|Year : 2020 | Volume
| Issue : 2 | Page : 87-95
Clinico-dermatoscopic and histopathological evaluation of cervico-facial hypermelanosis: a study from a tertiary care hospital
Simplepreet Kaur, Jasleen Kaur, Saurabh Sharma
Department of Dermatology, Venereology & Leprosy, Sri Guru Ram Das Institute of Medical Sciences & Research, Amritsar, Punjab, India
|Date of Submission||13-Jun-2019|
|Date of Decision||15-Oct-2019|
|Date of Acceptance||06-Dec-2019|
|Date of Web Publication||03-Dec-2020|
Dr. Simplepreet Kaur
Department of Dermatology, Venereology & Leprosy, Sri Guru Ram Das Institute of Medical Sciences & Research, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
Introduction: Hypermelanosis is a rampant cosmetic problem nowadays. Unvarying and uniform skin color is the essence of vibrant skin. Hypermelanosis involving the face and neck is quite common and often becomes a challenge to the diagnostician. Persisting cervico-facial hypermelanosis causes cosmetic disfigurement which immediately sets one apart and consequently threatens psychosocial and psychosexual identity. Combining different modalities like dermatoscope and histopathology helps in early diagnosis and in time management of these disorders. Aims and Objectives: The data regarding the characterization of face and neck hyperpigmentation are scarce. This study was performed to determine the clinical types of face and neck hypermelanoses and establishment of their diagnosis using clinical, dermatoscopic, and histopathological features. Material and Methods: A total of 100 clinically diagnosed patients with hyperpigmentation over face and neck, in the age group of 18–70 years of either sex were enrolled in the study. Thorough clinical examination followed by dermatoscopic and histopathological examination were performed. All the features were noted and tabulated along with photographic documentation. Results: Out of total 100 cases, there were 35% cases of melasma, 23% cases of lichen planus pigmentosus, 12% cases of ashy dermatosis, 7% cases of post inflammatory hyperpigmentation, 6% cases of periorbital hypermelanosis, 4% cases of drug induced hyperpigmentation, 3% cases of acanthosis nigricans, nevus of ota, and macular amyloidosis each, 2% cases of riehl’s melanosis and exogenous ochronosis each. Conclusion: Hyperpigmentary disorders are great mimickers. Clinical examination alone can misdiagnose certain conditions. Dermatoscope, a novel office tool, when used along with time tested modality like histopathology, can reduce the diagnostic burden of clinicians while treating hyperpigmentary conditions.
Keywords: Cervico-facial hypermelanosis, dermatoscope, histopathology, hyperpigmentation
|How to cite this article:|
Kaur S, Kaur J, Sharma S. Clinico-dermatoscopic and histopathological evaluation of cervico-facial hypermelanosis: a study from a tertiary care hospital. Pigment Int 2020;7:87-95
| Introduction|| |
The face being one of our most important possessions projects our deepest essence. Facial attractiveness is associated with various social consequences such as better opportunities at work, partner selection, etc. Incidence of hyperpigmentary conditions is increasing in general population hence, recognition and characterization of increased pigmentation over face and neck area are very crucial for a dermatologist. Out of total patients in dermatology clinic, 10.8% patients report with pigmentary disorders. Hypermelanosis is defined as increase in melanin pigment in the skin. In general, it is either due to increased melanin production by existing melanocytes (melanotic hypermelanosis) or from increased proliferation of active melanocytes (melanocytic hypermelanosis). Epidermal hypermelanosis is the term used when excess melanin is present in basal and suprabasal layers and it has a brownish hue. Dermal hypermelanosis presents as blue color is said to have excess melanin in the dermis. Mixed hypermelanosis occurs due to increased melanin in both epidermis and dermis. Cervico-facial hyperpigmentary disorders are more common in dark skin Asian population. This can be attributed to certain etiological factors such as prolonged sun exposure, misuse of depigmenting agents, use of certain oils, cosmetics, hair dyes, etc. There is a considerable overlap in clinical features among the various hyperpigmentary disorders. Using various modalities in diagnosing a particular disease lessens the chances of misdiagnosis. Dermatoscope is a non-invasive tool which magnifies surface features of skin lesions and also unveils some subsurface skin structures. Dermatoscope helps in visualizing the color, patterns, and symmetry of pigment. Level of pigment deposition and other changes like basal layer liquefaction and pigmentary incontinence can be visualized by doing skin biopsy from affected area for histopathological examination. Histopathology is a gold standard technique to confirm the diagnosis. The present study was performed to study clinical types of face and neck hypermelanosis and establishment of their diagnosis using clinical, dermatoscopic, and histopathological features.
