(BQ) Part 2 book Treatment for skin color presents the following contents: Pigmentary disorders, follicular disorders and alopecias, tumors benign and malignant, cosmetics, complementary and alternative medicine.
PART Pigmentary Disorders This page intentionally left blank Part Pigmentary Disorders 10â•… Hyperpigmented Disorders David A Rodriguez Acanthosis nigricans Benign melanonychia Confluent and reticulated papillomatosis of Gougerot and Carteaud (CRPGC) Drug-induced pigmentation Erythema dyschromicum perstans Exogenous ochronosis Gingival hyperpigmentation Melasma Mongolian spots Nevus of Ota Pigmentary demarcation lines Post-inflammatory hyperpigmentation (PIH) Solar lentigines Pediatric perspectives: Transient neonatal pustular melanosis 183 185 187 189 191 192 194 195 199 201 203 204 207 209 Acanthosis nigricans Classical acanthosis nigricans (AN) is characterized by symmetrical areas of verrucous, brown to black, velvety plaques, typically located on the posterior and lateral neck and axillae.1,2 Flexor surfaces, of the extremities, inframammary folds and perianal area may also be affected.3 Interestingly, patients often refer to the appearance of the lesions as a ‘dirty area’, which they are known to vigorously scrub (Fig 10.1) ©2011 Elsevier Ltd, Inc, BV The etiology of AN is unknown However, if the onset of lesions is rapid and the lesions are generalized, then malignancy must be suspected and an evaluation undertaken.4 AN can be seen in a wide range of individuals, from those completely healthy as a normal variant to those with underlying medical conditions, although it is most often observed in darker pigmented individuals One source reports the incidence of AN as 13%, 6% and 1% in African-Americans, Latinos and Caucasians respectively.5 AN is also believed to be a marker of endocrine disturbances, namely increased insulin secretion and insulin resistance.6 Therefore the most common type of AN is associated with conditions with an elevated insulin blood level, such as in diabetes and obesity There are many other possible causes of AN, including: • Hypothyroidism • Addison’s Disease • Pituitary disorders Medications associated with AN, • • • • • • • Insulin6 Glucocorticoids Growth Hormone Diethylstilbestrol Vitamin B3 (Niacin) Methyltestosterone Oral contraceptives.7 The mainstay of AN treatment is management of the underlying disease If AN occurs as a result of obesity, weight loss is required.4,6 If malignancy is the underlying cause, successful surgery or chemotherapy will ameliorate AN Topical treatments such as salicylic acid or tretinoin may be helpful in some individuals Lasers or dermabrasion have also been used successfully, especially with veruccous protrusions If AN is attributed to an offending agent, discontinuation of the drug should lead to resolution 183 Part Pigmentary Disorders topical 0.1% tretinoin gel (retinoic acid) times daily for a 2-week trial period The right axilla served as the control After the initial trial period, there was nearly complete resolution of clinical lesions in the left axilla Topical therapy with tretinoin and ammonium lactate for acanthosis nigricans associated with obesity Blobstein SH Cutis 2003; 71(1):33–34 This study reports the successful use of a combination of 12% ammonium lactate cream and 0.05% tretinoin cream to treat AN associated with obesity Topical tretinoin in acanthosis nigricans Lahiri K, Malakar S Indian J Dermatol Venerol Leprol 1996; 62: 159–161 Efficacy of topical tretinoin was assessed in 30 cases of idiopathic acanthosis nigricans which were recalcitrant to conventional modalities of treatment Topical tretinoin 0.05% qhs was found to be very effective both clinically and histologically A Treatment of acanthosis nigricans with oral isotretinoin Katz RA Arch Dermatol 1980; 116(1):110–111 This article describes a patient with extensive acanthosis nigricans who was treated successfully with oral isotretinoin to test its effectiveness in disorders of keratinization Selection of this disease for treatment with a oral retinoid agent was based on the success of using topical tretinoin in patients