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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 99-101

Adult onset progressive cribriform and zosteriform hyperpigmentation: a rare presentation


Department of Dermatology, Dr Ram Manohar Lohia Hospital and PGIMER, New Delhi, India

Date of Submission16-Oct-2019
Date of Decision25-Feb-2020
Date of Acceptance16-Apr-2020
Date of Web Publication03-Dec-2020

Correspondence Address:
M.B.B.S Prekshi Bansal
Junior Resident, 762-I, BRS Nagar, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/Pigmentinternational.Pigmentinternational_

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  Abstract 


Progressive cribriform and zosteriform hyperpigmentation (PCZH) is an uncommon pigmentary disorder characterized by the presence of asymptomatic cribriform brown macules involving a dermatome. Most cases of PCZH present in the second decade of life with gradual extension and absence of systemic involvement. Though the lesions of PCZH are usually localized, multiple lesions may be seen in some cases. We report a rare case of a 50 year old female with adult onset of this disease in fifth decade with extensive involvement of skin along multiple dermatomes.

Keywords: Adult onset, multiple dermatomes, PCZH


How to cite this article:
Gupta A, Bansal P, Arora P. Adult onset progressive cribriform and zosteriform hyperpigmentation: a rare presentation. Pigment Int 2020;7:99-101

How to cite this URL:
Gupta A, Bansal P, Arora P. Adult onset progressive cribriform and zosteriform hyperpigmentation: a rare presentation. Pigment Int [serial online] 2020 [cited 2021 Mar 8];7:99-101. Available from: https://www.pigmentinternational.com/text.asp?2020/7/2/99/302073



Key Messages: PCZH is a distinct clinical entity known to occur in localized pattern in early life. We report a rare case of adult onset PCZH presenting at multiple sites.


  Introduction Top


Progressive cribriform and zosteriform hyperpigmentation (PCZH) is an uncommon disorder of hyperpigmentation which manifests as cribriform brown to black macules in a dermatomal pattern. It is usually localized and occurs in the second decade. We hereby report a rare case of extensive PCZH in an adult female with onset of disease in fifth decade.


  Case history Top


A healthy 50 year old female presented to skin outpatient department (OPD) with complaints of asymptomatic brownish black lesions on her left lower limb, left side of upper abdomen and inner aspect of left upper arm for the past 4 years. The lesions appeared initially on left lower leg and gradually progressed to involve other sites in a year. A prior history of skin eruption, trauma or topical application of any cream was absent. There was no family history of similar lesions and past medical history was unremarkable. Cutaneous examination revealed multiple coalescent brownish macules of variable sizes present in a cribriform configuration on the medial aspect of left leg (L4 dermatome) and left thigh (L1, L2 dermatome) [Figure 1]. Similar macules were present just below submammary region (T5 dermatome) and medial aspect of left arm (T1 dermatome). Rest of the mucocutaneous and systemic examination was unremarkable. The routine blood investigations were within normal limits. Lesional skin biopsy from lower leg showed focal increased basal cell pigmentation [Figure 2]. Mild perivascular chronic inflammatory infiltrate was seen in papillary dermis. No nevus cells were seen. Based on the classical clinical and histopathology findings a diagnosis of adult onset PCZH was made.
Figure 1 (a) Cribriform pigmentation in zosteriform pattern on left lower limb, (b) hyperpigmented macules on left leg, (c) cribriform hyperpigmented macules on medial aspect of left thigh.

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Figure 2 Epidermis showsorthokeratosis and spongiosis with focal increased basal cell pigmentation (H & E, X40).

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  Discussion Top


Rower et al.[1] initially proposed a diagnostic criteria for PCZH comprising of (1) uniform tan cribriform pigmentation in a zosteriform pattern; (2) increased basal layer pigmentation in absence of naevus cells on histology; (3) absence of preceding rash, injury or inflammation suggestive of post-inflammatory hyperpigmentation; (4) onset well after birth with slow progression; and (5) lack of other anomalies. There are only few case reports of this entity with most cases having early onset in the second decade of life,[1],[2],[3] though Choi et al.[4] reported a patient with onset after fourth decade. Trunk has been reported as the most common site followed by upper and lower extremities.[2] Though the lesions of PCZH are usually localized, multiple lesions may be seen in some cases with an average of 1.57 lesions in each patient according to a study.[4]