| Material and methods|| |
This was a prospective observational cohort study. A total of 100 clinically diagnosed patients with hyperpigmentation over face and neck presenting to the outpatient department fulfilling the inclusion criteria were enrolled in the study. Ethical approval for the study was obtained from the ethics committee of the institution.
- Patients in the age group of 18–70 years of either sex.
- Patients with acquired as well as congenital hypermelanosis.
- Patients who were on any treatment for hypermelanosis since last 1 month.
- Patients who were not willing to give consent and undergo investigations.
A detailed history of all the patients was taken in terms of age of onset, duration of disease, site of onset of pigmentation, and associated symptoms. Information was noted regarding any precipitating factors, use of cosmetics, drug intake prior to the onset, similar past history, and family history. Local cutaneous examination was done to see morphology and distribution of lesions, extent of involvement, and color of pigmentation. All the patients were subjected to the following investigations:
- Dermatoscopic examination
- Skin biopsy for histopathological examination
| Procedure|| |
Dermatoscopic examination: Dermlite DL3N Dermatoscope (3Gen, Inc. 31521 Rancho Viejo Road, Suite 104 San Juan Capistrano, CA 92675, USA) with polarized mode and magnification of 10X was used. The site was selected, cleaned, and observed through the dermatoscope. Various features of the lesion such as color, symmetry, pattern, vascular structures were noted. The photographs of the lesion were taken and recorded.
Histopathological examination: Site of the biopsy was selected and prepared. Local anesthesia consisting of 2% lidocaine with/without epinephrine was given. Punch biopsy was taken from selected site using a punch of size 3 mm. Biopsy specimen was sent in 10% formalin for histopathological examination. The tissue was formalin fixed, processed, and stained with Hematoxylin and Eosin stain. Some special stains were also used.
Statistical analysis: The results were tabulated and analyzed statistically using SPSS Software 17.0 version. For comparing and finding correlation between different variables, Chi square test and Kappa stats were used respectively. Results were considered significant if value of probability P-value was less than 0.05.
| Results|| |
In present study, out of 100 patients, 80 were females and 20 males. Age of patients ranged from 18–63 years with mean age of 36.18 years. Mean duration of hyperpigmentation was 2.7 years with minimum duration of 3 months and maximum of 15 years [Table 1]. Face involvement was seen in 67 patients, that is 67% followed by involvement of neck in 17 patients (17%). Both face and neck together were involved in 16 patients (16%). Commonly encountered associated symptoms were pruritus in 57%, photosensitivity in 32%, and burning in 25% cases. Sun exposure came out to be the most common confounding factor followed by application of oils [Table 1]. On clinical examination, localized pattern of hyperpigmentation was seen in 62% whereas diffuse pattern in 38% cases. Color of pigmentation varied from brown to blue grey and in certain cases, mixed variant was also observed [Figure 1]. On the basis of clinical examination, provisional diagnosis in all patients were made. After correlating clinical, dermoscopic, and histopathological findings, final diagnosis was made [Table 1]. [Table 2] and [Table 3] represent dermoscopic and histopathological features of all diseases respectively. On comparing the provisional and final diagnosis, statistically significant difference was observed with P-value <0.05. The correlation between dermoscopic and histopathological findings of lichen planus pigmentosus (LPP), ashy dermatosis (AD), acanthosis nigricans (AN), nevus of Ota (NOO), macular amyloidosis (MA), exogenous ochronosis (EO), riehl’s melanosis (RM) came out to be significant (P < 0.05) whereas in cases of melasma and post inflammatory hyperpigmentation (PIH), correlation was non-significant [Table 4].