with acanthosis nigricans B Figure 10.1:╇ (A) Acanthosis nigricans on the lateral neck (B) Acanthosis nigricans in the axilla First-Line Therapies Tretinoin 0.05% Metformin Topical calcipotriol E D E Treatment of acanthosis nigricans with tretinoin Darmstadt GL, Yokel BK, Horn TD Arch Dermatol 1991; 127(8): 1139–1140 This case report details the treatment of a 55-year-old Indian man with AN involving the axillae, popliteal fossae, the dorsal surface of his toes and the posterior aspect of his neck, as well as a general darkening of his complexion, that began after taking nicotinic acid 500╯mg TID for hypercholesterolemia After 16 weeks of treatment, the patient’s cholesterol value dropped significantly; however, the skin changes were cosmetically unacceptable The left axilla was treated with 184 Comparison of metformin versus rosiglitazone in patients with acanthosis nigricans: a pilot study Bellot-Rojas P, Posadas-Sanchez R, Caracas-Portilla N, et╯al J Drugs Dermatol 2006; 5(9):884–889 The aim of this 12-week randomized, open-label pilot study was to compare the efficacy of metformin versus rosiglitazone on AN lesions of the neck as well as their effects on metabolic and anthropometric variables Overweight or obese subjects with AN were randomized to either metformin (n = 4) or rosiglitazone (n = 3) Only the rosiglitazone group showed a significant reduction in insulin levels No effect on the severity of AN was observed, but modest improvements of skin texture occurred in both treatment groups Results showed that metformin and rosiglitazone were well tolerated Although efficacy on skin lesions was very modest, their use in acanthotic subjects might be useful during longer treatment periods Hyperkeratosis of the nipple associated with acanthosis nigricans: treatment with topical calcipotriol Lee HW, Chang SE, Lee MW, Choi JH, Moon KC, Koh JK J Am Acad Dermatol 2005; 52(3 Pt 1):529–530 A 26-year-old obese woman presented with a 7-year history of asymptomatic, hyperpigmented, hyperkeratotic lesions on both nipples; velvety, hyperpigmented patches on both axillae and groin; and hyperpigmented papillary papules on the tip of the tongue, that began after a 10╯kg weight gain over a 3-month period She was diagnosed with hyperkeratosis of the 10â•… Hyperpigmented Disordersâ•… •â•… Benign melanonychia nipple associated with AN and treated with topical calcipotriol ointment twice daily After months, the lesions on both nipples were significantly improved Commonly encountered pitfalls Although acanthosis nigricans commonly occurs on the neck, it is important not to overlook other locations such as the axillae, lateral cheek and chest The finding of acanthosis nigricans, especially in an overweight patient, is likely a marker of insulin resistance, diabetes mellitus or another endocrine abnormality As such, referral to an endocrinologist should be initiated However, while clinicians reflexively focus on endocrinopathies, acanthosis may also indicate an underlying malignancy, especially in adults Gastric carcinoma is one such associated malignancy Hence, a thorough evaluation for malignancy is indicated Special management & counseling considerations If evidence of insulin resistance or diabetes mellitus is not found in overweight patients, it is likely that the condition will Benign melanonychia Melanonychia is a longitudinal or transverse brown streak involving the nail plate or alternatively, complete discoloration of the plate Longitudinal melanonychia also termed, melanonychia striata, is the most common presentation.1 It can present as a single band on one or more digit although the entire nail plate may also be involved Figure 10.2 illustrates such a case Transverse melanonychia is an uncommon condition caused by radiation therapy and chemotherapy A quite interesting study outlines cases caused by the use electron beam therapy.2 More prevalent in individuals of color, benign melanonychia may be associated with the normal aging process.1,3 Up to 100% of African Americans older than 50 years of age exhibit melanonychia, termed racial melanonychia.4 A study of 800 Japanese individuals