Pigment International

: 2016  |  Volume : 3  |  Issue : 1  |  Page : 54--55

Hyperpigmented skin lesions in a chronic renal failure patient: A diagnostic dilemma

P Arunprasath, Sneha Varghese, Sivasubramanian Vadivel 
 Department of Dermatology and STD, Vinayaka Missions Medical College and Hospital, Karaikal, Puducherry, India

Correspondence Address:
P Arunprasath
Department of Dermatology and STD, Vinayaka Missions Medical College and Hospital, Karaikal, Puducherry

How to cite this article:
Arunprasath P, Varghese S, Vadivel S. Hyperpigmented skin lesions in a chronic renal failure patient: A diagnostic dilemma.Pigment Int 2016;3:54-55

How to cite this URL:
Arunprasath P, Varghese S, Vadivel S. Hyperpigmented skin lesions in a chronic renal failure patient: A diagnostic dilemma. Pigment Int [serial online] 2016 [cited 2020 Jun 4 ];3:54-55
Available from: http://www.pigmentinternational.com/text.asp?2016/3/1/54/184249

Full Text


A 40-year-old male, chronic renal failure patient on dialysis presented with multiple asymptomatic hyperpigmented skin lesions of 2 weeks duration. Examination revealed multiple hyperpigmented lesions in a reticulate pattern involving the chest and back [Figure 1] and [Figure 2] and as diffuse patches involving the nape of the neck and both arms and forearms [Figure 3] and [Figure 4]. A diagnosis of tinea versicolor was considered, but scrapings examined with KOH were found to be negative for fungal hyphae. However, on wiping the lesions with spirit soaked cotton, the lesions got cleared instantly culminating in a diagnosis of terra-firma forme dermatosis (TFFD) [Figure 5].{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}

Duncan et al., 1987, described TFFD in Houston and hence is also referred to as Duncan's dirty dermatosis.[1] TFFD derived its name from the Latin phrase terra-firma meaning dry land or dirt, implicating the condition as dirt-likedermatosis.[2] TFFD is characterized by dirty or brown-gray cutaneous patches and plaques that can easily be removed by swabbing with alcohol or alcohol-containing solutions.[3],[4] The pathogenesis has been attributed to abnormal and delayed keratinization.[3]

TFFD most often involves the face, neck, and trunk but has also been reported on the scalp, lip, axilla, umbilicus, and pubic region.[2],[3] Histopathology is characterized by prominent lamellar hyperkeratosis with intracorneal orthokeratotic whorls associated with papillomatosis and mild acanthosis.[1],[2] Lora et al. with reflectance confocal microscopy demonstrated a thicker cornified layer and areas of different intensity of light reflection in comparison to normal stratum corneum and also the intracorneal keratin whorls visible microscopically were seen as hyper-refractile compact areas.[5]

Dermatitis neglecta is a condition akin to TFFD characterized by localized hyperpigmented patch or verrucous plaque occurring due to collection of sweat, sebum, keratin, and other debris.[6] It is attributed to inadequate cleansing of the skin in areas of trauma, hyperesthesia, surgical scar, or neurological deficit and can be easily removed with soap and water.[4],[6] In contrast, the skin lesions in TFFD are not amenable to cleanse with soap and water and moreover, can occur in patients with normal hygiene. The diagnosis of TFFD rests with removal of the lesions with 70% isopropyl alcohol or ethyl alcohol soaked gauze pads and the effective therapeutic measure also remains the same.[3]

The clinical differential diagnoses include tinea versicolor, dermatitis neglecta, confluent and reticulate papillomatosis, acanthosis nigricans, pseudoacanthosis nigricans, epidermolytic hyperkeratosis, dirty neck syndrome of atopic dermatitis, and idiopathic deciduous skin.[1],[3]

The present patient was a chronic renal failure patient on hemodialysis referred for a dermatology consult. Though an initial erroneous diagnosis of tinea versicolor was thought of swabbing with spirit soaked gauze established the diagnosis. Awareness about TFFD might avoid unnecessary investigations and inappropriate treatment and hence the case is focused.

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Conflicts of interest

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1Duncan WC, Tschen JA, Knox JM. Terra firma-forme dermatosis. Arch Dermatol 1987;123:567-9.
2Browning J, Rosen T. Terra firma-forme dermatosis revisited. Dermatol Online J 2005;11:15.
3Erkek E, Sahin S, Çetin ED, Sezer E. Terra firma-forme dermatosis. Indian J Dermatol Venereol Leprol 2012;78:358-60.
4Saritha M, Karthikeyan K. Dermatitis neglecta-to be remembered, not neglected! Indian Dermatol Online J 2015;6:138-9.
5Lora V, Ardigò M, Catricalà C, Cota C. Terra firma-forme dermatosis. J Cutan Pathol 2014;41:141-3.
6Choudhary SV, Bisati S, Koley S. Dermatitis neglecta. Indian J Dermatol Venereol Leprol 2011;77:62-3.