|Table 3 Histopathological features of various hyperpigmentary conditions|
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| Discussion|| |
On the basis of clinical examination, some hyperpigmentary disorders can be diagnosed easily while few can pose diagnostic challenge by mimicking other conditions. So besides basic evaluation, it’s important to have an easy to use and non-invasive office tool like a dermatoscope that can aid in making the diagnosis. Histopathology has proved its worth of being a gold standard tool for confirmation of diagnosis since its days of origin. Combining these two modalities can help in diagnosing skin conditions accurately and reducing the psychosocial burden on patients. Even a small discolored area over face can cause huge mental distress. Obsession of Indian society with fair skin makes one with facial hyperpigmentation feel under confident and dejected socially.
Study by Shahana et al. reported female preponderance in facial hyperpigmentation where female to male ratio was same as our study, that is 4:1. The higher female to male ratio in our study can be attributed to the reason that females are more concerned about their cosmetic appearance as compared to the males. Hence more number of females seek medical advice and present to the dermatology department. 54% patients had duration of illness ranging from 3 to 12 months and 46% patients had duration of >12 months. These findings correlated with findings of study by Kavya et al. where duration of illness ranged from 1 month to 18 years. The longer duration of these conditions can be attributed to the fact that patients tend to self-medicate themselves by using various over the counter available skin lightening agents. Study by Shah et al. in 25 patients of acquired facial melanosis showed presence of pruritus in 26% patients and photosensitivity in 48% patients. Incidence of pruritus was higher in our study as compared to the above-mentioned study. In current study, use of cosmetics was observed in 33% patients. Some of the cosmetics were bleach, fairness creams, perfumes, and hair cream. Similar findings were reported by Hassan et al., where cosmetic use was seen in 32.7% patients whereas lower rate of cosmetic use was documented by Kavya et al (22%). Immediate use of mustard oil to scalp and body after bath was observed. Hyperpigmentation of photoexposed areas due to mustard oil use can be attributed to the presence of certain photosensitizer compounds in these oils such as allylthiocyanate. On clinical examination, localized pattern, that is when pigmentation is localized to one particular area over face or neck such as malar area, temple area, perioral, periorbital area, etc, was seen in 62% patients. Diffuse pattern, that is when pigmentation is not restricted to one particular area but involves larger area of face or neck, was observed in 38% patients. These findings were consistent with those reported by Hassan et al. where localized pigment was seen in 62.1% cases and diffuse in 37.9% cases. Clinically color of the pigmentation helps in determining the level of pigment deposition. In present study, epidermal pigmentation was noticed in 64% patients, dermal in 29% patients while 7% patients showed both epidermal and dermal pigmentation. These findings were partly consistent with those reported by Hassan et al. and Kavya et al. where epidermal pigment was seen in 59.5% and 61%, dermal pigment was seen in 40.4% and 39%, respectively. So in our study, on the basis of clinical examination epidermal pigment was seen in majority as compared to dermal or mixed pigment.
