AssessmentsPigmentation skin disorders: Pathology review
USMLE® Step 1 style questions USMLE
A 27-year-old woman comes to her outpatient provider for skin lesions most prominent at the armpits and neck. In addition, the patient has a history of irregular menstrual cycles that occur every 2-3 months. She has not had any recent weight loss, fatigue, nausea, or weakness. Family history is notable for Addison disease in her mother. Temperature is 37.6°C (99.7°F), blood pressure is 130/74 mmHg, and pulse is 72/min. BMI is 31 kg/m2. Examination of the patient’s bilateral axillae reveals the following finding:
Reproduced from: Wikimedia Commons
Similar lesions are found in the neck folds. They are neither painful nor pruritic. Examination of the face reveals hair growth on the upper lip and chin. Cardiac and pulmonary examinations are noncontributory. Which of the following is the most likely underlying cause for this patient’s condition?
Content Reviewers:Antonella Melani, MD, Scott Caterine, BSc (Hons.), MSc, MB, BCh, BAO (Hons.)
21 year old Holly comes to her primary care provider's office complaining of pigment changes on her skin for the past year.
She denies any history of trauma or recent inflammation of the skin.
Her past medical history is significant for autoimmune thyroiditis.
Physical examination shows several sharply demarcated depigmented patches on the dorsum of both her hands and wrists.
On the same day, 30 year old Maria comes due to some tan spots that recently appeared on her cheeks.
Maria tells you she is pregnant and of hispanic descent.
Physical examination reveals that no other body area is involved.
Based on the initial presentation, Holly and Maria seem to have some form of pigmentation skin disorder.
Melanocytes are located in the stratum basale layer of the epidermis and they produce a pigment called melanin from tyrosine.
Melanin is then taken up by surrounding keratinocytes, and it contributes to the color of our skin, hair, and eyes.
Now, what’s high yield is that melanin acts as a natural sunscreen that absorbs and dissipates, or scatters, UV radiation from the sun or other sources such as tanning booths, preventing it from damaging the keratinocytes.
Now, as keratinocytes in the stratum basale mature, they migrate into the next layers of the epidermis, called the stratum spinosum, stratum granulosum, stratum lucidum, and finally, the stratum corneum, which is the uppermost and thickest epidermal layer.
Before we dive into the various disorders, there are several high yield terms to describe skin lesions.
So, macules are flat, well circumcised lesions up to 1 centimeter in diameter, while patches are similar to a macule but are larger than 1 centimeter.
Papules are raised bumps that are up to 1 centimeter in diameter, while plaques are like papules but larger than 1 centimeter.
Okay, now, let’s start with pigmentation skin disorders.
First, there’s hypopigmentation, which refers to any form of decreased or lost skin pigmentation compared to the baseline skin color.
Sometimes, this can progress to depigmentation, in which there’s total absence of all pigment.
These are in contrast to hyperpigmentation, which refers to darkening or increase in the natural color of the skin.
Let’s start with hypopigmentation disorders.
One of the most common and well known disorders is vitiligo, which is characterized by well defined, irregular shaped macules or patches of skin depigmentation.
Lesions can range in size from millimeters to centimeters, and can sometimes expand and merge with other lesions over time.
Vitiligo can affect any area of the body, but the most commonly affected body areas include the face, genitals, and body surfaces subjected to repeated trauma like the hands, wrists, and extensor forearms.
Vitiligo can be classified according to the location affected.
The most common type is non segmental vitiligo, which occurs at various locations that are often symmetrical on both sides of the face and body, and can affect any age group.
Now, the exact cause of vitiligo isn’t known, but it is thought to be an autoimmune disorder where immune cells attack and destroy melanocytes.
For your exams, remember that this is why vitiligo is often associated with other autoimmune disorders, like systemic lupus erythematosus and autoimmune thyroiditis.
Now, the diagnosis of vitiligo is mainly clinical, and a Wood’s lamp may be used for diagnostic aid.
Regarding treatment, topical corticosteroids are commonly used as first line therapy of smaller or more limited vitiligo, and if not effective then topical calcineurin inhibitors can be used.
On the other hand, when the affected area is large, systemic immunosuppressants, UV phototherapy, skin bleaching, and in severe cases, skin grafts, can all be tried.
Whatever the course of therapy, sunscreen is recommended to supplement the protection melanin would have provided.
Next, there’s albinism, which is caused by an autosomal recessive gene mutation encoding any one of the enzymes needed to produce melanin, typically tyrosinase.
The result is a dysfunctional or deficient enzyme that drastically decreases the amount of melanin that’s made within normal melanocytes.
Albinism can also occur if there are mutations in proteins responsible for the transport of tyrosine.
Now, a decrease or absence of melanin can reduce or obliterate pigmentation of the skin, hair, and eyes, causing them to appear lighter in color or completely white.
Diagnosis of albinism is mainly clinical, and definitive diagnosis can be made with genetic testing.
Those with albinism are at an increased risk of skin cancers, so it’s recommended that they get frequent monitoring for skin changes.
In addition, they can develop vision impairment, so they should get regular ocular examinations.
Treatment generally includes strict protection of the skin with sunscreen, and the eyes by wearing tinted glasses.
For your test, it’s important to know that albinism can be linked to Chediak Higashi syndrome, which is a rare autosomal recessive disorder that results in impaired lysosomal trafficking and phagocytosis.
Individuals affected by this syndrome present a characteristic tetrad of hypopigmentation, recurrent infections, coagulation defects, and neurologic problems.
Now, melanocytic nevi can be classified as congenital or acquired.
Congenital melanocytic nevi are typically present at birth or may appear within the first few months of life.
One of the characteristic features of congenital nevi is that they usually have hair growing out of them.
- "Robbins Basic Pathology" Elsevier (2017)
- "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
- "Vitiligo: A comprehensive overview" Journal of the American Academy of Dermatology (2011)
- "Albinism: epidemiology, genetics, cutaneous characterization, psychosocial factors." An Bras Dermatol. (2019)
- "Melanocytic nevi and melanoma: unraveling a complex relationship" Oncogene (2017)
- "Melasma: an Up-to-Date Comprehensive Review" Dermatology and Therapy (2017)
- "Seborrheic keratosis" Journal of Oral and Maxillofacial Pathology (2014)
- "An approach to acanthosis nigricans" Indian Dermatology Online Journal (2014)
- "Is Acanthosis Nigricans a Reliable Indicator for Risk of Type 2 Diabetes in Obese Children and Adolescents?" The Journal of School Nursing (2011)
- "Atopic dermatitis: natural history, diagnosis, and treatment" ISRN Allergy (2014)
- "Pathophysiology of atopic dermatitis: Clinical implications" Allergy and Asthma Proceedings (2019)
- "Urticaria: A comprehensive review" Journal of the American Academy of Dermatology (2018)
- "Recent advances in understanding and managing contact dermatitis" F1000Research (2018)
- "Seborrheic Dermatitis" P T (2010)
- "Acne vulgaris" The Nurse Practitioner (2013)
- "Rosacea: a clinical review" Dermatology Reports (2016)
- "Psoriasis Pathogenesis and Treatment" International Journal of Molecular Sciences (2019)