Laser treatment of imipramine-induced hyperpigmentation

Drug-Induced Pigmentation: A Review

Drug-induced pigmentation (DIP) is estimated to account for 20% of all cases of acquired hyperpigmentation. Over 50 agents have been implicated, including antibiotics, antimalarials, antiretrovirals, antipsychotics, prostaglandin analogs, heavy metals, and chemotherapeutic agents. The skin, mucosal surfaces, nails, and hair can all be affected, with the color, distribution, onset, and duration of pigmentation varying between offending agents. Both a thorough physical examination and medication history are necessary to determine the offending agent. In terms of mechanism, DIP occurs most frequently through the accumulation of melanin within the dermis but also by drug accumulation, pigment synthesis, and iron deposition. Photoprotection, including applying a broad-spectrum sunscreen, wearing photoprotective clothing, and seeking shade, plays an important role in the prevention of exacerbation of DIP. Multiple lasers, including the picosecond alexandrite, Q-switched Nd:YAG, Q-switched alexandrite, and Q-switched ruby lasers, have been successful in obtaining clearance of DIP. In this review, we examine the unique characteristics of each of the inciting agents in terms of incidence, clinical presentation, time to onset and resolution, and pathogenesis.

Novel hyperpigmentation pathophysiology following a prolonged course of imipramine therapy

Imipramine is a tricyclic antidepressant typically reserved for patients with treatment-resistant mood disorders. A rare side effect of long-term use of imipramine is a slowly progressive melanin-associated, slate gray-blue hyperpigmentation of the skin in a photo-distributed pattern. We report a case of imipramine-induced hyperpigmentation developing 50 years after initiating imipramine therapy, whose lesions were essentially devoid of melanin on histopathological exam. This differs from all other reported cases of imipramine-induced hyperpigmentation in two notable respects. First, the time between initiating imipramine therapy and the onset of pigmentation changes was nearly 30 years longer than prior case reports. Second, the lack of melanin in our samples suggests a divergence from the hypothesized melanin-imipramine complex mechanism of hyperpigmentation. Instead, we propose a novel pathogenesis of imipramine-induced hyperpigmentation that is unrelated to melanin.

Tricyclic antidepressant-induced photosensitivity; A case report and systematic review

BACKGROUND/PURPOSE

Tricyclic antidepressants (TCAs) are still widely used and are available to purchase without prescription in some countries. Awareness of adverse cutaneous drug reactions is essential.

METHOD

We reported a case of photo-distributed hyperpigmentation due to imipramine and carried out a systematic search of the related articles using the search terms "tricyclic antidepressants" or "tricyclic antidepressive agents", and "hyperpigmentation" or "photosensitivity disorder". Fifty non-duplicate citations were identified of which 28 articles which were independently assessed in full. The review was registered in PROSPERO, CRD42018107338.

RESULTS

The remaining 25 articles met our inclusion criteria. Photo-distributed hyperpigmentation tricyclic antidepressant-induced photosensitivity reactions (TIPs) was the most common presentation. In 21 cases, this presented as an asymptomatic discolouration of exposed sites. Imipramine (81%), amitriptyline (9.5%), desipramine hydrochloride (4.8%) and mirtazapine (4.8%) were reported to be the culprit drugs. Nineteen were female with a mean age at presentation of 55 years. Mean duration from commencing the culprit drug until the development of discolouration was 10.4 years. Mean daily dose was 222.7 mg for imipramine. Histology was characteristic with golden-brown or brownish granules deposited in dermis. Staining for Masson-Fontana and MEL-5 was positive in all cases. Phototesting had not been done in cases prior to ours (negative 3 months after discontinuation of imipramine). Three further reports of suspected TIP presented with non-specific and eczematous eruption. The two presentations were reported along with systemic problems (thrombocytopenia and hepatic injury).

CONCLUSIONS

This systematic review highlights the characteristic features of exposed site hyperpigmentation of TCA-induced photosensitivity occurring after prolonged drug exposure in many cases.

