CLINICAL HISTORY:

Signs and symptoms:  A 33-year-old Indian male complained of progressive darkening of his skin beginning on his neck, spreading to his face, and eventually involving both arms over the past 4 years.

Previous Treatment:  None.

Other information:  He has no significant past medical history and no known drug allergies. He denied using oral medications or topical preparations during the past five years. He reported only incidental sun exposure. Review of systems was negative for pain, xerosis, pruritus, dermatitis, alopecia, nail changes or other systemic symptoms.

PHYSICAL EXAM:

Well developed Indian male, skin type IV, with grey-brown macules coalescing into patches symmetrically along face, neck, antecubital fossae, axillae, and dorsal hands. (Figure 1 & 2)

Figure 1

Figure 2

LABORATORY TESTS:

CBC with diff: WNL
CMP: WNL
UA: Negative
Thyroid panel: WNL
ANA: WNL
Lipids: Trig 437, HDL 27, otherwise WNL

DERMATOHISTOPATHOLOGY:

A sparse superficial perivascular lymphocytic infiltrate is accompanied by melanophages and subtle basal cell epidermal damage with pigment incontinence. (Figure 3)

Figure 3

DIFFERENTIAL DIAGNOSIS:

1.   Erythema dyschromicum perstans (EDP)
2.   Confluent and reticulated papillomatosis
3.   Idiopathic eruptive macular pigmentation (IEMP)
4.   Ochronosis
5.   Phytophotodermatitis

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Erythema dyschromicum perstans (EDP)

DISCUSSION:

EDP is a chronic acquired dermatosis of unknown etiology. Most frequently, this condition occurs in Latin Americans but it shows a predilection for skin types III-IV with age of onset before 40. This dermatosis is asymptomatic and begins as irregularly shaped grey-blue hyperpigmented macules, sometimes with an erythematous or elevated border. These characteristic skin findings reflect the presence of melanin-laden macrophages. There is often a slow progression into symmetrical patches involving the face, neck, trunk, and/or arms with sparing of the palms and soles.

TREATMENT:

No consistently effective therapy
Small series studies
Clofazimine
Dapsone

Anecdotally:
Antibiotics
Isoniazid
Griseofulvin
Antimalarials
Topical corticosteroids
Hydroquinone

REFERENCES:

1. Bolognia JL, Jorrizo JL, Rapini RP. Dermatology. Mosby 2008. p. 941-942.
2. James WD, Berger TG, Elston D. Andrews’ diseases of the skin clinical dermatology tenth edition. Saunders 2006. p. 224.
3. Osswald SS, Proffer LH, Sartori CR. Erythema dyschromicum perstans: A case report and review. Cutis 2001; 68: 25-28.
4. Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller A, Leffell DJ. Fitzpatrick’s dermatology in general medicine seventh edition. McGraw Hill 2008.

Additional Comment:

© Copyright 2003-2006 by AOCD Grand Rounds

Top of Page