Generalised Pigmentation

Question 1

What are the causes of generalised oral pigmentation? (DAPH-M)

Answer 1

Developmental (racial/physiological pigmentation, pigmented naevi, peutz-jeghers)

Assoc. w/ Systemic disease (endocrine, metabolic, infections)

Post-inflammatory

Habits (smoking, betal use)

Medication

Question 2

Habitual Pigmentation:

How does Paan/Betal chewing cause pigmentation?
(State risks of use + management)

Answer 2

Pigment from areca nut may be deposited on OM + teeth
- colour ranging from yellow-orange-brown (can be confused w. turmeric)
(making assessment of OM difficult)

Risks of use:
TSL
Hard+ soft tissue staining
Lichenoid Reaction
Submucous Fibrosis (pre-malignant w scarring/marbling mucosa)
Epithelial Dysplasia
OSCC

Management: education, cessation, NRT, biopsy if needed

Question 2

Developmental Pigmentation:

What is Racial/ Physiological Pigmentation?

Answer 2

• Commonly seen in darker skinned people (but ~5% causations affected)
• Site: gingiva, but varied oral mucosal pres.
• Generalised
• Symmetrical or Asymmetrical

Question 3

Developmental Pigmentation:

What is Peutz-Jaegers Syndrome?

Answer 3

= Rare autosomal condition (mutation of gene playing role in apoptosis)

=Pres: multiple small perioral + vermillion freckles that fade w/ age
IO: Pigmented spots
EO: on extremities, nasal + rectal mucosa

Melantonic spots do not need tx + no risk of transformation to melanoma
- But are markers for Hamartomatous Intestinal Polyps - abdominal + rectal bleeding
- Risk of development of gut, breast or genital malignancy

Tx: Counselling + monitoring

Question 4

Habitual Pigmentation:

How does Tobacco smoking cause pigmentation?

Answer 4

Affects labial gingiva of smokers

tx: cessation (pigmentation resolved post 3yrs of cessation)

Question 5

What causes Post-Inflammatory Hyperpigmentation?

Answer 5

Development post irritation + inflammation (in the healing phase)

Usually = generalised

Common in chronic lichen planus in the buccal mucosa
Histology: melanin ‘drop out’

Question 6

Systemic disease:

What endocrine conditions are assoc. w/ pigmentary changes? (6)

PAANCH

Answer 6

Addison’s disease

Cushing’s disease

Hyperthyroidism

Pregnancy

Nelson’s syndrome

Albright’s syndrome

Question 7

Systemic disease (Endocrine):

How does Addison’s disease result in pigmentary changes?

🐶 called spaniel

Answer 7

Addison’s= adrenal insufficiency

Aetiology: autoimmune/ infection i.e. TB/HIV)

Pigmentation caused by: secondary melanocyte stimulation! (due to inc. ACTH)

IO pres: streaks or patches of blue-black oral pigmentation (water spaniel)

EO: pigmentation in Addison’s more pronounced in sun-exposed areas i.e. nails + hair

Tx: lifelong steroid HRT

Question 8

Exam q from Buchy lec:

What is the presentation of cutaneous Addison’s?

Answer 8

Bronzing in sun-exposed areas + hyperpigmentation of scars + flexures

(hyperpigmentation due to melanocyte stimulation from inc. ACTH resulting from cortisol insufficiency from infection or autoimmune disease)

Question 9

State key facts about drug related pigmentation:

Answer 9

• drugs can cause pigment induction by:
• IO inflammatory reactions
• Phenothiazines + minocycline directly react w/ melanin

Most common site: palate, buccal mucosa + gingiva

Common conditions these drugs used for: malaria prophylaxis + HIV tx

Tx: drug cessation

Question 10

List drugs causing brown pigmentation:

Answer 10

• minocycline
• doxycycline
• AZT
• propranolol

Question 10

List drugs causing blue-grey pigmentation:

Answer 10

• chloroquine
• minocycline
• fluoxetine
• amiodarone