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Tisack A, Mohammad TF. Drug-Induced Pigmentation: A Review. Drugs 2024; 84:1071-1091. [PMID: 39085684 DOI: 10.1007/s40265-024-02062-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 08/02/2024]
Abstract
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.
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Affiliation(s)
- Aaron Tisack
- Department of Dermatology, Henry Ford Health, 3031 W Grand Blvd, Detroit, MI, 48202, USA
| | - Tasneem F Mohammad
- Department of Dermatology, Henry Ford Health, 3031 W Grand Blvd, Detroit, MI, 48202, USA.
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Peng JP, Yang XY, Luo F, Yuan XM, Xiong H, Ma WK, Yao XM. Hydroxychloroquine-induced hyperpigmentation of the skin and bull's-eye maculopathy in rheumatic patients: a case report and literature review. Front Immunol 2024; 15:1383343. [PMID: 38660312 PMCID: PMC11039820 DOI: 10.3389/fimmu.2024.1383343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
Hydroxychloroquine (HCQ) is used as a traditional disease-modifying antirheumatic drugs (DMARDs), for the treatment of autoimmune diseases such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). However, it can cause serious adverse reactions, including hyperpigmentation of the skin and bull's-eye macular lesions. Here, we present a case of HCQ-induced hyperpigmentation of the skin and bull's-eye macular lesions in a patient who received HCQ for RA. A 65-year-old female patient developed blurred vision and hyperpigmentation of multiple areas of skin over the body for one month after 3 years of HCQ treatment for RA. Based on clinical presentation, ophthalmological examination and dermatopathological biopsy, a diagnosis of drug-induced cutaneous hyperpigmentation and bullous maculopathy of the right eye was made. After discontinuation of HCQ and treatment with iguratimod tablets, the hyperpigmentation of the patient 's skin was gradually reduced, and the symptoms of blurred vision were not significantly improved. We also reviewed the available literature on HCQ-induced cutaneous hyperpigmentation and bull's-eye macular lesions and described the clinical features of HCQ-induced cutaneous hyperpigmentation and bull's-eye macular lesions. In conclusion, clinicians should be aware of early cutaneous symptoms and HCQ-associated ophthalmotoxicity in patients with rheumatic diseases on HCQ sulphate and should actively monitor patients, have them undergo regular ophthalmological examinations and give appropriate treatment to prevent exacerbation of symptoms.
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Affiliation(s)
- Ji-peng Peng
- Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Xiao-yu Yang
- Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Feng Luo
- Guizhou University of Traditional Chinese Medicine, Guiyang, China
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Xue-mei Yuan
- Guizhou University of Traditional Chinese Medicine, Guiyang, China
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Hong Xiong
- Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Wu-kai Ma
- Guizhou University of Traditional Chinese Medicine, Guiyang, China
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Xue-ming Yao
- Guizhou University of Traditional Chinese Medicine, Guiyang, China
- Department of Rheumatology and Immunology, Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
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Kwak D, Grimes PE. A case of hyperpigmentation induced by hydroxychloroquine and quinacrine in a patient with systemic lupus erythematosus and review of the literature. Int J Womens Dermatol 2020; 6:268-271. [PMID: 33015284 PMCID: PMC7522856 DOI: 10.1016/j.ijwd.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 05/20/2020] [Accepted: 06/24/2020] [Indexed: 11/26/2022] Open
Abstract
Hydroxychloroquine (HQ) and quinacrine are widely used antimalarials for systemic lupus erythematosus (SLE) and other autoimmune diseases. We report a case of antimalarial-induced hyperpigmentation in a 57-year old African-American woman. The patient had a long-standing history of SLE that was treated with HQ and quinacrine in varying doses for 16 years. The disease improved considerably and entered remission; however, the patient subsequently developed severe, disseminated hyperpigmentation on her face, trunk, upper and lower extremities. A malar facial biopsy revealed numerous perivascular and scattered interstitial, heavily pigment laden dark brown to black macrophages. The Fontana Masson staining was positive for melanin, and Perl’s stain for iron was negative. This staining pattern, to our knowledge, has only been reported once before in the literature. Our patient represents a rare case of severe recalcitrant hyperpigmentation induced by combination HQ and quinacrine therapy for SLE.
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Affiliation(s)
- Daniel Kwak
- Vitiligo & Pigmentation Institute of Southern California, Los Angeles, CA, United States
| | - Pearl E Grimes
- Vitiligo & Pigmentation Institute of Southern California, Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
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Leung AK, McMillan T, Human A, Lam JM. Hydroxychloroquine-induced hyperpigmentation in a 14-year-old female with systemic lupus erythematosus. Drugs Context 2020; 9:dic-2020-5-8. [PMID: 32742294 PMCID: PMC7375853 DOI: 10.7573/dic.2020-5-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/17/2020] [Accepted: 06/24/2020] [Indexed: 11/21/2022] Open
Abstract
Hydroxychloroquine (HCQ)-induced hyperpigmentation is uncommon but is increasingly recognized. To our knowledge, HCQ-induced hyperpigmentation has not been reported in the pediatric age group. Herein, we present the case of a 14-year-old girl with systemic lupus erythematosus, who developed hyperpigmentation on her shins and dorsum of the left foot, approximately 3 years after initiating treatment with HCQ. Physicians who treat children with HCQ for reasons such as rheumatologic disorders, dermatologic disorders and, more recently, coronavirus disease-19 should be aware of this less-known side effect of HCQ.