[Treatment of pigmentation disorders in association with systemic diseases]

Pigmentation disorders are a frequent skin problem and incorporate a broad spectrum of diseases, caused by an abnormal melanin pigmentation or also non-melanin pigmentation of the skin. Both hypermelanosis and hypomelanosis can be hereditary or acquired. This article summarizes the treatment approaches that are used in the majority of acquired pigmentation disorders of the skin. The following forms of hypermelanosis are addressed: lentiginosis, hyperpigmentation due to endocrine disorders or other systemic diseases, drug-induced hyperpigmentation. Acquired hypomelanoses include postinflammatory hypomelanosis, chemical depigmentation, idiopathic guttate hypomelanosis and punctate leucoderma. With reference to non-melanin pigmentation, the exogenous pigmentation due to chemicals, metals and drug exposure are discussed. The treatment is primarily based on finding the cause of the alterations to the pigment. The affected area, age and ethnic origin are also important factors. The spectrum of therapeutic options is broad: topical agents, chemical peeling, systemic agents, laser and light-based treatment. As some of these treatment procedures can have side effects, the availability of a protocol that contains information on the drug concentration, dose, parameters for laser treatment and the number of sessions is important. For every disorder the specific dermatological treatment is presented even when some pigmentation alterations that occur in association with systemic diseases, are cured by the treatment of the primary disease. Most diseases are exacerbated by exposure to UV light. Therefore, sun protection is recommended and a cosmetic coverage is indicated.

Imipramine-Induced Facial Pigmentation: Case Report and Literature Review

Background:

Patients who present with facial pigmentation can be a diagnostic challenge. ObjectiveThe goal of this study was to discuss the diagnosis and management of imipramine-induced facial pigmentation.

Methods:

We describe a patient with facial pigmentation of 26 years' duration that was associated with imipramine treatment for depression. We discuss light and election microscopic findings and review 11 previously reported cases of imipramine-induced skin pigmentation.

Results:

Examination showed blue-gray facial pigmentation. Light microscopy showed perivascular pigment granule deposits in the upper dermis that stained positively with Fontana–Masson stain and negatively with Prussian blue stain. Electron microscopy showed electron-dense bodies within histiocytes without clearly identifiable melanin granules, consistent with drug-induced pigmentation. Six weeks after switching to sertraline the patient reported a slight improvement of her cutaneous pigmentation.

Conclusion:

Imipramine is a rare cause of gray-blue facial pigmentation. Light microscopy consistently shows granular dermal deposits that stain positively with Fontana-Masson stain but negatively with iron stain.

Psychiatric medications: adverse cutaneous drug reactions

Psychiatric medications are among the most widely prescribed medications in the United States. Adverse cutaneous drug reactions are associated with psychiatric medications in approximately 2% to 5% of the individuals for whom they are prescribed. Although most adverse cutaneous drug reactions associated with psychotropic medications are benign and easily treated, some can be disfiguring or life-threatening, particularly those associated with the mood stabilizers. Adverse cutaneous drug reactions associated with antidepressants, antipsychotics, and mood stabilizers are reviewed, and important issues that are of concern for the dermatologist who must consider when and how to safely discontinue a psychotropic medication in their patients are presented.

Imipramine-induced hyperpigmentation: a case report and review of the literature

Imipramine-induced hyperpigmentation is rare with only 13 cases reported in the literature to date. We report a 64-year-old female who presented with blue-gray discoloration on her face present for 4-5 years. The patient's medications included imipramine for depression for approximately 23 years. Physical examination revealed slate-gray hyperpigmented discrete and coalescing macules of the malar cheeks and the bilateral temples and periorbitally. She also had diffuse gray pigmentation of the bilateral dorsal hands. Histologic examination revealed an unremarkable epidermis with golden-brown round globules clustered in the superficial dermis, which stained strongly positive with a Fontana-Masson stain. Prussian blue stain for hemosiderin was negative. A diagnosis of imipramine-induced hyperpigmentation was made. Imipramine-induced hyperpigmentation as well as a detailed review of drug-induced hyperpigmentation is discussed.

Minocycline-Induced Hyperpigmentation Treated with a 755-nm Q-Switched Alexandrite Laser

BACKGROUND

Cutaneous pigmentation associated with minocycline therapy is an unusual adverse effect for which few successful treatments have been described. The pigment changes may persist for years, despite cessation of therapy, and is often cosmetically disfiguring, causing significant embarrassment and psychological depression in those affected. Few safe and effective treatments have been described in the past; however, recent pigment-specific laser technology has shown promise in the treatment of this condition.

