Volume 26 Number 3 March 1992

Briefcommunications 493

Pregnancy-associated hyperpigmentation: Longitudinal melanonychia Jennifer M. Fryer, MD, and Victoria P. Werth, MD Philadelphia, Pennsylvania Hyperpigmentation of the skin during pregnancy is commonly observed, but longitudinal melanonychia associated with pregnancy has not been reported. Longitudinal melanonychia is commonly seen in black persons and Orientals but is rarely present in white persons. We describe a white woman in whom longitudinal melanonychia developed during her two pregnancies and resolved after parturition. CASE REPORT A 32-year-old white woman of Ashkenazi extraction (skin type III) had a longitudinal dark brown streak on the nails of her second and third toes on the right foot during her first pregnancy. The pigmented streaks were uniformly dark brown, 1 to 2 mr:n in width, with sharp borders. Pigmentation of the periungual skin (Hutchinson's sign) was present on the cuticle and proximal nail bed and extended to the proximal and one lateral nail fold. During pregnancy, the patient also noted the development of 15 to 20 brown macules on the anterior aspect oiher torso. The longitudinal melanonychia resolved after delivery and the brown macules on her trunk became lighter but did not resolve completely. During her second pregnancy, the patient again noted the development of dark brown streaks of the nails of her right second and left third fingers that were 2 and 3 mm wide, respectively (Fig. 1), and on several toenails. She also noted darkening of the macules on her trunk, as well as the development of new macules. These changes were noted during the fifth month of pregnancy. Six months after delivery, the pigmented streaks on the fingernails and two toenails had completely resolved and the macules on her trunk became lighter. A biopsy specimen of a macule on the abdomen was obtained 11 months after delivery. On histologic examination, the epidermis showed elongation of the rete and basilar melanocytic hyperplasia and hyperpigmentation.

From the Department of Dermatology, University of Pennsylvania. Reprint requests: Victoria P. Werth, MD, Department ofDermato!ogy, Hospital of the University ofPennsylvania, Gates Building 2nd Floor, 3600 Spruce St., Philadelphia, PA 19104.

16/4/32994

Fig. 1. Pigmented streaks can be seen on right second and left third fingernails with pigmentation also visible on cuticle and proximal nail bed extending to proximal and one lateral nailiold.

In addition, focal dermal melanophages were present. These findings are consistent with a diagnosis of lentigo.

DISCUSSION

Numerous causes and simulators of longitudinal melanonychia have been reported. 1,2 Our patient had no history of trauma to the affected nails and no significant medical history. Cutaneous hyperpigmentation during pregnancy occurs to some degree in 90% of women. This hyperpigmentation may be generalized, but most commonly occurs in normally hyperpigmented areas such as the areolae, nipples, axillae, perineum, and anus and in areas prone to friction such as the inner thighs. The linea alba may darken and extend superiorly to the xiphoid process to form the linea nigra. Hyperpigmentation may be noted in scars that formed immediately before or during pregnancy. Pigmented lesions, such as ephelides and nevocellular nevi, may develop, darken, or enlarge during pregnancy. Pigmentary demarcation lines may develop on the legs during pregnancy. Melasma occurs in 50% to 75% of pregnant women, especially in those with dark hair and skin. All forms of gestational hyperpigmentation usually regress postpartum. However, there may be some residual hyperpigmentation in darker-skinned women. 3

Journal of the American Academy of Dermatology

494 Briefcommunications The hyperpigmentations that occur during pregnancy may result from hormonal changes, a greater population of melanocytes in affected areas or greater sensitivity of the melanocytes to hormonal stimulation. 4 Melanocyte-stimulating hormone (MSH), estrogen, and progesterone have each been implicated as causes. However, if these pigmentary changes are classified into two groups based on abnormalities of either MSH or estrogen/progesterone levels, there are specific clinical findings associated with each of these abnormalities as well as an area of overlap. The formation of new lentigines and nevi or darkening and enlargement of preexisting lesions may also result from increased levels of MSH and estrogen/progesterone. 4,5 Ellis and Wheeland4 showed that melanocytic nevi excised from pregnant women, women who had delivered within I month, and women who were taking oral contraceptives had increased estrogen and progesterone binding compared with control subjects.

In our patient only longitudinal melanonychia and 15 to 20 lentigines on her trunk developed during each of her pregnancies. Although biopsies of the affected nails were not performed, it is likely that the pigmented streaks were also lentigines. Goldberg6 reported longitudinal melanonychia that proved to be a lentigo in a 13-year-old white boy. REFERENCES I. Baran R, Kechijian P. Longitudinal melanonychia (melanonychia striata): diagnosis and management. JAM ACAD DERMATOL 1989;21:1165-75. 2. Daniel CR, Scher RK. Nail changes caused by systemic drugs or ingestants. Dermatol Clin 1985;3:491-500. 3. Murray JC. Pregnancy and the skin. Dermatol Clin

1990;8:327-34.

4. Ellis DL, Wheeland RG. Increased nevus estrogen and progesterone ligand binding related to oral contraceptives or pregnancy. J AM ACAD DERMATOL 1986;14:25-31. 5. Fitzpatrick TB, Eisen AZ, Wolff K, et ai, eds. Dermatology in general medicine. New York: McGraw-Hill, 1979:1247-

50, 1363-70.

6. Goldberg DJ. Melanonychia striata longitudinalis: multiple benign pigmented streaks in a caucasian. J Derm Surg Oncol 1986;12:188-9.

Low-dose intralesional interferon alfa for discoid lupus erythematosus Jesus Martinez, MD, Ricardo F. de Misa, MD, Antonio Torrelo, MD, and Antonio Ledo, MD Madrid, Spain Multiple topical and systemic drugs have been used for the treatment of refractory discoid lupus erythematosus (DLE). Interferon alia 2 (IFN-a2) has been used systemically in the treatment ofDLE and other diseases of possible autoimmune origin. I We present a case of long-lasting DLE in which low doses of intralesional IFN-a2 induced dramatic clinical and histologic improvement. CASE REPORT

A 32-year-old white woman reported a 3-year history of erythematous plaques with central scarring and pe-

From the Department of Dermatology, Hospital "Ramon y Cajal." Reprint requests: Antonio Ledo, MD, Paseo de 1a Castellana 167, 28046, Madrid, Spain. 16/4/33472

ripheral follicular plugs on her left cheek (Fig. 1, A). No other symptoms were present. Routine laboratory studies, serum immunoglobulins, rheumatoid factor, and antinuclear, anti-Ro and anti-La antibodies were normal or negative. A skin biopsy specimen showed hydropic degeneration of basal cells, thickening of basal membrane, follicular hyperkeratosis, and a marked periadnexallymphohistiocytic infiltrate (Fig. 1, B). Direct immunofluorescence (OIF) showed IgM granular deposits in the basement membrane zone (BMZ). A diagnosis of DLE was made, and the patient was treated with photoprotection and topical and intralesional steroids. No response was apparent after 12 months, so hydroxychloroquine (200 mg twice daily) and prednisone (0.5 mg/kg/day) were administered for 12 months and 2 months, respectively. However, the lesions were still unresponsive. In February 1991 intralesional IFN-a2 was administered (5 X 106 IU twice weekly) together with acetaminophen (2 hours after injection). Lesions started to improve after

Pregnancy-associated hyperpigmentation: longitudinal melanonychia.

Volume 26 Number 3 March 1992 Briefcommunications 493 Pregnancy-associated hyperpigmentation: Longitudinal melanonychia Jennifer M. Fryer, MD, and V...
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