Abstract:

Cutaneous pigmentation mimicking erythema dyschromicum perstans (EDP) has been described in association with the proton-pump inhibitors (PPIs) omeprazole and esomeprazole. We present a case of an 80-year-old Caucasian woman who presented with a solitary, asymptomatic, well-demarcated violaceous to dark brown-grey plaque on the nasal tip. A punch biopsy revealed scattered histiocytes with intracytoplasmic pigment within the superficial and deep dermis. There was no evidence of active inflammation or interface change. A Fontana-Masson stain highlighted the pigment within the histiocytes, and an iron stain was negative. A thorough review of the patients medications was performed, and the patients omeprazole was discontinued. Within 8 weeks, improvement in her cutaneous pigmentation was observed, with significant reduction in the size and pigmentation of the lesion. She has had no disease recurrence. Although the face is a somewhat less common location for EDP, the rapid and marked improvement upon discontinuation support a hypothesis that the patients pigmentation was associated with omeprazole use. The histopathological differentiation of pigment incontinence is challenging, and the presence of an active phase (typically vacuolar interface changes, absent in our case) aids in differentiating EDP from other causes of pigment incontinence. However, many older lesions display only melanin incontinence with perivascular melanophages and lymphocytes. PPIs are commonly used over-the-counter medications prescribed primarily for the treatment of gastrointestinal reflux disease. The increasing use of PPIs necessitates awareness of cutaneous hyperpigmentation as a potential adverse effect to allow early recognition, accurate diagnosis, and removal of the offending agent.

Financial Disclosure:
No current or relevant financial relationships exist.

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Suzanne Tintle, MD, MPH