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Affiliation(s)
- Alexander Kc Leung
- The University of Calgary, The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Tara McMillan
- British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrea Human
- British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph M Lam
- Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Sharma AN, Mesinkovska NA, Paravar T. Characterizing the adverse dermatologic effects of hydroxychloroquine: A systematic review. J Am Acad Dermatol 2020; 83:563-578. [DOI: 10.1016/j.jaad.2020.04.024] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/31/2020] [Accepted: 04/04/2020] [Indexed: 11/26/2022]
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Abstract
Drug-induced pigmentation accounts for up to 20% of all cases of acquired pigmentation. A thorough review of medical history and previous and ongoing medications as well as a complete skin examination can guide diagnosis. Implicated agents include alkylating/cytotoxic agents, analgesics, antiarrhythmics, anticoagulants, antiepileptics, antimalarials, antimicrobials, antiretrovirals, metals, prostaglandin analogs, and psychotropic agents, among others. Confirming true drug associations can be challenging, especially in the setting of delayed onset of pigmentation and coexisting polypharmacy.
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Affiliation(s)
- Amanda F Nahhas
- Department of Dermatology, Beaumont-Farmington Hills, Farmington Hills, MI, USA
- Department of Dermatology, Henry Ford Hospital, 3031 W. Grand Blvd., Suite 800, Detroit, MI, 48202, USA
| | - Taylor L Braunberger
- Department of Dermatology, Henry Ford Hospital, 3031 W. Grand Blvd., Suite 800, Detroit, MI, 48202, USA
| | - Iltefat H Hamzavi
- Department of Dermatology, Henry Ford Hospital, 3031 W. Grand Blvd., Suite 800, Detroit, MI, 48202, USA.
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Abstract
Pigmented deposits can occur in the skin due to many and varied causes. Some of them are systemic conditions accompanied by involvement of internal organs. Others have serious prognostic implications, and early diagnosis can help in the correct and adequate management of the diseases. In addition, some of them are quite innocuous and the correct diagnosis avoids unnecessary treatments. In this article, we review the morphologic features of some of the most common and some of the less usual pigmented deposits in skin other than tattoos.
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Lau JF, Dean SM, Rooke TW, Olin JW. Serpentine supravenous hyperpigmentation due to hydroxychloroquine. Vasc Med 2016; 21:558-559. [DOI: 10.1177/1358863x16650276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Joe F Lau
- Northwell Health, Long Island Jewish Medical Center and North Shore University Hospital, Department of Cardiology, Hofstra Northwell School of Medicine, New Hyde Park, NY, USA
| | - Steven M Dean
- Department of Cardiovascular Medicine, Davis Heart Lung Institute, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thom W Rooke
- Division of Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey W Olin
- Zena and Michael A. Wiener Cardiovascular Institute & Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
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Joo K, Park W, Kwon SR, Lim MJ, Jung KH. Improvement of vitiligo in a patient with rheumatoid arthritis after hydroxychloroquine treatment. Int J Rheum Dis 2014; 18:679-80. [PMID: 25243922 DOI: 10.1111/1756-185x.12442] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kowoon Joo
- Division of Rheumatology, Department of Internal Medicine, Inha University Hospital, Incheon, Korea
| | - Won Park
- Division of Rheumatology, Department of Internal Medicine, Inha University Hospital, Incheon, Korea
| | - Seong Ryul Kwon
- Division of Rheumatology, Department of Internal Medicine, Inha University Hospital, Incheon, Korea
| | - Mie Jin Lim
- Division of Rheumatology, Department of Internal Medicine, Inha University Hospital, Incheon, Korea
| | - Kyong-Hee Jung
- Division of Rheumatology, Department of Internal Medicine, Inha University Hospital, Incheon, Korea
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Hydroxychloroquine-associated hyperpigmentation mimicking elder abuse. Dermatol Ther (Heidelb) 2013; 3:203-10. [PMID: 24318415 PMCID: PMC3889308 DOI: 10.1007/s13555-013-0032-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Indexed: 12/04/2022] Open
Abstract
Background Hydroxychloroquine may result in cutaneous dyschromia. Older individuals who are the victims of elder abuse can present with bruising and resolving ecchymoses. Purpose The features of hydroxychloroquine-associated hyperpigmentation are described, the mucosal and skin manifestations of elder abuse are reviewed, and the mucocutaneous mimickers of elder abuse are summarized. Case Report An elderly woman being treated with hydroxychloroquine for systemic lupus erythematosus developed drug-associated black and blue pigmentation of her skin. The dyschromia was misinterpreted by her clinician as elder abuse and Adult Protective Services was notified. The family was eventually cleared of suspected elder abuse. A skin biopsy of the patient’s dyschromia confirmed the diagnosis of hydroxychloroquine-associated hyperpigmentation. Conclusion Hyperpigmentation of skin, mucosa, and nails can be observed in patients treated with antimalarials, including hydroxychloroquine. Elder abuse is a significant and underreported problem in seniors. Cutaneous findings can aid in the discovery of physical abuse, sexual abuse, and self-neglect in elderly individuals. However, medication-associated effects, systemic conditions, and accidental external injuries can mimic elder abuse. Therefore, a complete medical history and appropriate laboratory evaluation, including skin biopsy, should be conducted when the diagnosis of elder abuse is suspected.
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Skare T, Ribeiro CF, Souza FHM, Haendchen L, Jordão JM. Antimalarial cutaneous side effects: a study in 209 users. Cutan Ocul Toxicol 2010; 30:45-9. [DOI: 10.3109/15569527.2010.521225] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jallouli M, Leroux G, Halabi-Tawil M, Morel N, Francès C, Piette JC, Amoura Z, Costedoat-Chalumeau N. Une pigmentation cutanée chez une patiente lupique. Rev Med Interne 2010; 31:566-7. [DOI: 10.1016/j.revmed.2010.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 02/28/2010] [Indexed: 11/28/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2008. [DOI: 10.1002/pds.1492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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