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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 115-117

Isolated postinflammatory perioral hyperpigmentation: A rare case report


Department of Oral Maxillofacial Pathology, Pushpagiri College of Dental Sciences, Tiruvalla, Kerala, India

Date of Submission29-Apr-2019
Date of Acceptance07-Jan-2020
Date of Web Publication3-Feb-2020

Correspondence Address:
Dr. Tibin K Baby
Department of Oral Maxillofacial Pathology, Pushpagiri College of Dental Sciences, Tiruvalla, Pathanamthitta, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmd.ijmd_28_19

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  Abstract 


Postinflammatory hyperpigmentation (PIH) is an acquired hypermelanosis occurring after cutaneous inflammation or injury that can affect all skin types but more in dark-skinned patients. Etiologies for facial PIH include infections, allergic reactions, papulosquamous diseases such as psoriasis or lichen planus, medication-induced hypersensitivity reactions, and cutaneous injury from irritants, burns, or cosmetic procedures. PIH results from the melanocyte's response to the cutaneous insult causing increased production and/or redistribution of melanin. Literature search could show that this is the first case report on isolated acute perioral PIH following perioral contact dermatitis.

Keywords: Perioral dermatitis; perioral hyperpigmentation; postinflammatory hyperpigmentation


How to cite this article:
Baby TK. Isolated postinflammatory perioral hyperpigmentation: A rare case report. Indian J Multidiscip Dent 2019;9:115-7

How to cite this URL:
Baby TK. Isolated postinflammatory perioral hyperpigmentation: A rare case report. Indian J Multidiscip Dent [serial online] 2019 [cited 2020 Aug 5];9:115-7. Available from: http://www.ijmdent.com/text.asp?2019/9/2/115/277449




  Introduction Top


Postinflammatory hyperpigmentation (PIH) is an acquired hypermelanosis occurring after cutaneous inflammation or injury that can affect all skin types but more frequently affects dark-skinned patients, including African–Americans, Hispanics/Latinos, Asians, Native Americans, Pacific Islanders, and those of Middle-Eastern descent. PIH results from the melanocytes response to the cutaneous insult causing increased production and/or redistribution of melanin.[1]

Etiologies for facial PIH include infections such as dermatophytoses or viral exanthems, allergic reactions from insect bites or contact dermatitis, papulosquamous diseases such as psoriasis or lichen planus, medication-induced hypersensitivity reactions, and cutaneous injury from irritants, burns, or cosmetic procedures.[2] Systemic conditions causing facial noninflammatory hyperpigmentation include Peutz–Jeghers syndrome, Addison's diseases, malignant melanoma, hemochromatosis, thyrotoxicosis, drug eruptions, and ochronosis.[3]

Perioral dermatitis is characterized by erythematous red papules or papulopustules involving skin around the lips, with a characteristic clear zone adjacent to the vermilion border of the lips. In many cases, perioral dermatitis appears to be related to the application of one or more cosmetic preparations, topical corticosteroids, tartar control toothpaste, bubble gum, etc.[4] Simplest form of perioral dermatitis represents a contact dermatitis from repeated wetting and drying of the skin associated with persistent lip licking or thumb sucking, especially during the winter months.[5] Herewith reports a rare case of an isolated acute perioral PIH following perioral contact dermatitis. An extensive literature search could not show any case report on an isolated perioral PIH.


  Case Report Top


A 13-year-old medium complexion healthy boy presented with an asymptomatic blackish circle around the lips for 2 days. Detailed case history taking could reveal that he had a recent history of dry lips along with rash and scaling around the lips following winter. He used to wet his lips with saliva to get rid of dryness. The skin became normal within a week, but blackish pigmentation started appeared on the same area soon. There was no positive history of previous same lesion, systemic/dermatological illness, recent medication, topical applications, or change in toothpaste.

On clinical examination, there was an isolated blackish discoloration of 0.5-cm thick macular circle surrounding his lips, with a characteristic clear zone around the lips [Figure 1]a and [Figure 1]b. The oral mucosa and other areas of the skin were found unaffected. Hence, it was diagnosed with postinflammatory perioral hyperpigmentation following perioral contact dermatitis. The patient was kept under regular follow-up without any treatment as condition can get worsen with topical applications. The patient was advised to avoid lip-licking habit. It remained the same for 2 weeks and started fading slowly. The obvious difference was noted within 3 weeks [Figure 1]c and [Figure 1]d, and it took more than 2 months to become almost normal color [Figure 1] e].
Figure 1: Original photographs showing isolated acute perioral hyperpigmentation (a and b), follow-up after 3 weeks showing fading of the lesion (c and d), follow-up after 2 months showing almost regression of the lesion (e)

