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Drug-Induced Pigmentation

  • Author: David F Butler, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Mar 08, 2016
 

Background

Adverse cutaneous reactions to medications are a common reason for consultations with dermatologists. Drug-induced skin disorders may manifest in a variety of ways. Drugs may cause exanthems, urticaria, hypersensitivity syndromes, pustular eruptions, erythema multiforme, toxic epidermal necrolysis, cutaneous necrosis, and abnormal pigmentation of the skin and mucosa. Although pigmentary changes caused by drugs usually result in a limited degree of morbidity, these changes may be very disturbing to the patient.

The image below depicts a patient with amiodarone pigmentation.

Amiodarone pigmentation. Amiodarone pigmentation.

Drug-induced pigmentary abnormalities may be classified into 3 groups, which are (1) hyperpigmentation/melanosis, (2) hypopigmentation/leukoderma, and (3) dyspigmentation or occurrence of unusual skin color.

A related article is Fixed Drug Eruptions. Additionally, the Medscape Adverse Drug Event Reporting Resource Center may be of interest.

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Pathophysiology

Multiple pathologic mechanisms are responsible for drug-induced pigmentation disorders. Compared with the immunological etiology underlying many drug allergies, most cases of pharmacologic pigmentation are not immunologically mediated.

The pathogenesis underlying drug-related dyspigmentation can also be categorized into 3 mechanisms, which are (1) drug or drug metabolite deposition in the dermis and epidermis, (2) enhanced melanin production with or without an increase in the number of active melanocytes, and (3) drug-induced postinflammatory changes to skin. Similarly, chemical hypopigmentation is also thought to occur through a variety of pathologic mechanisms, including a reduced number of skin melanocytes, enzymatic blockade of melanogenesis, and inhibition of melanosome transfer.

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Epidemiology

Frequency

United States

The rate of drug-induced dyspigmentation varies depending on the drug and cumulative dose. Some drugs, such as amiodarone, have been reported to have a rate of blue-gray dyspigmentation as high as 24% when the cumulative dose is greater than 200 mg.

International

Drug-induced skin pigmentation is estimated to account for 10-20% of all cases of acquired dyspigmentation worldwide.

Race

Drug-induced pigmentary changes can occur in persons of any race, but hypomelanosis is seen more frequently and appears more dramatically in patients with darker-pigmented skin. Additionally, people with darker skin often exhibit more intense hyperpigmentation than individuals with fair skin.[1]

Sex

No differences are reported in the prevalence of drug-related pigmentation among males versus females.

Age

Drug-related dyspigmentation is seen in persons of all ages.

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Contributor Information and Disclosures
Author

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jeffrey P Callen, MD Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: XOMA; Biogen/IDEC; Novartis; Janssen Biotech, Abbvie, CSL pharma<br/>Received honoraria from UpToDate for author/editor; Received honoraria from JAMA Dermatology for associate editor and intermittent author; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for i inherited these trust accounts; for: Celgene; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble; Amgen.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Harry Dao, Jr, MD Assistant Professor, Department of Dermatology, Baylor College of Medicine

Harry Dao, Jr, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Deborah Zimmer Henderson, MPH University of Texas Southwestern Medical School

Deborah Zimmer Henderson, MPH is a member of the following medical societies: Texas Medical Association

Disclosure: Nothing to disclose.

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Perioral chloroquine pigmentation.
Bleomycin flagellate pigmentation.
Adriamycin pigmented macule (arrow) on the tongue.
Minocycline pigmentation of the sclera.
Minocycline pigmentation of the forearms.
Minocycline pigmentation of the lower leg.
Minocycline "muddy" pigmentation of the face in photodistribution.
Amiodarone pigmentation.
 
 
 
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