eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses

Erythema Dyschromicum Perstans: Differential Diagnoses & Workup

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Coauthor(s): Santiago A Centurion, MD, Staff Physician, Department of Dermatology, New Jersey Medical School, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Aug 31, 2009

Differential Diagnoses

Addison Disease
Contact Dermatitis, Allergic
Hemochromatosis
Leprosy
Lichen Planus

Other Problems to Be Considered

  • Lichen planus pigmentosus
  • Lichen planus–like drug eruption14
  • Atrophic lichen planus
  • Tuberculoid leprosy
  • Pinta
  • Idiopathic eruptive macular pigmentation (IEMP): This is a rare disease that can be distinguished by different clinical appearance of the macules: gray with an erythematous border and possibly confluent in erythema dyschromicum perstans, versus brownish and nonconfluent in IEMP.15
  • Drug reaction: Ashy dermatosis–like pigmentation has been described attributed to ethambutol.16

Workup

Laboratory Studies

  • All cases of erythema dyschromicum perstans (EDP), to date, have resulted in negative laboratory study results, which include the following:
    • Bacterial, viral, and mycologic cultures
    • Erythrocyte sedimentation rate
    • Glucose studies
    • Liver function test
    • Urinalysis

Imaging Studies

  • Radiographic studies in erythema dyschromicum perstans patients have not shown abnormalities.

Histologic Findings

The biopsy specimen is obtained as much to rule out other diagnoses as to confirm that of erythema dyschromicum perstans because the erythema dyschromicum perstans histologic pattern is relatively nonspecific. One should attempt to obtain a biopsy sample of the border of an active macule, which usually demonstrates mild basal cell layer vacuolar degeneration overlying an upper dermis with a mild perivascular mononuclear cell infiltrate and increased melanophages.

Distinguishing ashy dermatosis from lichen planus pigmentosus (LPP) is not always easy. A Mexican study of 20 patients with erythema dyschromicum perstans and 11 with LPP provided clear clinical delineation between the 2 often histologically indistinguishable disorders.17 LPP has pruritic brownish black macules or patches, with no active border, on the face and the flexor folds. Erythema dyschromicum perstans does not involve mucosal surfaces, where LPP does. In favor of erythema dyschromicum perstans being either a subset of idiopathic lichen planus or a lichenoid drug eruption are reports of lichen planus and erythema dyschromicum perstans occurring in the same patient, the clinical resemblance of erythema dyschromicum perstans to atrophic lichen planus, and similar histologic patterns with immunofluorescence in both erythema dyschromicum perstans and LPP.

The border of an active erythema dyschromicum perstans lesion and the border of an LPP lesion often both show hyperkeratosis, a thinned epidermis, hydropic degeneration of the basal layer, pigment incontinence, and a perivascular lymphohistiocytic infiltrate (see Media Files 3-4). Colloid bodies are occasionally seen in both.

Photomicrograph of a lesion on the patient's back...

Photomicrograph of a lesion on the patient's back shows slight basilar vacuolar change, extensive pigment incontinence, dilatation of dermal lymphatics, and lack of inflammation (hematoxylin & eosin, original magnification X24.8). Reprint with permission from Cutis 1986; 37: 42-44.

[ CLOSE WINDOW ]
Photomicrograph of a lesion on the patient's back...

Photomicrograph of a lesion on the patient's back shows slight basilar vacuolar change, extensive pigment incontinence, dilatation of dermal lymphatics, and lack of inflammation (hematoxylin & eosin, original magnification X24.8). Reprint with permission from Cutis 1986; 37: 42-44.



Higher-power photograph shows slight vacuolar bas...

Higher-power photograph shows slight vacuolar basilar change, marked dilatation of intradermal lymphatics, incontinence of melanin pigment, and lack of inflammation (hematoxylin & eosin, original magnification X238). Reprint with permission from Cutis 1986; 37: 42-44.

[ CLOSE WINDOW ]
Higher-power photograph shows slight vacuolar bas...

Higher-power photograph shows slight vacuolar basilar change, marked dilatation of intradermal lymphatics, incontinence of melanin pigment, and lack of inflammation (hematoxylin & eosin, original magnification X238). Reprint with permission from Cutis 1986; 37: 42-44.


Immunopathologic study of erythema dyschromicum perstans shows immune-associated (Ia) antigen expression in keratinocytes and strong OKT 4 and OKT 6 staining of Langerhans cells. It also shows dermal infiltration by T lymphocytes of both helper-inducer and suppressor-cytotoxic phenotypes, a pattern commonly seen with lichen planus. CD36 expression is evident in the viable upper epidermis on lesional keratinocytes, which may imply a delayed hypersensitivity reaction. Beneath, in the dermis, the cellular infiltrate has been found to express CD69 and the cytotoxic cell marker CD94. In addition, as with lichen planus, the colloid bodies stained immunoglobulin G positive.

