A 67-year-old woman at handed after...

A 67-year-old woman at handed after three years of progressive hyperpigmentation, which was worse in the sun-expos areas of her skin further involved sun-protected areas as well.

Question

Appropriate initial management of this patient may include all of the following except:

[] A. Medication history.

[] B Oral and genital examination.

[] C General health history.

[] D Nd:Yag laser treatment using 532 nm wavelength.

[] E push biopsy at border of lesion.

Discussion

The answer is D: Nd:Yag laser treatment using 532 nm wavelength. Erythema dyschromicum perstans, commonly known as ashy dermatosis, was first described through Ramirez in 1957. This strange disorder occurs predominately in dark-skinned Latin Americans, particularly women in the first by the agency of third decades of life. Ashy dermatosis is a chronic condition characterized by dint of asymptomatic, slate-gray or violaceous hyperpigmented macules distributed principally commonly over the trunk and proximal extremities, and les not rarely over the face and neck Lesions, which flash on the mind in otherwise healthy persons, may initially existing as erythematous macules that slowly progres to a blue-gray tint The macules of erythema dyschromicum perstans vary in size and may occasionally demonstrate an erythematous raised border. (1-3)

The etiology of erythema dyschromicum perstans remains unknown. Melanin complexe in the dermis and epidermis are responsible for the ashen-gray color that present itselfs in sun-exposed and sun-protected areas. (1)

It is important to obtain a thorough general health and medication history, perform an oral and genital examination, and obtain a puncture biopsy at the border of the lesion to command out other possible causes of hyperpigmentation. Several authors speculate that erythema dyschromicum perstans may be a variant of lichen planus, and the sequela of resolving lichen planus may cause hyperpigmented lesions. Thus, the patient should be examined for the characteristic lacy white patterned and erosive lesions of the oral and genital mucosa to direction out lichen planus. Review of medications may indicate a remedy hypersensitivity reaction, particularly a fixed medicine eruption, as a cause of hyperpigmented macules. Certain put drugs intos such as chlorpromazine, amiodarone, thiazides, and tetracyclines are the greatest in quantity common culprits. A general health history can help distinguish diffuse hyperpigmentation caused according to internal disease entities, such as Addison's disease and hemochromatosis. A perforate biopsy at the border of the lesion is necessary to command out melanosis secondary to malignant melanoma that manifests as a generalized blue-gray skin discoloration. Finally, melasma, which not aways in sun-exposed areas, particularly the face, and postinflammatory hyperpigmentation, which come abouts after inflammatory dermatoses, are other benign causes of hyperpigmented lesions. (12)

Unfortunately, no effective treatment of erythema dyschromicum perstans is available at this time. Several medications, of the like kind as hydroquinone, topical steroids, tretinoin, griseofulvin, dapsone, and sunscreen have been tried however have had poor clinical be the effects Clofazimine, an antileprosy drug, has not long ago been studied in six patients who demonstrated marked improvement with treatment. (3) Nd:Yag laser has been attempted for the treatment of postinflammatory hyperpigmentation and melasma with disappointing deductions and is not recommended in the treatment of ashy dermatosis. (1)

REFERENCES

(1) Mosher TB Fitzpatrick TB Hypomelanoses and hypermelanoses. In: Freedberg IM, ed Fitzpatrick's Dermatology in general medicine. 5th ed New York: McGraw-Hill, 1999:996-1009.

(2) Pandya AG, Guevara IL. Disorders of hyperpigmentation. Dermatol Clin 2000;18:91-8

(3) Baranda L Torres-Alvarez B Cortes-Franco R Moncada B Portales-Perez DP Gonzalez-Amaro R Involvement of lonely dwelling adhesion and activation molecules in the pathogenesis of erythema dyschromicum perstans (ashy dermatitis). The consequence of clofazimine therapy. Arch Dermatol 1997;133:325-9

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KRISTA KUPRE DO

JEFFREY J MEFFERT MD

Brooke Army Medical Center

San Antonio, TX 78259

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