascular mononuclear cell infiltrate and melanophages in the upper dermis with increased epidermal melanin seen

Question 6

main ddx of EPD

Answer 6

idiopathic eruptive macular hyperpigmentation (IEMH), but in the latter there is primarily epidermal pigment; also lichenoid drug eruption, lichen planus pigmentosus

Question 7

lichen planus pigmentosus

Answer 7

variant of LP, mostly in darker skin types; irregularly shaped or oval, brown to gray brown macules and patches in either sun exposed areas (e.g. forehead, temples, neck) or intertriginous areas; decent response to tacrolimus (clinically difference from EDP is distribution)

Question 8

melasma triggers

Answer 8

sun exposure, pregnancy, oral contraceptives

Question 9

melasma three classic patterns

Answer 9

centrofacial, malar, and mandibular; less common sites area forearms and mid upper chest

Question 10

hyperfunctional melanocytes (d/t UV radiation) in melasma supported by

Answer 10

increased number of mitochondria, Golgi apparati, and RER in lesional melanocytes

Question 11

tx of melasma

Answer 11

1st line: 
- hq + retinoid + CS 
- 4% hq 
- azelaic acid 15-20%
adjunctive: 
- L-ascorbic acid 
- kojic acid 
2nd line:
-glycolic acid and salicylic acid peels every 4-6 weeks 
3rd line:
-fractional laser 
intense pulsed light (IPL)

Question 12

cutaneous amyloidosis

Answer 12

macular and lichenoid forms, have asso hyperpigmentation, in the upper back (macular amyloidosis) and extensor LE (lichen amyloidosis), characteristic rippled pattern with parallel bands or ridges of hyperpigmentation; often pruritic, caused by rubbing

Question 13

urticaria pigmentation

Answer 13

maculopapular form of mastocytosis which features hyperpigmented lesions: red-brown macules and papules which urticate when stroked (Darier’s sign), when in children - often resolves with adolescence

Question 14

lesion urticates when stroked, sign:

Answer 14

Darier’s sign

Question 15

atrophic form of morphea in young adults, presents with multiple oval hyperpigmented patches 4-10 cm in daimeter on the posterior trunk; lesions have a subtle depression (cliff sign)

Answer 15

atrophoderma of Pasini and Pierini

Question 16

solar lentigines pathogenesis

Answer 16

epidermal hyperplasia in response to chronic sun exposure, in spectrum with macular SK’s, rete ridges with club-shaped or bud-like extensions with increased basal layer pigmentation; variable proliferation of melanocytes and accumulation of melanin within keratinocytes

Question 17

looks like a CALM but with speckled macules

Answer 17

nevus spilus

Question 18

main causes of DIH

Answer 18

minocycline, antimalarials, chemotherapeutic agents, zidovudine

Question 19

drug in DIH that is diffuse

Answer 19

think chemotherapeutic drugs: bisulfan, cyclophosphamide, dactinomycin (face>body), mechlorethamine (N mustard, when used topically for tx of CTCL), PUVA (after exposure to UVA light)

Question 20

drug in DIH that is in sun-exposed areas

Answer 20

think metals, MTX and psychotropic
-daunorubicin, 5FU (in patient’s treated systemically), MTX, gold, silver (argyria), ACTH/MSH/afamelnotide, amiodarone, diltiazem, dioxins (when chlorinated think chloracne), psychotropic drugs

Question 21

drug in DIH at pressure points, overlying joints, or sites of trauma

Answer 21

bleomycin (flagellate), doxorubicin (joints of hands), hydroxyurea

Question 22

drug in DIH most prominent on the face

Answer 22

dactinomycin, bismuth, amiodarone

Question 23

drug in DIH at mucosa

Answer 23

cyclophosphamide, chloroquine, bismuth, lead (gingival), zidovudine (oral macules), minocycline

Question 24

drug in DIH at skin folds/groin

Answer 24

arsenic (also volar), mercury

Question 25

drug in DIH at special sites

Answer 25

antimalarials and minocycline (tibial), gold (around the eyes)

Question 26

common nail finding in DIH

Answer 26

transverse melanonychia

Question 27

an adverse rxn to hydroquinone

Answer 27

exogenous ochronosis

Question 28

pigmentary demarcation lines

Answer 28

seen between dorsal surfaces and ventral surface

Question 29

flagellate pigmentation in bleomycin vs shiitake mushroom

Answer 29

shiitake mushroom more pruritic and a/w scratching

Question 30

incontinentia pigmenti stages

Answer 30

XLD multi-system disorder with skin lesions along Blaschko lines

1) inflammatory vesicular
2) verrucous
3) hyperpigmented

Question 31

CARP

Answer 31

confluent and reticulated pillomatosis

Question 32

prurigo pigmentosa

Answer 32

pruritic eruption of erythematous papules and paplovesicles on the trunk and neck, crops develop rapidly then involute w/in a week, leaving behind a macular reticulated hyperpigmentation; think Japanese females

Question 33

dyskeratosis congenita

Answer 33

XLR, triad of triculated hyperpigmentation, nail dystrophy (peterygium) and leukoplakia

Question 34

segmental pigmentation disorder

Answer 34

a subtype of pigmentary mosaicism