Differential diagnoses: Pigment formation

Dr Nigel Stollery explains the differences between four common skin pigment conditions.

Postinflammatory hyperpigmentation

Presentation

  • Occurs anywhere on the body
  • More commonly seen in darker-skinned patients
  • Develops after inflammatory skin conditions such as eczema or acne

Management

  • Treatment usually not required
  • Treating the underlying condition will reduce further pigment formation
  • Topical retinoids can be helpful
  • Avoiding UV exposure will reduce the degree of pigmentation
  • Sunblocks should be used, even in darker-skinned patients

Freckles

Presentation

  • Well-demarcated 1-5mm orange-brown macules
  • Occur on sun-exposed sites, such as face, hands, forearms
  • Usually much reduced in the winter months
  • More common in those with type I skin (red hair, pale skin)
  • Histologically, normal numbers of melanocytes, but increased pigment

Management

  • No treatment necessary
  • Sunblock use can help to reduce pigment


Chloasma affects forehead, cheeks and upper lip

Chloasma

Presentation

  • Symmetrical distribution, occurring mainly in women
  • Affects forehead, cheeks and upper lip
  • Occurs most commonly in association with pregnancy and use of the combined oral contraceptive pill (COC)

Management

  • Usually fades after pregnancy or with cessation of the COC
  • Pigment more pronounced with UV light exposure
  • Sunblock can be helpful in lightening pigment
  • 4% hydroquinone alone or in combination with a retinoid can be helpful

Poikiloderma of Civatte

Presentation

  • Occurs in middle-aged and older patients
  • Pigment presents at the sides of the neck, with sparing under the chin
  • Associated with telangiectasia and atrophy
  • Mottled red-brown colour

Management

  • No reliable treatment available
  • Exacerbated by UV light, so sunblock can be helpful
  • Possibly associated with photosensitisers, such as perfumes
  • Lasers can be helpful in reducing pigment

Poikiloderma of Civatte: pigment presents at the sides of the neck

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