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Dermatology

Blue Pigmentation of the Skin, Sclera, and Teeth

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA

Published Online: November 9, 2021

JAMA Clinical Challenge

Article Information and Disclosures

Nina A. Ran, MD¹;

Matthew L. Hedberg, MD, PhD¹;

Misha Rosenbach, MD¹

Author Affiliations

¹Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia

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A 69-year-old man presented with a 1-month history of progressive skin discoloration. His medical history included chronic kidney disease, chronic hepatitis C infection, cirrhosis, ischemic cardiomyopathy with an implantable cardioverter-defibrillator (ICD), and atrial fibrillation with prophylactic apixaban. He had recurrent staphylococcus bacteremia due to infection of an ICD lead and had been treated for the past 6 months with minocycline, 100 mg twice daily. His arms had been purple and bruise-like for several years but turned a near black color 1 month ago. He reported no discoloration of his sweat or urine. He had no history of malnutrition and reported infrequent alcohol use.

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A 69-year-old man presented with a 1-month history of progressive skin discoloration. His medical history included chronic kidney disease, chronic hepatitis C infection, cirrhosis, ischemic cardiomyopathy with an implantable cardioverter-defibrillator (ICD), and atrial fibrillation with prophylactic apixaban. He had recurrent staphylococcus bacteremia due to infection of an ICD lead and had been treated for the past 6 months with minocycline, 100 mg twice daily. His arms had been purple and bruise-like for several years but turned a near black color 1 month ago. He reported no discoloration of his sweat or urine. He had no history of malnutrition and reported infrequent alcohol use.

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Article Information

Corresponding Author: Misha Rosenbach, MD, Department of Dermatology, University of Pennsylvania, 3600 Spruce St, 2 Maloney, Philadelphia, PA 19104 (Misha.Rosenbach@pennmedicine.upenn.edu).

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank David E. Elder, MBChB (University of Pennsylvania Perelman School of Medicine) for his work in evaluating the biopsy and highlighting histopathologic features important for determining this patient’s diagnosis. We thank the patient for granting permission to publish this information.

References

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Bolognia JL , Schaffer JV , Cerroni L . Dermatology. Elsevier; 2017.

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Dwyer CM , Cuddihy AM , Kerr REI , Chapman RS , Allam BF . Skin pigmentation due to minocycline treatment of facial dermatoses. Br J Dermatol. 1993;129(2):158-162. doi:10.1111/j.1365-2133.1993.tb03519.x PubMed Google Scholar Crossref

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Okada N , Sato S , Sasou T , Aoyama M , Nishida K , Yoshikawa K . Characterization of pigmented granules in minocycline-induced cutaneous pigmentation: observations using fluorescence microscopy and high-performance liquid chromatography. Br J Dermatol. 1993;129(4):403-407. doi:10.1111/j.1365-2133.1993.tb03166.x PubMed Google Scholar Crossref

Argenyi ZB , Finelli L , Bergfeld WF , et al. Minocycline-related cutaneous hyperpigmentation as demonstrated by light microscopy, electron microscopy and X-ray energy spectroscopy. J Cutan Pathol. 1987;14(3):176-180. doi:10.1111/j.1600-0560.1987.tb00493.x PubMed Google Scholar Crossref

Nakamura S , Yokozeki H , Nishioka K . Acute pigmentation due to minocycline therapy in atopic dermatitis. Br J Dermatol. 2003;148(5):1073-1074. doi:10.1046/j.1365-2133.2003.05271.x PubMed Google Scholar Crossref

Green D , Friedman KJ . Treatment of minocycline-induced cutaneous pigmentation with the Q-switched Alexandrite laser and a review of the literature. J Am Acad Dermatol. 2001;44(2)(suppl):342-347. doi:10.1067/mjd.2001.103036 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.