found the prevalence of melaÂ� nonychia at 20% and 23% for males and females respectively.5 It is a much rarer phenomenon among Caucasians.6 There are many causes of melanonychia both benign and malignant.7,8 The physiologic processes responsible for melanonychia are melanocyte activation and melanocyte hyperplasia The majority of cases of melanonychia occur as a result of melanocyte activation, during which hypermelanotic melanocytes are taken up from the nail bed and incorporated resolve with weight loss Therefore, these patients should be counseled regarding weight reduction and diet modification When a concomitant pathologic process has been ruled out, one can safely assume AN is benign Benign hereditary forms of acanthosis also exist In the aforementioned cohort, cosmetic treatment should be offered References Schwartz RA, Archer JA, Gorden P, Martin MM Acanthosis nigricans J Am Acad Dermatol 1994; 31:1–19 Schwartz RA Acanthosis nigricans In: Demis DJ, ed Clinical dermatology (unit 12–26) 18th edn Philadelphia: JB Lippincott; 1999:1–11 Pollitzer S Acanthosis nigricans: a symptom of a disorder of the abdominal sympathetic J Am Med Assoc 1909; 53:1369–1373 Kahn CR, Flier JS, Bar RS, et al The syndromes of insulin resistance and acanthosis nigricans: insulin-receptor disorders in man N Eng J Med 1976; 294:739–745 Kim NY, Pandya AG Pigmentary Diseases Med Clin North Am 1998; 82(5):1185–1207 Curth HO Acanthosis nigricans Birth Defects 1971; 7:31–39 Stals H, Vercammen C, Peeters C, Morren M-A Acanthosis nigricans caused by nicotinic acid: case report and review of the literature Dermatology 1994; 189:203–206 into the nail matrix.7 Dominguez and Martin biopsied 68 patients with longitudinal melanonychia and determined that 68% had racial melanonychia, 5.7% benign melanocytic hyperplasia and 5.7% a nail malignancy.9 The following common etiologies of melanonychia involve melanocyte activation:4 • Drug-induced: – Antimalarials – Antiretrovirals – Chemotherapeutic agents (doxorubicin, cyclophosphamide, and hydroxyurea) – Metals • Post-inflammatory: – Chronic paronychia – Onychotillomania (nail biting) – Friction/trauma • Infectious: – Onychomycosis • Systemic causes – Endocrinopathies • Benign tumors: – Myxoid cysts – Verrucae • Non-melanocytic malignant causes: – Bowen’s disease – Squamous cell carcinoma 185 Part Pigmentary Disorders A B Figure 10.2:╇ (A and B) Benign longitudinal melanonychis The following conditions are caused by melanocytic hyperplasia and can also lead to ML:4 Commonly encountered pitfalls • Lentigo/benign melanocytic hyperplasia • Nail matrix nevi • Melanoma While longitudinal melanonychia is a common and often normal finding in individuals with dark skin, the clinician should not lower his or her index of suspicion for subungual melanoma Additionally, melanoma should be suspected in patients with lighter skin tones who have melanonychia It is imperative that a biopsy specimen be obtained from the nail matrix to ensue the diagnosis of melanoma, as a nail plate biopsy will not be sufficient Melanonychia induced by chemotherapy is reversible and most commonly occurs when the patient is treated with drugs like doxorubicin, cyclophosphamide, and hydroxyurea Evaluation of melanonychia includes a thorough inspection of the nail and associated structures, such as the proximal and lateral nail folds and hyponychium, as well as the exact location of the pigmentation.9 In order to assist the clinician distinguish benign from malignant longitudinal melanonychia, Levit et╯al proposed the following guidelines for malignant melanonychia.4 • • • • A – Age (peak incidence in the fifth to seventh decade) B – Brownish-black band with breadth greater than 3╯mm C – Change in morphology D – Digit that is involved (The thumb is more likely than the great toe; the great toe more likely than the index finger.) • E – Extension of the brownish-black pigment of the nail bed, nail matrix, and nail plate onto the adjacent cuticle and proximal and/or lateral nail folds (Hutchinson’s sign) • F – Family history If melanoma or another serious condition is suspected, nail matrix biopsy