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Case Reports

Abstract

Kratom, an herbal supplement derived from the leaves of the Mitragyna speciosa tree, has gained popularity in recent years for its purported medicinal properties. Ingestion of kratom has been associated with adverse effects including rare cutaneous reactions. We present a case of a 37-year-old male with striking photodistributed hyperpigmentation secondary to kratom. The patient presented with large blue-grey pigmented patches in sun-exposed areas of his face, neck, and hands. In taking a medical history, the patient noted using kratom supplements to treat his chronic back pain.  A punch biopsy of the neck was performed which revealed an unremarkable epidermis, slightly thickened basement membrane, and a mild superficial perivascular and periadnexal lymphohistiocytic infiltrate. Additionally, prominent pigment-laden macrophages which appeared as multiple spherical pigmented particles were noted in the superficial dermis. The pigmented particles stained with Fontana-Masson and were negative with an iron stain, consistent with melanin pigment. The differential diagnosis included post inflammatory pigment alteration, lichenoid drug reaction, lichen planus pigmentosus, erythema dischromicum perstans and drug-related pigment deposition.  The clinical and morphologic findings in this case were consistent with a photo-drug induced hyperpigmentation secondary to kratom use. A review of the literature revealed four case reports noting similar pigmentary changes and histological findings in patients consuming kratom. The underlying pathophysiology linking kratom use to photodistributed hyperpigmentation remains speculative. Our case demonstrates the importance of considering drug induced etiologies when post inflammatory pigmentary alteration is seen.