Medical Student Core Curriculum in Dermatology Blotches: Dark rashes Medical Student Core Curriculum in Dermatology Last updated April 18, 2011

Module Instructions The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology. We encourage the learner to read all the hyperlinked information.

Goals and Objectives The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with hyperpigmented rashes. After completing this module, the medical student will be able to: Identify and describe the morphology of common hyperpigmented rashes Provide an initial treatment plan for selected dark rashes Determine when to refer a patient with a dark rash to a dermatologist

Case One Scott Goff

Case One: History HPI: Scott Goff is a 28-year-old male who presents with “blotches” on his upper back and chest for several years. They do not cause any symptoms other than anxiety because he has these dark spots. PMH: no major illnesses or hospitalizations Allergies: none Medications: protein supplements Family history: none Social history: accountant; weightlifter ROS: negative

Case One: Skin Exam

Case One: Skin Exam

Case One, Question 1 Mr. Goff’s chest shows hyperpigmented, scaly macules on his upper chest and back. Which is the best test to confirm the diagnosis? Bacterial culture Direct fluorescent antibody (DFA) test Potassium hydroxide (KOH) exam Wood’s light

Case One, Question 1 Answer: c Mr. Goff’s chest shows hyperpigmented, scaly macules on his upper chest and back. Which is the best test to confirm the diagnosis? Bacterial culture Direct fluorescent antibody (DFA) test Potassium hydroxide (KOH) exam Wood’s light

Case One, KOH exam Spores (yeast forms) Short Hyphae The KOH exam shows short hyphae and small round spores. This is diagnostic of tinea (pityriasis) versicolor.

Diagnosis: Tinea versicolor Based on his skin findings and KOH exam, Mr. Goff has tinea versicolor It’s called “versicolor” because it can be light, dark, or pink to tan Let’s look at some examples of the various colors of tinea versicolor

Tinea versicolor: lighter

Tinea versicolor: darker

Tinea versicolor: pink or tan

Case One, Question 2 What is the best treatment for Mr. Goff? Ketoconazole shampoo Narrow band UVB phototherapy Oral griseofulvin Tacrolimus cream Triamcinolone cream

Case One, Question 2 Answer: a What is the best treatment for Mr. Goff? Ketoconazole shampoo Narrow band UVB phototherapy (may worsen appearance by increasing contrast) Oral griseofulvin (does not work for Malassezia species) Tacrolimus cream (does not fight yeast) Triamcinolone cream (does not fight yeast)

Case One, Question 3 Which of the following statements is true about the treatment of tinea versicolor? Normal pigmentation should return within a week of treatment Oral azoles should be used in most cases When using shampoos as body wash, leave on for ten minutes before rinsing

Case One, Question 3 Answer: c Which of the following statements is true about the treatment of tinea versicolor? Normal pigmentation should return within a week of treatment (usually takes weeks to months to return to normal) Oral azoles should be used in most cases (mild cases can be treated with topicals) When using shampoos as body wash, leave on for ten minutes before rinsing

Case Two Melinda Kinsley

Case Two: History HPI: Melinda Kinsley is a 48-year-old Guatemalan woman who presents with ten years of dark spots on her face. She tried a bleaching cream she got from Mexico but her friend told her it could make the spots worse. PMH: three normal pregnancies; s/p tubal ligation Allergies: none Medications: supplements black cohosh, evening primrose Family history: noncontributory Social history: lives with husband and children ROS: negative

Case Two: Skin Exam

Case Two, Question 1 Which of the following is most likely associated with this symmetric hyperpigmentation? Ginseng Limes Minocycline Malassezia furfur Pregnancy

Case Two, Question 1 Answer: e Which of the following is most likely associated with this symmetric hyperpigmentation? Ginseng Limes Minocycline Malassezia furfur Pregnancy

Melasma

Melasma (aka Chloasma) Melasma is characterized by patchy light to dark brown hyperpigmentation of the face Usually affects women, runs in families Associated with hormonal changes Called the “mask of pregnancy” May occur with pregnancy, birth control pills, and hormone replacement therapy

Melasma (aka Chloasma) Worse with exposure to UV radiation Treatments Strict sun avoidance, daily sunscreen with broad spectrum coverage and SPF > 30 Hydroquinone 4% cream BID If this fails, may refer to dermatology for cosmetic treatments like triple topical therapy, lasers, or chemical peels, but these will usually be at the patient’s expense

Case Three Henry Fontana

Case Three: History HPI: Henry Fontana is a 78-year-old man who presents with of darkening of his arms and neck over the past few years. He recently underwent knee replacement surgery, and the orthopedist noticed a greenish pigmentation of his bones. PMH: hypertension, GERD, osteoarthritis, BPH, basal cell and squamous cell carcinomas, rosacea Allergies: none Medications: atenolol, felodipine, celecoxib, oxybutinin, rabeprazole, minocycline Family history: noncontributory Social history: widower; lives alone ROS: negative

Case Three: Skin Exam

Case Three, Question 1 Which of the following medications is most likely associated with this pigmentation? Atenolol Celecoxib Minocycline Oxybutinin Rabeprazole

Case Three, Question 1 Answer: c Which of the following medications is most likely associated with this pigmentation? Atenolol Celecoxib Minocycline Oxybutinin Rabeprazole

Minocycline pigmentation

Minocycline pigmentation Deposition appears after months to years in a small percentage of patients First noticeable on the alveolar ridge, palate, sclera May involve bones, thyroid, but this is harmless Skin deposition can be brown or blue-grey Blue-grey pigmentation may occur in scars Skin pigmentation may not fade after discontinuation Patients on long-term minocycline should be screened; if seen on gums or sclerae, discontinue