More on Erythema Dyschromicum Perstans

Overview: Erythema Dyschromicum Perstans
Differential Diagnoses & Workup: Erythema Dyschromicum Perstans
Treatment & Medication: Erythema Dyschromicum Perstans
Follow-up: Erythema Dyschromicum Perstans
Multimedia: Erythema Dyschromicum Perstans
References
[ CLOSE WINDOW ]

References

  1. Ramirez CO. Los cenicientos: Problema Clinica. Memoria del Primer Congresso Centroamericano de Dermatologica,. 1957;122-130.

  2. Convit J, Kerdel-Vegas F. Erythema dyschromicum perstans a hitherto undescribed skin disease. J Invest Dermatol. 1961;36:457-62.

  3. Berger RS, Hayes TJ, Dixon SL. Erythema dyschromicum perstans and lichen planus: are they related?. J Am Acad Dermatol. Aug 1989;21(2 Pt 2):438-42. [Medline].

  4. Kark EC, Litt JZ. Ashy dermatosis--a variant of lichen planus?. Cutis. Jun 1980;25(6):631-3. [Medline].

  5. Naidorf KF, Cohen SR. Erythema dyschromicum perstans and lichen planus. Arch Dermatol. Sep 1982;118(9):683-5. [Medline].

  6. Penagos H, Jimenez V, Fallas V, O'Malley M, Maibach HI. Chlorothalonil, a possible cause of erythema dyschromicum perstans (ashy dermatitis). Contact Dermatitis. Oct 1996;35(4):214-8. [Medline].

  7. Molinero J, Vilata JJ, Nagore E, Obon L, Grau C, Aliaga A. Ashy dermatosis in an HIV antibody-positive patient. Acta Derm Venereol. Jan-Feb 2000;80(1):78-9. [Medline].

  8. Nelson MR, Lawrence AG, Staughton RC, Gazzard BG. Erythema dyschromicum perstans in an HIV antibody-positive man. Br J Dermatol. Dec 1992;127(6):658-9. [Medline].

  9. Correa MC, Memije EV, Vargas-Alarcon G, et al. HLA-DR association with the genetic susceptibility to develop ashy dermatosis in Mexican Mestizo patients. J Am Acad Dermatol. Apr 2007;56(4):617-20. [Medline].

  10. Carboni I, Costanzo A, Campione E, Paterno EJ, Chimenti S. [Ashy dermatosis: clinico-pathological associations in two cases]. Clin Ter. Sep-Oct 2008;159(5):321-3. [Medline].

  11. Silverberg NB, Herz J, Wagner A, Paller AS. Erythema dyschromicum perstans in prepubertal children. Pediatr Dermatol. Sep-Oct 2003;20(5):398-403. [Medline].

  12. Torrelo A, Zaballos P, Colmenero I, Mediero IG, de Prada I, Zambrano A. Erythema dyschromicum perstans in children: a report of 14 cases. J Eur Acad Dermatol Venereol. Jul 2005;19(4):422-6. [Medline].

  13. Zaynoun S, Rubeiz N, Kibbi AG. Ashy dermatoses--a critical review of the literature and a proposed simplified clinical classification. Int J Dermatol. Jun 2008;47(6):542-4. [Medline].

  14. Mizukawa Y, Shiohara T. Fixed drug eruption presenting as erythema dyschromicum perstans: a flare without taking any medications. Dermatology. 1998;197(4):383-5. [Medline].

  15. Volz A, Metze D, Bohm M, Bruckner-Tuderman L, Nashan D. Idiopathic eruptive macular pigmentation in a 7-year-old girl: case report and discussion of differences from erythema dyschromicum perstans. Br J Dermatol. Oct 2007;157(4):839-40. [Medline].

  16. Srivastava N, Solanki LS, Chand S, Garbyal RS, Singh S. Ashy dermatosis-like pigmentation due to ethambutol. Indian J Dermatol Venereol Leprol. May-Jun 2008;74(3):281-2. [Medline].

  17. Vega ME, Waxtein L, Arenas R, Hojyo T, Dominguez-Soto L. Ashy dermatosis and lichen planus pigmentosus: a clinicopathologic study of 31 cases. Int J Dermatol. Feb 1992;31(2):90-4. [Medline].

  18. Arbiser JL, Moschella SL. Clofazimine: a review of its medical uses and mechanisms of action. J Am Acad Dermatol. Feb 1995;32(2 Pt 1):241-7. [Medline].

  19. Bahadir S, Cobanoglu U, Cimsit G, Yayli S, Alpay K. Erythema dyschromicum perstans: response to dapsone therapy. Int J Dermatol. Mar 2004;43(3):220-2. [Medline].