The possible clinical differentials include Becker’s nevus (non-hypertrichotic variant), linear lichen planus pigmentosus and linear and whorled nevoid hypermelanosis (LWNH). Becker’s nevus is distinguished by presence of smooth muscle hypertrophy on histopathology and pubertal onset. Lichen planus pigmentosus can be differentiated by the presence of bluish grey lesions over face and flexures in a non-dermatomal pattern and lichenoid infiltrate on histology. The closest mimicker LWNH can be distinguished by the features as depicted in [Table 1]. However, lesions of PCZH have been reported along the lines of Blaschko in the past[2],[3] and due to a relative grey zone between zosteriform pattern and blaschkoid phenotype it may be considered to be late onset LWNH. In fact, according to many authors these entities are similar dermatosis which include various pigmentary disorders namely “zebra-like hyperpigmentation in whorls and streaks”, zosteriform lentiginous nevus”, “reticulate hyperpigmentation of Iijima” and “reticulate hyperpigmentation distributed in a zosteriform fashion” and Taibjee et al.[6] suggested a unified nomenclature, “pigmentary mosaicism” for such disorders.
Table 1 Depiction of differences between pigmentary disorders

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Association between LWNH and mosaicism could be understood as lines of Blaschko mirror the embryonic migration pathway of skin cells.[7] But the role of mosaicism in PCZH has not been consistently noted.[8] It should be conceived that mosaic skin conditions do not necessarily follow Blaschko’s lines in every case.[9] This may be the possible cause of somatic mosaicism manifesting as zosteriform pattern seen in PCZH.[10]

We report this case due to the rarity of this disorder and late onset, in the fifth decade, with involvement of multiple (3) sites (trunk, upper and lower extremities). There is a paucity of universal consensus in naming these disorders of pigmentation and further studies are needed to decipher the pathogenesis of pigmentary diseases which would simplify their classification and nomenclature.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rower JM, Carr RD, Lowney ED. Progressive cribriform and zosteriform hyperpigmentation. Arch Dermatol 1978;114:98-9.  Back to cited text no. 1
    
2.
Cho E, Cho SH, Lee JD. Progressive cribriform and zosteriform hyperpigmentation: a clinicopathologic study. Int J Dermatol 2012;51:399-405.  Back to cited text no. 2
    
3.
Gutte R. Progressive cribriform and zosteriform hyperpigmentation. Indian Dermatology Online J 2014;5:38-40.  Back to cited text no. 3
    
4.
Choi J, Yang J, Lee U, Park H, Chun D. Progressive cribriform and zosteriform hyperpigmentation − the late onset linear and whorled nevoid hypermelanosis. J Eur Acad Dermatol Venereol 2005;19:638-9.  Back to cited text no. 4
    
5.
Kalter DC, Griffiths WA, Atherton DJ. Linear and whorled nevoid hypermelanosis. J Am Acad Dermatol 1988;19:1037-44.  Back to cited text no. 5
    
6.
Taibjee SM, Bennett DC, Moss C. Abnormal pigmentation in hypomelanosis of Ito and pigmentary mosaicism: the role of pigmentary genes. Br J Dermatol 2004;151:269-82.  Back to cited text no. 6
    
7.
Lal K, Di Lernia V. Linear and whorled naevoid hypermelanosis in a patient with trisomy 4 mosaicism. Clin Exp Dermatol 2015;40:45-7  Back to cited text no. 7
    
8.
Ghunawat S, Sarkar R, Garg V. Progressive cribriform and zosteriform hyperpigmentation: need for change in nomenclature. Pigment Int 2015;2:41-3.  Back to cited text no. 8
  [Full text]  
9.
Moss C, Browne F. Mosaicism and linear lesions. In: Bolognia J, Schaffer JV, Cerroni L, editors. Dermatology. 4th ed. China: Elsevier; 2018. p. 100425.  Back to cited text no. 9
    
10.
Das A, Bandyopadhyay D, Mishra V, C Gharami R. Progressive cribriform and zosteriform hyperpigmentation. Indian J Dermatol Venereol Leprol 2015;81:321-3  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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