In melasma cases, on dermatoscopic examination, the most common pattern observed was accentuated pseudoreticular network, seen in 88.5% cases followed by reticuloglobular pattern in 77.1% [Figure 2]. These findings were comparable to those documented by Neema et al. where reticuloglobular pattern was seen in 83% and dotted pattern in 28%. Histopathological features of melasma patients were comparable to findings of another study. In LPP cases, hem-like pattern observed was more appreciated over neck as compared to face. This pattern was formed by small pigment granules which corresponded to the presence of dermal melanophages on histopathology [Figure 3]. Pirmez et al. reported pseudonetwork, dotted pattern, arcuate pattern, and telangiectasia under dermatoscope. Shah et al. reported epidermal thinning, basal layer liquefaction, interface changes, and dermal melanophages in all cases (100%). Kanwar et al. described basal layer vacuolization in 78.5%, hyperkeratosis in 13.8%, epidermal thinning in 7.2%, dermal melanophages in 63%, band-like infiltrate in 18.5%, and perivascular infiltrate in 81.5% cases of LPP. In AD, curvilinear pattern was diagnostic on dermoscopy and formed by pigment granules. Peri-eccrine involvement was present in all cases (100%) whereas perifollicular involvement was seen in seven cases. These findings were consistent with those reported in literature. Vega et al. reported hyperkeratosis in 80%, epidermal thinning in 65%, basal layer vacuolization in 85%, perivascular infiltrate in 95%, and dermal melanophages in 100% cases. In present study, PIH developed secondary to acne in three patients (43%), external trauma in two patients (29%), systemic lupus erythematosus, and post chemical peeling in one patient (14%) each. Kavya et al. observed post acne PIH in 24%, secondary to connective tissue diseases in 12% and trauma induced in 8% cases. On extensive search of literature, we could not find any study with dermatoscopic findings in PIH. In POH, history of topical drug application in 50% patients, constant rubbing of bilateral infraorbital area in 17%, being under constant stress and insomnia (33%) were noteworthy causes. Ahuja et al. found homogenous and cobble stone pigment in 39% patients and blotchy pattern in 9% patients of POH. In DIH, implicated drugs were phenytoin (25% cases), risperidone (25%), and multibacillary multidrug therapy (MB MDT) for leprosy in 50% patients [Figure 4]. In another study, drugs implicated were MB MDT, anti-tuberculosis therapy and phenytoin. In AN, one study reported presence of hypertrophic epidermis, pigmentary incontinence, interface changes, and lymphocytic infiltrate in all cases. In our study, dermoscopic findings of linear crista cutis and milia-like cysts corresponded histologically to papillomatosis [Figure 5]. In cases of NOO, under dermoscopy pigment was deposited in the form of blotches and these findings were consistent with those reported in the literature. In MA, dermoscopic features of central brown hub with brown radiating streaks (spoke and hub pattern) corresponded histologically to hyperkeratosis and increased basal layer pigment. Amyloid deposition in the papillary dermis was seen in all cases [Figure 6]. These findings were consistent with another study on MA. In a study by Wang et al. in patients of RM, dermatoscopic findings of pseudonetwork, grey dots and telangiectatic vessels in all cases (100%), follicular plugs, and perifollicular white structures in 46.7% cases respectively were observed. Histopathological findings in present study were consistent with above-mentioned study. Gil et al. reported the dermoscopic features of EO as irregular, brown grey, globular, annular, and arciform structures. In certain cases of current study where clinico-dermatoscopic findings were non-specific, histopathology helped in clinching the diagnosis and in non-specific histopathology cases, correlation with clinical and dermatoscopic findings helped. Hence, the present study emphasizes on the need of correlation between different modalities in hyperpigmentary disorders.
|Figure 2 Clinical, dermatoscopic, and histopathological picture of melasma. Black arrow represents increased melanin pigment throughout epidermis (H & E stain, 100X).|
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|Figure 3 Clinical, dermatoscopic, and histopathological picture of Lichen Planus Pigmentosus. Black arrow represents hem-like pattern under dermatoscope (H & E stain, 100X).|
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|Figure 4 Clinical, dermatoscopic, and histopathological picture of drug-induced hyperpigmentation. Black arrow shows pigmentary incontinence (H & E stain, 100X).|
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|Figure 5 Clinical, dermatoscopic, and histopathological picture of acanthosis nigricans (H & E stain, 100X).|
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|Figure 6 Clinical, dermatoscopic, and histopathological picture of macular amyloidosis. In dermatoscopic picture, black arrows depict spoke and hub pattern. In histopathological picture, black arrow shows hyperkeratosis, red arrow amyloid deposition and blue arrow melanophages (H & E stain, 100X).|
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| Conclusion|| |
By looking at the observations, we can conclude that performing only clinical examination and history of a patient can misdiagnose a case. Various hyperpigmentary disorders can mimic each other so it’s necessary to perform proper evaluation using various modalities to establish a final diagnosis. Dermatoscope, a non-invasive tool, though not a confirmatory tool but definitely aids in making a diagnosis. Histopathology is a gold standard technique to confirm a diagnosis. So, patients with hyperpigmentation over face and neck should be evaluated using clinico-dermatoscopic-pathological correlation. The data regarding the characterization of face and neck hyperpigmentation and correlation of different diagnostic tool’s findings are scarce. There is need of more studies in this field with larger cohorts.
