The Journal of the Arkansas Medical Society Med Journal June 2020 | Page 16

derm dilemma
Special Section: Short Dermatological Cases
by Shelby Webb, md candidate, class of 2020
uams dept of dermatology
An 82-year-old previously healthy man initially
presents to the clinic with new-onset scalp folliculitis
and rosacea. The patient was started on doxycycline
and was to follow up in four to six weeks.
The patient was lost to follow up for 10 months,
during which time another physician switched
him from doxycycline to continuous minocycline
to try and achieve better control of the folliculitis.
Eight months later, he now presents with severe
gram-negative scalp folliculitis and new blue-gray
hyperpigmentation of bilateral lower extremities,
as well as persistent rosacea. The patient has no
reported history of renal, cardiac, lung, or hepatic
disease. He denies other prescription medications,
over-the-counter medications, or herbal
supplements. The patient also denies consuming
any products containing silver. The patient does
saturation and ferritin, along with genetic testing
for HFE mutations to rule out hereditary hemochromatosis.
C. This is drug-induced hyperpigmentation from
long-term use of minocycline. Immediate discontinuation
of the minocycline may result in resolution
of hyperpigmentation.
D. This is likely argyria, and the patient is not
sharing his full medication list. Obtain a skin biopsy
to evaluate for silver granule deposition.
Answer: C
While the differential diagnosis of new-onset skin
hyperpigmentation includes the diseases listed
above, the patient history and presentation are
the legs, as is present in this patient. Type III is
the least common type and presents as diffuse
muddy-brown pigmentation of sun-exposed areas.
Early recognition and discontinuation of the
offending agent is key in promoting resolution of
skin hyperpigmentation, though such resolution
may take months to years.
Chronic venous stasis can result in stasis dermatitis
as venous blood pools in the legs and causes
local endothelial damage of the microvasculature.
This may occur in one or both legs and rarely
develops in other areas. Skin discoloration can
range from scaly, pruritic plaques and irregular
shaped areas of hyperpigmentation to ulceration.
Topical corticosteroids can help to control acute
dermatitis, but treating the venous stasis using
compression stockings is the mainstay of treatment.
Hemochromatosis is one of the most common
inherited errors of metabolism. It is a condition of
increased absorption and storage of dietary iron.
The skin discoloration in this disorder is characterized
by a slate-gray or bronze hyperpigmentation
in sun-exposed areas due to iron and melanin
deposition. Disease onset generally is between 30
to 50 years of age. This condition is treated with
repeated phlebotomy to decrease iron stores.
not report fluctuations in symptoms related to
sun exposure. He is started on isotretinoin for his
recalcitrant rosacea and scalp folliculitis.
Considering the patient history given and clinical
image provided here, what is likely the cause of
his new-onset blue grey pigmentation, and what
appropriate steps should be taken?
A. This is venous stasis, with hemosiderin related
pigmentation. Obtain Ultrasound Doppler to assess
for venous stasis and advise the use of compression
stockings bilaterally.
B. This is bronze-pigmentation of hemochromatosis.
Obtain measurements of serum transferrin
most consistent with drug-induced hyperpigmentation,
which is most commonly noted to be due
to minocycline, amiodarone, various chemotherapy
agents, prostaglandins, oral contraceptives,
and antimalarial drugs. The patient has been
on minocycline for almost approximately eight
months now, raising the suspicion that the skin
hyperpigmentation is from long-term minocycline
use. This drug turns black when oxidized,
resulting in discoloration of skin, as noted here.
There are three types of cutaneous hyperpigmentation
induced by minocycline. Type I is the
most common type and presents as blue-black
pigmentation of previous areas of inflammation
or scarring. In Type II, there is characteristic bluegray
discoloration of previously normal skin of
Agyria is a rare skin condition related to chronic
exposure to silver-containing products that deposit
diffusely in the skin, conjunctiva, oral mucosa,
and nailbeds. The skin discoloration in this
condition is often more pronounced in sun-exposed
areas, especially the hands and face. This
is related to the reduction of colorless silver in the
dermis upon exposure to sunlight. Hence, discontinuation
of silver-containing products, avoidance
of sun and use of sunscreen is encouraged
to prevent further skin discoloration.
It is also important to note that as the minocycline
is discontinued due to adverse effects, we
must also address the worsening gram-negative
folliculitis. Treatment options include Isotretinoin
or other various antibiotics directed against
gram-negative bacteria.
280 • The Journal of the Arkansas Medical Society www.ArkMed.org