Thursday, February 21, 2008

Facial Pigmentation in a 31 yr old woman with Protein S deficiency

A 31 yr old woman presented with one year history of pigmentation on her face. It appeared as sun burn and confined to the facial areas with sparing of the areas underneath the eyes and nose. It was made worse after application of some skin care products. She was otherwise well.

She had a past history of hypercoagulation and mitral valve prolapse with Protein S deficiency and is on warfarin.

Examination of the skin showed diffuse hyperpigmentation on the face extending to the frontal hairline, preauricular hairline and mentum. The areas under the eyes and nose were spared.

Blood counts and biochemistry were normal ANA serology mildly positive. Titre 1:80 (RR<80)

Differentials: photodermatitis > LE > melasma > irritant dermatitis

Q Is the serology titre of 1:80 significant? Could this be LE or melasma? Would you biopsy her skin? If you biopsy, where would you biopsy her? Thanks for your comments.


  1. This is an interesting case and the photos are excellent. My first thought was dermal melasma but I would also consider pigmented contacted dermatitis. It is important to find out what creams she was using. A good review of facial hyperpigmentation was published in the IJD in 1991:
    Int J Dermatol. 1991 30(3):186-9.

    Regional dermatoses in the African. Part I. Facial hypermelanosis.

    Olumide YM, Odunowo BD, Odiase AO.

    Department of Medicine, College of Medicine, University of Lagos, Nigeria.

    Acquired facial hyperpigmentation is a common problem among African patients, particularly women, where the causes of the dermatoses are identified largely from circumstantial evidence of exposure to known agents. These include
    hydroquinone-induced exogenous ochronosis from skin-bleaching creams, mercury deposits from mercury-containing skin-lightening soaps and creams, sulfonamide- related drugs, antimalarials, fixed drug eruptions, clofazimine, and
    photosensitizing herbal concoctions. The differential diagnosis includes melasma and facial erythema ab igne (local cooks).

  2. I think she is having allergic photo contact dermatitis as she has been using different topical preparation in the past.I would suggest sun avoidence, use of superpotent sun block, and topical application of combination of hydroquinone and tretinoin at bed time.

  3. I would favor for Melasma. What about anamnesis of pregnancy,oral contraceptive pills,photosensitizing medications, mild ovarian or thyroid dysfunction, and certain cosmetics?
    As a ddx i supposed a Drug-induced photosensitivity.
    About Melasma i have seen good effect with Iglen(inhibits tyrosinase, leading to the decreased production of melanin). As a alternative treatment i use topical Retinoid with Azelaic acid 20% but they can used it min 6 months to see good effect.
    Ofcourse sun block with high SPF and sun avoidence is needed also.

    About biopsy i will wait.

  4. I think this is mask varient of melasma which is commonly seen among Iraqi women.Although melasma is only seen during active reproductive life on top of genetic element but there are many triggering factors like hormonal excess during pregnancy, contraceptive intake nd sunlight exposure.So please ask the patient about these factors.I do not think the present case is directly related to ANA,lupus or even photosensitivity.
    khalifa sharquie


We welcome your comments. We endeavor to serve your patients and you. If you want us to respond, please add your name and email address. Some people have trouble uploading comments. In that case, please send comments directly to Thank you.