CLINICAL HISTORY:

Signs and symptoms:  No associated pruritus, pain or previous skin lesions. No new medications.

Previous Treatment:  None

Other information:  Hypertension, not on medication

PHYSICAL EXAM:

Hyperpigmented blue-gray macular eruption coalescing into patches on the anterior shoulders, neck, upper extremities, back and mid-chest. No overlying scale or erythema.

Clinical #1

Clinical #2

Clinical #3

LABORATORY TESTS:

CBC, CMP, thyroid were within normal limits.

DERMATOHISTOPATHOLOGY:

mild basal cell layer vacuolar degeneration overlying an upper dermis with a mild perivascular mononuclear cell infiltrate and increased melanophages

Histology #1

Histology #2

Histology #3

DIFFERENTIAL DIAGNOSIS:

1.   Exogenous ochronosis
2.   Lichen planus pigmentosa
3.   Erythema dyschromicum perstans
4.   Drug-induced hyperpigmentation
5.   Contact dermatitis

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Erythema dyschromicum perstans

DISCUSSION:

Erythema dyschromicum perstans (EDP) is a chronic hyperpigmentation disorder characterized by asymptomatic blue-gray patches with slightly elevated erythematous borders in the early stages. Usually it presents as a symmetrical eruption involving the face, neck, trunk, and proximal extremities, although there have been reports of asymmetric unilateral EDP affecting the lower extremity. EDP can affect persons of all ages, however it usually presents before the age of 40. Women tend to be affected more than men, and there is a predilection for intermediate to darker skin types, in particular Latin Americans. The etiology of EDP remains unknown; several predisposing factors have been suggested: ammonium nitrate ingestion, whipworm infection, oral ingestion of radiographic contrast material, following treatment of hookworm infection, HIV infection as well as immunological and genetic associations.

TREATMENT:

There is no standard treatment for EDP. Past treatments have included sun protection, topical retinoids, topical and systemic corticosteroids, keratolytics, hydroquinone, antibiotics, isoniazid, griseofulvin, chemical peels, and laser therapy. There are also reports of using Clofazamine and Dapsone, however given the wide side effect profiles of these medicaitons, the risks versus benefits should be weighed carefully.

REFERENCES:

1. Bolognia JL, Jorizzo JL, Rapini RP. Dermatology. Mosby 2008. p.941-942.
2. Osswald SS et al. Erythema dyschromicum perstans: a case report and review. Cutis 2001;68:25-28.
3. Baranda L et al. Involvement of cell adhesion and activation molecules in the pathogenesis of erythema dyschromicum perstans (ashy dermatitis): the effect of clofazamine therapy. Archives of Dermatology 1997;133:325-329.
4. Correa MC, et al. HLA-DR association with the genetic susceptibility to develop ashy dermatosis in Mexican mestizo patients. JAAD 2007;56:617-620.
5. Bahadir S, et al. Erythema dyschromicum perstans: response to dapsone therapy. International Journal of Dermatology 2004;43:220-222

Additional Comment:

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