is recommended for diagnosis Traditional biopsy techniques should be considered, provided they yield an adequate tissue sample.2,11 Treatment should be directed towards the underlying cause of the melanonychia If the melanonychia is suspected to be drug-induced, removal of the offending drug may be necessary, if medically feasible 186 Special management & counseling considerations Skin of color patients are often unaware that melanoma may present as longitudinal melanonychia Therefore, education regarding this possibility and self-examination is important They should also be counseled to have yearly cutaneous examinations by a dermatologist including fingernails and toenails Finally, patients undergoing nail matrix biopsy, should be warned regarding possible permanent post-biopsy nail distrophy References Leung AK, Kao CP An atlas of nail disorders Consultant 2001; 41:58–64 Braun RP, Baran R, Le Gal FA, et al Diagnosis and management of nail pigmentations J Am Acad Dermatol 2007; 56(5):835–847 Duhard E, Calvet C, Mariotte N, Tichet J, Vaillant L [Prevalence of longitudinal melanonychia in the white population] Ann Dermatol Venereol 1999; 122(9):586–590 Tosti A, Piraccini BM, de Farias DC Dealing with melanonychia Semin Cutan Med Surg 2009; 28(1):49–54 Tasaki K On band or linear pigmentation of the nail Jpn J Dermatol 1933; 33:568 10â•… Hyperpigmented Disordersâ•… •â•… Confluent and reticulated papillomatosis of Gougerot and Carteaud Kopf A, Waldo E Melanonychia striata Aust J Dermatol 1980; 21:59–70 André J, Lateur N Pigmented nail disorders Dermatol Clin 2006; 24(3):329–339 Levit EK, Kagen MH, Scher RK, Grossman M, Altman E The ABC rule for clinical detection of subungual melanoma J Am Acad Dermatol 2000; 42(2 Pt 1):269–274 Baran R, Kechijian P Longitudinal melanonychia (melanonychia striata): diagnosis and management J Am Acad Dermatol Dec 1989; 21(6):1165–1175 Confluent and reticulated papillomatosis of Gougerot and Carteaud (CRPGC) Gougerot and Carteaud described this dermatologic condition in the early part of the twentieth century It was first labeled ‘papillomatose pigmenteé innominée’ and then ‘confluent and reticular papillomatosis’ became the widely accepted term.1 Lesions are characterized by hypochromic or blue-gray papules which coalesce and become confluent in the center A 10 Quinlan KE, Janiga JJ, Baran R, Lim HW Transverse melanonychia secondary to total skin electron beam therapy: a report of cases J Am Acad Dermatol 2005; 53(2 Suppl 1):S112–S114 11 Bormann G, Marsch WC, Haerting J, Helmbold P Concomitant traumas influence prognosis in melanomas of the nail apparatus Br J Dermatol 2006; 155(1):76–80 with a reticular pattern in the periphery Lesions are typically located in the epigastrium and inframammary areas (Fig 10.3) However, they may involve the neck, shoulders and pubic area in advanced cases.2,3 The disease has shown no gender or racial predilection.4 Electron microscopy imaging has shown a defect of keratinization, a granular layer decrease and associated hypermelanosis.5 The etiology of CRPGC etiology is unknown, but theories abound Since response to antifungal agents has been documented, heavy colonization with Pityrosporum orbiculare has been theorized as the causative agent.6,7 Several antibiotics have also been effective, and their anti-inflammatory properties have been thought to be the responsible mechanism of action.8 Others have posited abnormal keratinization as a factor, and this is supported by the histopathologic findings mentioned above.9 A propensity towards obesity and an endocrinopathy have been observed anomalies.10 Finally, genetics may play a role.11 B Figure 10.3:╇ (A and B) Confluent and reticulated papillomatosis 187 Part Pigmentary Disorders cases, response to this agent and to other medications, both antifungal and keratolytic, were variable First-Line Therapies Minocycline Azithromycin Fusidic acid Ketoconazole Selenium sulfide (typically found in shampoos) Retinoids D D E E E E Confluent and reticulated papillomatosis: response to minocycline Montemarano AD, Hengge M, Sau P, Welch M J Am Acad Dermatol 1996; 34:253–256 