Hydroxychloroquine-induced Hyperpigmentation

 Presented by DJ Elpern

 

This 23-year-old woman presents for evaluation of patchy hyperpigmentation of her face, arms, and abdomen that has been progressing for the past two years.  She has had systemic lupus erythematosus with renal involvement for a decade.  Her current medications include prednisone 15 mg a day, mycophenolic acid, 2 tablets twice a day, hydroxychloroquine (HQ) 400 mg a day, torsemide, Zoloft, olanzapine, losartan, and recently voclosporin.  She has been on 400 mg of HQ since the early days of her Lupus diagnosis.

 

OE:  The examination shows large hyperpigmented patches on the face, ears, arms and in the abdominal striae.  There is no scarring.  She has Cushingoid facies.
 

 

IMPRESSION: Hydroxychloroquine-induced Hyperpigmentation

 

 

PLAN:  We will consult some colleagues with experience in this area and see the patient back in a few weeks.  Recent serologies may be helpful. 

 

Discussion:  HQ hyperpigmentation is well-reported; but most of the articles are small case reports.  It seems to be related to duration of treatment.  This young woman has been on 400 mg of HQ for at least eight years.  Other than stopping HQ, it’s unclear what may help.  The drug may have been of value for her renal disease; but the downside – the hyperpigmentation – is a significant problem for this young person.  So, too is the Cushingoid effects of her prednisone.  A review of the literature was not helpful for therapeutic guidelines regarding the hyperpigmentation other than discontinuing the HQ.

 

 

References:

1. Daniel Kwak, Pearl E Grimes. A case of hyperpigmentation induced by hydroxychloroquine and quinacrine in a patient with systemic lupus erythematosus and review of the literature. Int J Womens Dermatol. 2020 Jun 30;6(4):268-271. Free PMC

 

2. Moez Jallouli. Hydroxychloroquine-induced pigmentation in patients with systemic lupus erythematosus: a case-control study. JAMA Dermatol. 2013 Aug;149(8):935-40.

 

3. Michela Gasparotto et. al. Lupus nephritis: clinical presentations and outcomes in the 21st century. Rheumatology (Oxford). 2020 Dec 5;59(Suppl5):v39-v51.  Free PMC.

 

4. Sendhil Kumaran Muthu. Low-dose oral isotretinoin therapy in lichen planus pigmentosus: an open-label non-randomized prospective pilot study. Int J Dermatol. 2016 Sep;55(9):1048-54. PMID 27062273