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  Discussion Top


Structural and functional variations in the skin, as well as the influence of cultural practices, produce differences in skin disease, its presentation, and treatment. Darker skin phenotypes are characterized by the higher content of melanin, higher eumelanin to pheomelanin ratio, and better distribution of melanin for the protection against ultraviolet (UV) radiation.[6] Biosynthesis of melanin occurs within the melanosome, metabolic unit of the melanocyte where melanin granules are synthesized using the amino acid tyrosine as the major substrate.[7] There are no racial differences in the overall number of melanocytes, and the head and forearm have the highest numbers of melanocytes. Darker skin phenotypes have nonaggregated and larger melanosomes with greater total melanin content. Although the increased melanin in dark skin provides protection from harmful effects of UV radiation, preventing photodamage and skin cancers, it is more vulnerable to postinflammatory dyspigmentation.[7]

PIH typically manifests as macules or patches in the same distribution of prior initial inflammatory process. The location of the excess pigment within the layers of the skin will determine its color. Epidermal hypermelanosis appears as tan, brown, or dark brown and may take months to years to resolve without treatment. While hyperpigmentation within the dermis is due to melanophages, it has a blue-gray clinical appearance. It may be permanent or resolve over a protracted period of time if left untreated.[7],[8] PIH get worsen with UV irradiation or with persistent or recurrent inflammation.[9]

Although the exact mechanism of PIH is unknown, the rise in melanocyte activity has been shown to be stimulated by prostanoids, cytokines, chemokines, and other inflammatory mediators as well as reactive oxygen species that are released during the inflammatory process. Studies have demonstrated the melanocyte-stimulating properties of leukotrienes, prostaglandins E2 and D2, thromboxane-2, interleukin (IL)-1, IL-6, tumor necrosis factor-α, epidermal growth factor, and reactive oxygen species such as nitric oxide.[10]

Although usually a clinical diagnosis, difficult cases can be aided with a biopsy for histopathological evaluation. Disorders such as melasma, morphoea, atrophoderma, fixed drug eruptions, and other rarer etiologies should be considered in patients without evidence of preceding inflammation by history or examination. PIH can take years to resolve and can be psychologically distressing. The management of PIH should begin first with recognizing the underlying inflammatory conditions. Treatments with skin-lightening agents, chemical peeling agents, and lasers can be tried; however, these can cause worsening of the lesion and should always be used with caution.[7]


  Conclusion Top


Although facial hyperpigmentation is common, isolated perioral PIH is a rare lesion that requires a detailed history exploring as well as proper examination to reach the precise diagnosis. A comprehensive knowledge and approach to assessment and treatment are necessary to care properly these lesions. A thorough understanding of the underlying etiologies of hyperpigmentation is essential for the diagnosis and selecting the best treatment options.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chang MW. Disorders of hyperpigmentation. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 2nd ed. Elsevier, Mosby; 2009. p. 333-89.  Back to cited text no. 1
    
2.
Taylor S, Grimes P, Lim J, Im S, Lui H. Postinflammatory hyperpigmentation. J Cutan Med Surg 2009;13:183-91.  Back to cited text no. 2
    
3.
Sreeja C, Ramakrishnan K, Vijayalakshmi D, Devi M, Aesha I, Vijayabanu B. Oral pigmentation: A review. J Pharm Bioallied Sci 2015;7:S403-8.  Back to cited text no. 3
    
4.
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3rd ed. St. Louis: Saunders Elsevier Publications; 2009. p. 252.  Back to cited text no. 4
    
5.
Cohen BC. Padiatric Dermatology. Fourth Edition. Elsevier; 2013. p. 240-63.  Back to cited text no. 5
    
6.
Sharma VK, Sahni K, Wadhwani AR. Photodermatoses in pigmented skin. Photochem Photobiol Sci 2013;12:65-77.  Back to cited text no. 6
    
7.
Vashi NA, Kundu RV. Facial hyperpigmentation: Causes and treatment. Br J Dermatol 2013;169 Suppl 3:41-56.  Back to cited text no. 7
    
8.
Ranu H, Thng S, Goh BK, Burger A, Goh CL. Periorbital hyperpigmentation in Asians: An epidemiologic study and a proposed classification. Dermatol Surg 2011;37:1297-303.  Back to cited text no. 8
    
9.
Kaidbey KH, Agin PP, Sayre RM, Kligman AM. Photoprotection by melanin – A comparison of black and Caucasian skin. J Am Acad Dermatol 1979;1:249-60.  Back to cited text no. 9
    
10.
Davis EC, Callender VD. Postinflammatory hyperpigmentation: A review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol 2010;3:20-31.  Back to cited text no. 10
    


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