The objective of this study was to evaluate the effectiveness of oral minocycline in patients with CRP These subjects were treated with oral minocycline 50╯mg twice a day, for weeks The average follow-up period was 11 months Recurrence rate, side effects, and effectiveness of therapy were assessed All patients except two had a 90–100% response to therapy Recurrences were noted in patients, all of whom responded to re-treatment with minocycline None of the patients had an adverse reaction Minocycline 50╯mg twice a day is safe and effective for treatment of CRP Confluent and reticulated papillomatosis was improved by treatment with minocycline hydrochloride: report of two cases Koizumi N, Hatamochi A, Shinkai A Rinsho Derma 2002; 44:63–67 An 18-year-old male and a 12-year-old female with CRPGC, both obese, responded to treatment with minocycline Treatment of confluent and reticulated papillomatosis with azithromycin Atasoy M, Ozdemir S, Aktas¸ A, Aliagˇaogˇlu C, Karakuzu A, Erdem T J Dermatol 2004; 31:682–686 This is the case of a 21-year-old male patient with confluent and reticulated papillomatosis initially treated with ketoconazole cream for weeks without improvement The patient demonstrated a significant response to treatment with azithromycin A case of confluent and reticulated papillomatosis responsive to ketoconazole cream Hamaguchi T, Nagase M, Higuchi R, Takiuchi I Nippon Ishinkin Gakkai Zasshi 2002; 43: 95–98 A case report of a patient responding to ketoconazole cream, as fungal spores were found in the skin Confluent and reticulated papillomatosis responsive to selenium sulfide Nordby CA, Mitchell AJ Int J Dermatol 1986; 25:194–199 Case report of CRP that showed a significant therapeutic response to topical selenium sulfide In previously described 188 Confluent and reticulated papillomatosis: response to tazarotene Bowman P, Davis LS J Am Acad Dermatol 2003; 48(5):S80–S81 Case report of an 11-year-old Black girl with confluent and reticulated papillomatosis who was treated with tazarotene gel The treatment was well tolerated and the patient cleared completely Six cases of confluent and reticulated papillomatosis alleviated by various antibiotics Jang HS, Oh CK, Cha JH, Cho SH, Kwon KS J Am Acad Dermatol 2001; 44(4):652–655 This study reports cases of CRP alleviated by various antibiotics The patient described in case is a 16-year-old girl whose disease was alleviated by oral minocycline, 100╯mg daily for weeks Cases and describe an 18-year-old woman and a 17-year-old male adolescent whose disease was reduced by oral fusidic acid, 1000╯mg daily for weeks Case describes a 14-year-old girl who received oral clarithromycin, 500╯mg daily for weeks Case describes a 22-year-old woman whose disease was reduced by oral erythromycin, 1000╯mg daily for weeks Case reports a 24-year-old man who received oral azithromycin, 500╯mg daily times per week for weeks Complete clearing after treatment with the above mentioned antibiotics was reported References Inalöz HS, Patel G, Knight AG Familial confluent and reticulated papillomatosis Arch Dermatol 2002; 138:276–277 Schwartz RA Confluent and reticulated papillomatosis Emedicine http://emedicine.medscape.com/article/1106748-overview [accessed December 18, 2009] Ferreira LM, Diniz LM, Ferreira CJ Confluent and reticulated papillomatosis of Gougerot and Carteaud: report of three cases An Bras Dermatol 2009; 84(1):78–81 Scheinfeld N Confluent and reticulated papillomatosis: a review of the literature Am J Clin Dermatol 2006; 7:305–313 Lee SH, Choi EH, Lee WS, et al Confluent and reticulated papillomatosis: a clinical, histopathological, and electron microscopic study J Dermatol 1991; 18:725–730 Hamaguchi T, Nagase M, Higuchi R, Takiuchi I A case of confluent and reticulated papillomatosis responsive to ketoconazole cream Nippon Ishinkin Gakkai Zasshi 2002; 43:95–98 Roberts SO, Lachapelle JM Confluent and reticulate papillomatosis (Gougerot–Carteaud) and pityrosporum orbiculare Br J Dermatol 1969; 81:841–845 Chang SN, Kim SC, Lee SH, Lee WS Minocycline treatment for confluent and reticulated papillomatosis Cutis 1996; 57:454–457 Carrozzo