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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 56-58

Exaggerated physiological hyperpigmentation of pregnancy in the post-partum period


Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission06-Aug-2019
Date of Decision06-Dec-2019
Date of Acceptance25-Feb-2020
Date of Web Publication10-Jul-2020

Correspondence Address:
Dr. Preema Sinha
Department of Dermatology, Armed Forces Medical College, Pune-411040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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  Abstract 


Hyperpigmentation during pregnancy is commonly due to endocrinological changes. The pigmentation generally fades away in a few months post-partum. However sometimes it may persist for longer periods causing distress to the patient. Here we report one such case where the pigment persisted for more than a year.

Keywords: Physiological pigmentation in pregnancy, persistent


How to cite this article:
Sinha P, Verma R, Bhattacharjee S, Sinha A. Exaggerated physiological hyperpigmentation of pregnancy in the post-partum period. Pigment Int 2020;7:56-8

How to cite this URL:
Sinha P, Verma R, Bhattacharjee S, Sinha A. Exaggerated physiological hyperpigmentation of pregnancy in the post-partum period. Pigment Int [serial online] 2020 [cited 2020 Aug 14];7:56-8. Available from: http://www.pigmentinternational.com/text.asp?2020/7/1/56/289338




  Introduction Top


Hyperpigmentation during pregnancy is commonly due to endocrinological changes.[1] Extensive hyperpigmentation, however, is unusual, especially in people with dark coloured skin. The exact cause of physiologic hyperpigmentation is not known. The physiology of hyperpigmentation appears to be related to the increased production of oestrogens, increased levels of progesterone or a melanocyte-stimulating hormone. In pregnancy, hypertrophy of the intermediate lobe of the pituitary gland occurs due to the increased metabolism of proopiomelanocortin to µ-melanotropin.[1],[2] Such hyperpigmentation may sometimes be associated with hyperthyroidism.[3]


  Case report Top


A 22-year-old primipara presented to our dermatology department worried about persisting darkening of skin over the abdomen and thighs six months after delivery of her baby. Her antenatal record was unremarkable except for this unusual onset of abnormal skin colour over the neck, breasts, abdomen and thighs since the fourth month of gestation. The darkening was not associated with itching or irritation of the skin. She had no previous history of allergies or skin ailments. She was not on any medication except for iron and folic acid tablets prescribed during antenatal consultations. Her past medical history was unremarkable with no history suggestive of thyroid disorders.

Findings from her physical examination were unremarkable, and she had a normal blood pressure of 120/70 mmHg. Dermatological examination revealed that her abdominal skin had darkly coloured, diffuse, deep hyperpigmentation extending onto the thighs. Multiple striae were noted over the abdomen and thighs [Figure 1]. Other examination findings were unremarkable. A provisional diagnosis of exaggerated pigmentation of pregnancy persisting onto post-partum period was considered at this stage. The evaluation for thyroid dysfunction and abnormal serum B12 levels in the patient were normal. Patient was unwilling for skin biopsy. Patient was counselled regarding the condition and was reviewed monthly. After one-year post-partum marked decrease occurred in colour of the hyperpigmented lesions [Figure 2].
Figure 1 Persisting hyerpigmentation over abdomen and thighs at six months post-partum.

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Figure 2 Marked decrease in hyperpigmention over abdomen and thighs at one year post-partum.

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  Discussion Top


Skin hyperpigmentation is common in pregnancy, well described in literature and completely benign in nature.[2] [Table 1] enumerates the common pigmentary changes seen in pregnancy. Kumari R et al in their clinical study on skin changes in pregnancy found that pigmentary changes were the most common physiological changes, seen in nearly 91% of pregnant ladies whereas generalized darkening of skin was reported in 0.66% cases.[4]
Table 1 Pigmentary changes seen in pregnancy