Limitation of present study is small cohort size.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sayal SK, Das AL, Gupta CM. Pattern of skin diseases among civil population and armed forces personnel at Pune. Indian J Dermatol Venereol Leprol 1997;63:29-32.
] [Full text]
Khanna N, Rasool S. Facial melanoses:Indian perspective. Indian J Dermatol Venereol Leprol 2011;77:552-64.
] [Full text]
Nirmal B. Dermatoscopy: Physics and principles. Indian J Dermatopathol Diagn Dermatol 2017;4:27-30. [Full text]
Nischal KC, Khopkar U. Dermoscope. Indian J Dermatol Venereol Leprol 2005;71:300-3.
] [Full text]
Werner B. Skin biopsy and its histopathologic analysis. Why? What for? How? Part I. An Bras Dermatol 2009;84:391-5.
Shahana M, Padma A, Khan PM. Study of clinical patterns of facial pigmentation. Int J Biomed Res 2016;7:94-8.
Kavya M, Nataraj HV. Clinico-epidemiological study of facial hypermelanoses. Sch J App Med Sci 2014;2:1621-26.
Shah AN, Patel D, Kasundara V, Shah K. A clinical, etiological and histopathological study of acquired facial melanosis. Sch J App Med Sci 2016;4:4439-45.
Hassan I, Aleem S, Bhat YJ, Anwar P. A clinicoepidemiological study of facial melanosis. Pigment Int 2015;2:34-40.
Shenoi SD, Rao R. Pigmented contact dermatitis. Indian J Dermatol Venereol Leprol 2007;73:285-7.
Neema S, Chatterjee M. Dermoscopic characteristics of melasma in Indians. A cross sectional study. Int J Dermoscop 2017;1:6-10.
Pirmez R, Duque EB, Donati A, Campos CG, Valente NS, Romiti R et al.
Clinical and dermoscopic features of lichen planus pigmentosus in 37 patients with frontal fibrosing alopecia. Br J Dermatol 2016;175:1387-90.
Kanwar AJ, Dogra S, Handa S, Parsad D, Radotra BD. A study of 124 Indian patients with lichen planus pigmentosus. Clin Exp Dermatol 2003;28:481-5.
Khopkar U, editor. Dermoscopy and trichoscopy in diseases of the brown skin. Atlas and short text. New Delhi: Jaypee; 2012.
Vega ME, Waxtein L, Arenas R, Hojyo T, Dominguez-Soto L. Ashy dermatosis and lichen planus pigmentosus: a clinicopathologic study of 31 cases. Int J Dermatol 1992;31:90-4.
Ahuja SK, Deshmukh AR, Khushalani SR. A study of dermatoscopic pattern of periorbital hypermelanosis. Pigment Int 2017;4:29-34. [Full text]
Nischal KC, Khopkar US. Principles and Technique of Dermoscopy and Videodermoscopy. In: Khopkar U, editor. Dermoscopy and Trichoscopy in Diseases of the Brown Skin. Atlas and short text. 1st ed. New Delhi: Jaypee; 2012 pp. 1-9.
Sathyanarayana BD, Dukkipati M, Swaroop MR, Yogesh D, Aneesa. To study the correlation of clinical, dermoscopic and histopathological features of clinically suspected macular amyloidosis. Indian J Clin Exp Dermatol 2017;3:9-13.
Wang L, Xu AE. Four views of Riehl’s melanosis: clinical appearance, dermoscopy, confocal microscopy and histopathology. J Eur Acad Dermatol Venereol 2014;28:1199-206.
Gil I, Segura S, Martínez Escala E, Lloreta J, Puig S, Vélez M et al.
Dermoscopic and reflectance confocal microscopic features of exogenous ochronosis. Arch Dermatol 2010;146:1021-25.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]