  20. Baranda L, Torres-Alvarez B, Cortes-Franco R, Moncada B, Portales-Perez DP, Gonzalez-Amaro R. Involvement of cell adhesion and activation molecules in the pathogenesis of erythema dyschromicum perstans (ashy dermatitis). The effect of clofazimine therapy. Arch Dermatol. Mar 1997;133(3):325-9. [Medline].

  21. Combemale P, Faisant M, Guennoc B, Dupin M, Heyraud JD. Erythema dyschromicum perstans: report of a new case and critical review of the literature. J Dermatol. Nov 1998;25(11):747-53. [Medline].

  22. Convit J, Piquero-Martin J, Perez RM. Erythema dyschromicum perstans. Int J Dermatol. Apr 1989;28(3):168-9. [Medline].

  23. Epps RE. Case reports: selected dermatoses in children of color. J Drugs Dermatol. Jan 2007;6(1):78-82. [Medline].

  24. Gellin GA, Hilger R. Erythema dyschromicum perstans (Ashy dermatosis). Arch Dermatol. 1974;110:963.

  25. Gougerot MH. Lichen atypiques ou invisibles pigmentogenes reveles par des pigmentations. Bull Soc Fr Dermatol Syphiligr. 1935;42:792-4.

  26. Gougerot MH. Lichen atypiques ou invisibles pigmentogenes. Bull Soc Fr Dermatol Syphiligr. 1935;42:894-8.

  27. Henderson CD, Tschen JA, Schaefer DG. Simultaneously active lesions of vitiligo and erythema dyschromicum perstans. Arch Dermatol. Aug 1988;124(8):1258-60. [Medline].

  28. Lambert WC, Schwartz RA, Hamilton GB. Erythema dyschromicum perstans. Cutis. Jan 1986;37(1):42-4. [Medline].

  29. Miyagawa S, Komatsu M, Okuchi T, Shirai T, Sakamoto K. Erythema dyschromicum perstans. Immunopathologic studies. J Am Acad Dermatol. May 1989;20(5 Pt 2):882-6. [Medline].

  30. Paradisi M, Mostaccioli S, Celano G, et al. [Erythema dischromicum perstans (ashy dermatosis). Report of two cases]. Pathologica. Sep-Oct 1993;85(1099):533-41. [Medline].

  31. Piquero-Martín J, Perez-Alfonzo R, Abrusci V, et al. Clinical trial with clofazimine for treating erythema dyschromicum perstans. Evaluation of cell-mediated immunity. Int J Dermatol. Apr 1989;28(3):198-200. [Medline].

  32. Ramirez C. The ashy dermatosis (erythema dyschromicum perstans): epidemiological study and report of 139 cases. Cutis. 1967;3:244-7.

  33. Ramirez O, Lopez Lino DG. [Current status of ashy dermatosis. Synonym--erythema dyschromicum perstans]. Med Cutan Ibero Lat Am. 1984;12(1):11-8. [Medline].

  34. Samos-Zielinksa J, Lancucki J. Chronic toxic erythemo-macular skin hyperpigmentation (erythema dyschromicum perstans. Przegl Dermatol. 1978;66:385-91.

  35. Schwartz RA. Erythema dyschromicum perstans: the continuing enigma of Cinderella or ashy dermatosis. Int J Dermatol. Mar 2004;43(3):230-2. [Medline].

  36. Sebbag N, Lacour JP. [Erythema dyschromicum perstans]. Ann Dermatol Venereol. Jan 2006;133(1):79-82. [Medline].

  37. Soter NA, Wand C, Freeman RG. Ultrastructural pathology of erythema dyschromicum perstans. J Invest Dermatol. Feb 1969;52(2):155-62. [Medline].

  38. Tschen JA, Tschen EA, McGavran MH. Erythema dyschromicum perstans. J Am Acad Dermatol. Apr 1980;2(4):295-302. [Medline].

  39. Zenorola P, Bisceglia M, Lomuto M. Ashy dermatosis associated with cobalt allergy. Contact Dermatitis. Jul 1994;31(1):53-4. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

erythema dyschromicum perstans, EDP, ashy dermatosis, dermatosis cenicienta, erythema chronicum figuratum melanodermicum, lichen planus

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Santiago A Centurion, MD, Staff Physician, Department of Dermatology, New Jersey Medical School, University of Medicine and Dentistry of New Jersey
Santiago A Centurion, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Shyam Verma, MBBS, DVD, FAAD, Adjunct Clinical Assistant Professor, Department of Dermatology, University of Virginia, State University of New York at Stonybrook, Penn State University
Shyam Verma, MBBS, DVD, FAAD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey P Callen, MD, Professor of Medicine, 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, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Medicis Honoraria Consulting; Celgene Honoraria Consulting

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.