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The exact pathogenesis for hyperpigmentation and its distribution remain elusive till date and evades complete explanation. Hyperpigmentation in pregnancy is attributed to an increased level of placental, pituitary, and ovarian hormones namely, melanocyte stimulating hormone, oestrogen, progesterone, and bioactive sphingolipids derived from the placenta.[1],[2],[3],[4],[5],[6] Blood levels of progesterone depict a constant increment during pregnancy. Blood levels of oestrogen rises from the 8th week and begins to decline after the 30th week of pregnancy. This pattern follows the progression of hyperpigmentation. Increased density of epidermal melanocytes and the upregulation of tyrosinase by human placental lipids may also contribute to pigmentation.[7] The placenta was found to be rich in bioactive sphingolipids, which were found to induce melanogenesis by upregulating the expression of various melanogenic enzymes − tyrosinase and tyrosinase-related proteins 1 and 2 at the translational and transcriptional levels.[7]

The relative hypersensitivity to hormonal stimulation of certain body areas more than others is the explanation offered by Wade et al.[1] to account for the disproportionate increase in hyperpigmentation in these areas during gestation. Appearance of the linea nigra, a band like area of pigmentary change, running vertically in the midline between the xiphoid process upto the pubic symphysis is the most frequently occurring physiological pigmentary change associated with pregnancy. Other parts of the body that may show this hypermelanosis are the regions in and around the areolae and the nipples, axillary fossae, vulvo-vaginal region, perineum, perianal region, medial aspects of the thigh, the nuchal region and scars of recent onset; ephelides or lentigines may show darkening.[1],[2],[3]

Gradual achromatisation of the pigmentation after delivery is usual but may fail to occur completely in a few cases.[2] The intensity of hyperpigmentation may be related to environmental factors or even intake of some drugs and other factors include pre-existing conditions like hyperthyroidism and a genetic predisposition to increased pigmentation.[1],[2] In hyperthyroidism the pattern of hyperpigmentation is generally a diffuse brown Addisonian pigmentation or pigmentation may be localised to the face, neck and palmar creases.[8] The pigmentation seen in Vit B12 deficiency has a mottled appearance usually affecting the face, hands especially knuckles and nails.[9]


  Conclusion Top


Skin hyperpigmentation is common in pregnancy, however, intense hyperpigmentation, as in this case, is rare and has been infrequently reported. Patients may be cosmetically concerned, but reassurance and conservative management may be all that is required to allay a patient’s anxiety.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wade TR, Wade SL, Jones HE. Skin changes and diseases associated with pregnancy. Obstet Gynecol 1978;52:233-42.  Back to cited text no. 1
    
2.
Ingber A. Hyperpigmentation and melasma. In Lebwohl M, editor. Obstetric Dermatology. Springer 2009 7-17.  Back to cited text no. 2
    
3.
Massinde A, Ntubika S, Magoma M. Extensive hyperpigmentation during pregnancy: a case report. J Med Case Reports 2011;5:464.  Back to cited text no. 3
    
4.
Kumari R, Jaishankar TJ, Thappa DM. A clinical study of skin changes in pregnancy. Indian J Dermatol Venereol Leprol 2007;73:141.  Back to cited text no. 4
  [Full text]  
5.
Tunzi M, Gray GR. Common skin conditions during pregnancy. Am Fam Physician 2007;75:211-8.  Back to cited text no. 5
    
6.
Muzzafar F, Hussain I, Haroon TS. Physiological skin changes during pregnancy: a study of forty cases. Int J Dermatol 1998;37:429-31.  Back to cited text no. 6
    
7.
Mallick S, Singh SK, Sarkar C, Saha B, Bhadra R. Human placental lipid induces melanogenesis by increasing the expression of tyrosinase and its related proteins in vitro. Pigment Cell Res 2005;18:25-33.  Back to cited text no. 7
    
8.
Banba K, Tanaka N, Fujioka A, Tajima S. Hyperpigmentation caused by hyperthyroidism: differences from the pigmentation of Addison’s disease. Clin Exp Dermatol 1999;24:196-8.  Back to cited text no. 8
    
9.
Mori K, Ando I, Kukita A. Generalized hyperpigmentation of the skin due to vitamin B12 deficiency. J Dermatolol 2001;28:282-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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