AM, Gatti S, Ferranti G, et al Calcipotriol treatment of confluent and reticulated papillomatosis (Gougerot–Carteaud syndrome) J Eur Acad Dermatol Venereol 2000; 14:131–133 10 Koizumi N, Hatamochi A, Shinkai A Confluent and reticulated papillomatosis was improved by treatment with minocycline hydrochloride: report of two cases Rinsho Derma 2002; 44:63–637 11 Inalöz HS, Patel G, Knight AG Familial confluent and reticulated papillomatosis Arch Dermatol 2002; 138:276–277 10â•… Hyperpigmented Disordersâ•… •â•… Drug-induced pigmentation Drug-induced pigmentation Exposure to a wide range of pharmacologic agents can induce clinically significant pigmentary changes Though these changes are typically benign, the cosmetic effects can have a severe psychological impact on affected individuals, especially on those with darker skin (Fig 10.4).1 Three classes of drug-induced pigmentary changes have been described:2 • hyperpigmentation/melanosis • hypopigmentation/leukoderma • dyspigmentation Pharmacologically related cutaneous changes are fairly common as 10–20% of all cases of hyperpigmentation are attributed to drug reactions.3 Drug reactions have been strongly associated with specific drugs and/or classes of drugs: • • • • • • • • • chloroquine minocycline amiodarone chlorpromazine NSAIDs trimethoprim-sulfamethoxazole phenolphthalein (found in laxatives) heavy metals chemotherapeutic agents The pathophysiology of medications may vary However, several broad mechanisms of action exist:2 • drug or drug metabolite deposition in the dermis and epidermis • enhanced melanin production • cutaneous drug-induced post-inflammatory changes • reduced number of skin melanocytes • enzymatic blockade of melanogenesis • inhibition of melanosome transfer Table 10.1 describes the particular cutaneous manifestations of common medications Cutaneous manifestations are specific to each drug.4 The effect of the antimalarial chloroquine on the pigmentary system has been well described This medication appears to bind to melanin and becomes concentrated in melanin-containing structures The popular antibiotic, minocycline, can lead to diffused pigmentary changes which have been categorized into three types: • Type I – blue-black/gray pigment on the face in areas of scarring or inflammation associated with acne • Type II – blue-gray pigment on normal skin on the shins and forearms • Type III – diffuse muddy-brown discoloration in areas of sun exposure According to Geria et╯al, Types I and II will resolve over time while type III seems to be permanent.5 Treatment is outlined below A complete history and physical examination will typically elucidate the diagnosis with a biopsy reserved for equivocal cases Discontinuation of the offending agent is the sine qua non of this condition Reassurance of the (usually) temporal nature of the event is also important Use of sunscreen to prevent progression is recommended as the combination of sunlight and certain drugs may exacerbate the condition Finally, laser therapy is useful in selected cases First-Line Therapies Q-switched alexandrite laser Q-switched ruby laser Figure 10.4:╇ Drug-induced pigmentation resulting from chloroquine (Courtesy of Neil Fenske, MD, Tampa, FL; From Callen, Color Atlas of Dermatology, 2e, copyright Elsevier 1999.) D E Minocycline-induced hyperpigmentation treated with a 755-nm Q-switched alexandrite laser Alster TS, Gupta SN Dermatol Surg 2004: 30(9):1201–1204 patients with minocycline-induced hyperpigmentation on the face or legs were treated with a Q-switched alexandrite laser on a bimonthly basis until pigmentation was eradicated Cutaneous pigmentation resolved completely in all patients in an average of four laser sessions Side effects were limited to transient purpura and mild desquamation without scarring or dyspigmentation 189 Part Pigmentary Disorders Table 10.1╇ Cutaneous manifestations of common offending agents Drug/drug group Clinical features Antipsychotics (chlorpromazine and related phenothiazines) • Bluish-gray pigmentation, especially in sun-exposed areas • Pigmentation is cumulative and some areas may develop a purplish tint • Pigmentation of the conjunctiva in the eye may also occur, along with cataracts and corneal opacities Phenytoin • 10% of patients develop pigmentation of the face and neck resembling chloasma (clearly defined, roughly symmetrical dark brown patches) • Fades after a few months when drug has been stopped Antimalarials • About 25% of patients receiving chloroquine or hydroxychloroquine for several years develop bluish-gray pigmentation on face, neck and sometimes lower legs and forearms • Continuous long-term use may lead to blue-black patches, especially in sunexposed areas • Nail bed and corneal and retinal changes may also develop Cytotoxic drugs Amiodarone NSAIDs 190 • Busulfan, cyclophosphamide, bleomycin and adriamycin have all produced hyperpigmentation to some degree • Banded or diffuse pigmentation of nails often occurs • Blue-gray pigmentation in sun-exposed areas (face and hands) • Photosensitivity occurs in 30–57% of patients whilst 1–10% show skin pigmentation • Skin pigmentation is reversible but may take up to year for complete resolution after the drug has been stopped • Often associated with fixed drug eruptions (drugs that cause a single or few sharply demarcated erythematous lesions which resolve promptly but leave a local brown pigmentation) • May occur on the face, extremities and genitalia Laser treatment of imipramine-induced hyperpigmentation Atkin DH, Fitzpatrick RE J Am Acad Dermatol 2000; 43(1 Pt 1):77–80 One patient with significant imipramine- (a tricyclic antidepressant) induced pigmentation underwent treatment with carbon dioxide, erbium, alexandrite, and ruby lasers on hyperpigmented areas Biopsies were performed before treatment, immediately after treatment, and at clearing with the alexandrite laser The Q-switched alexandrite and ruby lasers resulted in clinical improvement in the patient’s hyperÂ� pigmentation and a decrease in pigment granules on light microscopy Amiodarone-induced skin pigmentation: Q-switched laser therapy, an effective treatment option Wiper A, Roberts DH, Schmitt M Heart 2007; 93(1):15 Case report of successful treatment of amiodarone-induced hyperpigmentation using a Q-switched ruby laser on a 48-yearold man Commonly encountered pitfalls Drug induced hyperpigmentation can be confused with a variety of dermatoses This may lead to a delay in both diagnosis and discontinuation of the offending medication The consequences of misÂ�diagnosis can be particularly deleterious as drug-induced pigmentation may be permanent Special management & counseling considerations If possible, the causative agent should be immediately discontinued Patients should be informed that drug induced hyperpigmentation may be permanent Pigmentation caused by amiodarone, for example, may require one year to resolve The use of sunscreen, sun avoidance and protective clothing can help ameliorate the condition References Halder RM, Nandedkar MA, Neal KW Pigmentary disorders in ethnic skin Dermatol Clin 2003; 21(4):617–628 Butler DF, Henderson DZ Drug-induced pigmentation Emedicine 2008 http://emedicine.medscape.com/article/1069686-overview [AccÂ� essed August 23, 2009] Dereure O Drug-induced skin pigmentation: epidemiology, diagnosis and treatment Am J Clin Dermatol 2001; 2(4):253–262 Dermnet NZ Photosensitivity http://www.dermnetnz.info/reactions/ photosensitivity.html [accessed August 25, 2009] Geria AN, Tajirian AL, Kihiczak G Minocycline-induced skin pigmentation: an update Acta Dermatovenerol Croat 2009; 17(2):123–126 ... diagnosis and treatment of iron deficiency and its potential relationship to hair loss J Am Acad Dermatol 20 06; 54: 824 –844 Goette DK, Odom RB Alopecia in crash dieters JAMA 1976; 23 5 :26 22 26 23 Rushton... therapy Bahadir S, Cobanoglu U, Cimsit G, Yayli S, Alpay K Int J Dermatol 20 04: 43(3) ;22 0 22 2 Various treatments have been used for EDP but without benefit, including sun protection, chemical peels,... photosensitivity.html [accessed August 25 , 20 09] Geria AN, Tajirian AL, Kihiczak G Minocycline-induced skin pigmentation: an update Acta Dermatovenerol Croat 20 09; 17 (2) : 123 – 126 10â•… Hyperpigmented Disordersâ•…