OBJECTIVE

The objective was to describe a series of patients with minocycline-induced hyperpigmentation who were successfully treated with a 755-nm Q-switched alexandrite laser.

METHODS

Six patients with minocycline-induced hyperpigmentation on the face or legs were treated with a Q-switched alexandrite laser on a bimonthly basis until pigmentation was eradicated.

RESULTS

Cutaneous pigmentation resolved completely in all patients in an average of four laser sessions. Side effects were limited to transient purpura and mild desquamation without scarring or dyspigmentation.

CONCLUSION

Minocycline-induced cutaneous pigmentation can be effectively cleared without risk of adverse sequelae by Q-switched alexandrite (755-nm) laser irradiation.

Síndrome de Peutz-Jeghers: tratamento da lentiginose oral com laser Alexandrita

Descreve-se o caso de uma paciente de 10 anos de idade, com síndrome de Peutz-Jeghers, que há oito anos apresentava manchas escuras nos lábios. As lesões da mucosa oral foram tratadas com laser de Alexandrita 755 nm, de pulso longo(3ms),com bons resultados estéticos.

Imipramine-associated hyperpigmentation

OBJECTIVE

To inform clinicians of the potential for severe and persistent facial hyperpigmentation with the long-term use of imipramine.

CASE SUMMARY

A 65-year-old white male veteran with a history of paranoid schizophrenia was referred to the psychiatry service by a dentist who thought that the patient was both cyanotic and psychotic. The history and biopsy results indicated the possibility of imipramine-associated hyperpigmentation, only the second reported case in a male patient. The presentation was complex, with a history of neuroleptic exposure and multiple signs of parkinsonism. A brain single photon-emission computed tomography scan demonstrated frontal lobe hypermetabolism and bilateral caudate hypermetabolism, which normalized 14 months later. Despite discontinuation of imipramine, the patient continued to appear cyanotic, leading to worsening social isolation. He became known as "the man with the purple face." On his rare ventures outside the home, he was embarrassed by sporadic calls to 911 by persons fearing he was ill.

DISCUSSION

Although facial hyperpigmentation secondary to the use of phenothiazines has been reported frequently, it is much less common with imipramine, and is very rare in males. Failure to recognize this adverse reaction led to continuing treatment with imipramine and to an apparently irreversible condition. The brain imaging findings have no link with the hyperpigmenting process, but raise questions about neuroleptic-induced metabolic changes in the brain.

CONCLUSIONS

Clinicians need to be aware of rare adverse reactions such as hyperpigmentation, and be prepared to take appropriate and early action to prevent such reactions from becoming irreversible.

Drug-induced skin pigmentation. Epidemiology, diagnosis and treatment

Drug-induced pigmentation represents 10 to 20% of all cases of acquired hyperpigmentation and this hypothesis must be systematically raised in unexplained pigmented lesions especially in elderly people. The pathogenesis of drug-induced pigmentation is variable according to the causative medication and can involve an accumulation of melanin, sometimes following a nonspecific cutaneous inflammation and often worsened by sun exposure, an accumulation of the triggering drug itself, a synthesis of special pigments under the direct influence of the drug or deposits of iron following damage to the dermal vessels. The influence of sun exposure is usually obvious in most cases, either by sun-induced melanin synthesis stimulation with formation of complexes between melanin and the causative drug or by transformation of the drug in visible particles usually taken up by dermal macrophages under the influence of sunlight. The main drugs implicated in causing skin pigmentation are nonsteroidal anti-inflammatory drugs, antimalarials, amiodarone, cytotoxic drugs, tetracyclines, heavy metals and psychotropic drugs. Clinical features are very variable according to the triggering molecule, with a large range of patterns and shades which are sometimes more or less reminiscent of the culprit drug. Histological findings are very variable as well but the colored particles are often concentrated within dermal macrophages which are sometimes localized in a distinctive fashion with respect to dermal structures such as vessels or adnexes. Treatment is often limited to sun-avoidance or interruption of treatment with the offending drug but laser therapy recently gave rise to hope of a cure in some cases. These measures are often followed by a fading of the lesions but the pigmentation may last for a long time or may even become permanent in a small percentage of patients.