Pigmentation

Instruction by the examiner:

• Perform the general examination of the patient.

• Look at the patient. What is your finding? (Pigmentation may be found). Examine the relevants.

Once there is pigmentation, look carefully at the following points:

• Is it generalized or localized to a part?

• Look at the—

• Lips, gum, inner side of mouth or buccal mucosa and tongue.

• Exposed parts (face, neck and extensors of arm).

• Palm (especially the creases).

• Pressure areas (knee or elbow).

• Scars (especially recent).

• Nipples.

• Genitalia.

 Causes of pigmentatios:

 Kala-azar (history of fever).

 Addison’s disease.

 Haemochromatosis.

 Primary biliary cirrhosis (especially in middle aged or elderly female).

 Drugs (e.g., busulphan, amiodarone, phenothiazine).

 Chronic debilitating illness (malignancy, CKD, TB).

 Chronic arsenic toxicity.

Malabsorption syndrome (e.g., Whipple’s disease).

causes of hyperpigmentation:

A. Physiological: familial, racial, pregnancy, prolonged exposure to sun.

B. Pathological:

1. Endocrine causes:

• • Addison’s disease (brown or dark brown).
• • Cushing’s syndrome.
• • Acromegaly.
• • Nelson’s syndrome (after bilateral adrenalectomy).
• • Thyrotoxicosis.
• • Ectopic ACTH syndrome.

2. Infections: kala-azar.

3. Chronic liver disease:

• • Haemochromatosis (greenish or bronze, less involvement of mucous membrane).
• • Cirrhosis of liver (common in PBC).

4. GIT: Malabsorption syndrome (Whipple’s disease, Peutz–Jeghers syndrome).

5. Chronic debilitating illness:

• Internal malignancy (commonly ectopic ACTH syndrome), CKD, any chronic illness.

6. Drugs:

• • Cytotoxic drugs e.g., busulphan (diffuse brown), bleomycin (diffuse brown, often in
• flexural parts), any cytotoxic drug.
• • Amiodarone (violaceous or brown or blue or slaty-grey, in exposed parts).
• • Phenothiazine (slaty-grey, exposed site).
• • Phenytoin (melasma-like pigmentation).
• • Oral contraceptive pill.
• • Chloroquine (blue-grey, in exposed parts).
• • Clofazimine (red or pinkish).
• • Psoralen (brown, exposed site).
• • Minocycline (Slaty-grey, scars, temples, shins and sclera).
• • Mepacrine (yellow).

7. Others:

• • Chronic arsenic poisoning.
• • Pellagra (necklace area and exposed part).
• • Systemic sclerosis.
• • Ochronosis (mainly in the joint, nose, ear and face).
• • Argyria (slaty grey hue due to silver deposition).
• • Porphyria cutanea tarda.
• • Acanthosis nigricans.