Photoclinic: Erythema Dyschromicum Perstans

Numerous flat, brown lesions with sharp, irregular borders had been present on the upper extremities, abdomen, back, and the proximal legs and neck of a 28-year-old woman for 4 months. The asymptomatic lesions—some with a narrow, slightly raised halo—were more pronounced on the anterior and posterior trunk. Robert P. Blereau, MD, of Morgan City, La, performed an excisional biopsy of an entire lesion with halo under local anesthesia. The pathologic microscopic diagnosis was erythema dyschromicum perstans. Periodic acid–Schiff and Gomori methenamine silver stains were negative for fungi. Erythema dyschromicum perstans (ashy dermatosis, dermatosis cenicienta) consists of slowly progressive, asymptomatic, ash-colored or brown macules and papules that measure a few millimeters to several centimeters. The condition occurs worldwide—although it is most prevalent in Latin America—and usually develops before 40 years of age. Although there is predilection for the trunk, the lesions may be widespread and are symmetric throughout the body. Nails and mucosa are not affected. The course is chronic. The differential diagnosis includes fixed drug eruption, urticaria pigmentosa, lichen planus, pediculosis (maculae ceruleae), argyria, Addison disease, hemochromatosis, pinta (carate), tinea versicolor, erythema annulare centrifugum, and erythema gyratum.1  Erythema dyschromicum perstans is considered a variant of lichen planus.2  Since both lesions have occurred simultaneously in the same patient with similar immunopathologic findings, some believe lichen planus pigmentosus to be the same condition.3-5 Histologically, there is a lichenoid tissue reaction with basal vacuolar changes, occasional Civatte bodies, and prominent pigment incontinence (especially in older patients).6  A bandlike inflammatory infiltrate in the superficial epidermis is present at the active border. Immunofluorescence has shown IgM, IgG, and complement that contains colloid bodies in the dermis. Electron microscopy shows apoptosis and residual filamentous bodies.6 Treatment with oral dapsone or clofazimine for several months has been helpful.7  More than 50% of clofazimine-treated patients report complete resolution.8 High-potency topical corticosteroids may produce a response. Use of sunless tanning products may be of cosmetic value. This patient was treated with oral clofazimine, 100 mg once daily. After 4 months, the lesions have almost completely resolved. REFERENCES: 1. Nelson BR, Ramsey ML, Bruce S, et al. Asymptomatic progressive hyperpigmentation in a 16-year-old girl. Erythema dyschromicum perstans. Arch Dermatol. 1988;124:769, 772. 2. Bhutani LK. Ashy dermatosis or lichen planus pigmentosus: what is in a name? Arch Dermatol. 1986;122:133. 3. Novick NL, Phelps R. Erythema dyschromicum perstans. Int J Dermatol. 1985;24:630-633. 4. Miyagawa S, Komatsu M, Okuchi T, et al. Erythema dyschromicum perstans. Immunopathologic studies. J Am Acad Dermatol. 1989;20(5 pt 2):882-886. 5. Tschen JA, Tschen EA, McGavran MH. Erythema dyschromicum perstans. J Am Acad Dermatol. 1980;2:295-302. 6. Person JR, Rogers RS 3rd. Ashy dermatosis. An apoptotic disease? Arch Dermatol. 1981;117:701-704. 7. Kontochristopoulos G, Stavropoulos P, Panteleos D, Aroni K. Erythema dyschromicum perstans: response to dapsone therapy. Int J Dermotol. 1998;37: 796-798. 8. Piquero-Martin 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. 1989;28:198-200.