Other causes of medication-related hyperpigmentation Amiodarone Antimalarials Hydroxychloroquine Chloraquine Calcium channel blockers Verapamil Diltiazem Zidovudine Imipramine Some antipsychotics Some chemotherapy agents

Case Four Elaine Gosnel

Case Four: History HPI: Elaine Gosnel is a 66-year-old woman with a two-year history of an itchy rash on her legs that has resulted in dark spots. PMH: hypertension, diabetes, hyperlipidemia Allergies: none Medications: metoprolol, simvastatin, metformin Family history: noncontributory Social history: widowed; lives in a retirement community ROS: edematous legs

Case Four: Skin Exam

Case Four, Question 1 The patient’s legs show scaly brown plaques on her lower legs bilaterally. Pedal pulses are normal. What is the most likely diagnosis for Mrs. Gosnel’s rash? Atopic dermatitis Erysipelas Irritant contact dermatitis Stasis dermatitis Tinea corporis

Case Four, Question 1 Answer: d The patient’s legs show scaly brown plaques on her lower legs bilaterally. Pedal pulses are normal. What is the most likely diagnosis for Mrs. Gosnel’s rash? Atopic dermatitis (wrong location, no history) Erysipelas (usually unilateral, acute not chronic) Irritant contact dermatitis (not good location, no history) Stasis dermatitis Tinea corporis (more superficial)

Stasis dermatitis

Case Four, Question 2 You correctly diagnose Mrs. Gosnel with stasis dermatitis. What do you recommend? Bacitracin ointment twice daily Daily oral trimethoprim-sulfamethoxazole Debridement of superficial erosions Elevation and compression stockings Immediate referral to vascular surgery

Case Four, Question 2 Answer: d You correctly diagnose Mrs. Gosnel with stasis dermatitis. What do you recommend? Bacitracin ointment twice daily (likely to cause allergic contact dermatitis) Daily oral trimethoprim-sulfamethoxazole (no active infection) Debridement of superficial erosions (may worsen) Elevation and compression stockings Immediate referral to vascular surgery (not indicated for most stasis dermatitis)

Stasis dermatitis Venous stasis dermatitis is an eczematous eruption that occurs in venous insufficiency and leg edema Acute eczematous dermatitis (itchy red scaly plaques) leads to chronic eczematous dermatitis; may be weepy Extravasation leads to brown pigmentation and petechiae Venous ulcers may result, especially on medial malleolus Refer to the module on Stasis Dermatitis and Leg Ulcers for more information

Stasis dermatitis: Treatment Reduce edema with elevation and compression stockings Wet compresses may aid in healing erosions or ulcers Mid-potency topical steroids control inflammation Avoid topical antibiotics because up to half develop allergic contact dermatitis, especially to neomycin and bacitracin

Quick Case: Dark spot on the leg This 32-year-old man who had a small laceration two years ago and presents with a dark spot He’s worried it might be something bad

Quick Case: Diagnosis? What is the most likely diagnosis? Drug-induced pigmentation Melanoma Postinflammatory hyperpigmentation Post-traumatic fungal infection

Quick Case: Diagnosis? Answer: c What is the most likely diagnosis? Drug-induced pigmentation Melanoma Postinflammatory hyperpigmentation Post-traumatic fungal infection

Postinflammatory hyperpigmentation Postinflammatory hyperpigmentation describes a common phenomenon of darkening of the skin at or around sites of injury or inflammation Individuals with olive or slightly darker complexion are at particular risk The pigmentation takes months to years to fade but usually improves gradually over time

Postinflammatory hyperpigmentation Reassure patients this is normal This is not a scar; it’s just increased pigment Use sunscreen after injuries or surgical procedures For significant or problematic hyperpigmentation, refer to a dermatologist

Postinflammatory hypopigmentation Some patients heal with light spots instead Stigma may be caused by fear of infectious diseases Social impact can be more severe than original rash Pigmentation may return slowly It is important to treat rashes aggressively to avoid this if possible

Common dark rashes Tinea versicolor Melasma Drug pigmentation Stasis dermatitis Postinflammatory hyperpigmentation

Take Home Points: Dark Rashes Tinea versicolor may be hyperpigmented Symmetric brown patches on the zygomatic, buccal, and mandibular cheeks of adult women are usually melasma Some medications (especially minocycline) cause hyperpigmentation; warn patients and monitor for it Venous stasis can cause hyperpigmentation Postinflammatory hyperpigmentation and hypopigmentation are very common in darker skin types, so treat skin conditions aggressively

Acknowledgements This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012. Primary author: Patrick McCleskey, MD, FAAD. Peer reviewers: Timothy G. Berger, MD, FAAD; Peter A. Lio, MD, FAAD; Jennifer Swearingen, MD; Sarah D. Cipriano, MD, MPH. Revisions: Patrick McCleskey, MD, FAAD. Last revised April 2011.

References Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web- Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462. Habif TP. Clinical Dermatology: a color guide to diagnosis and therapy, 4th ed. New York, NY: Mosby; 2004. Layton AM, Cunliffe WJ. Minocycline induced skin pigmentation in the treatment of acne—a review and personal observations. J Dermatol Treatment 1989;1:9-12. Lio PA. Little white spots: an approach to hypopigmented macules. Arch Dis Child Pract Ed 2008;93:98-102. Marks Jr JG, Miller JJ. Chapter 13. White Spots (chapter). Lookingbill and Marks’ Principles of Dermatology, 4th ed. Elsevier; 2006:187-197. Wolverton SE. Systemic drugs for infectious diseases (Chapter 5) and Topical Antifungal Agents (Chapter 29). Comprehensive Dermatologic Drug Therapy, 2nd ed. Elsevier; 2007: 80-99, 547-559.