A Middle Aged Woman with a Mottled Eruption on her Face

presented by

Shahbaz Janjua MD

Lalamusa, Pakistan

on February 28, 2005

Dermatologist, Ayza Skin and Research Center, Lalamusa, Pakistan

Abstract A middle aged woman with two-month history of depigmented and hyperpigmented mottled macular eruption on the face.
S.M. 50-year-old woman
2 months

This 50-year-old woman with lifelong history of excessive sun exposure while working in the fields, presented for the evaluation of an asymptomatic eruption on the face that consisted of multiple depigmented and hyperpigmented discrete and confluent macules and patches. No other area of the body was involved. There was no history of recent illness or drug intake.

Physical Examination

The physical examination revealed symmetrically distributed multiple discrete and cofluent depigmented macules and confluent patches on the forehead, cheecks and perioral areas. The depigmented lesions were associated with multiple dark brown macules especially on the forehead and cheeks giving a mottled appearance. No follicular plugging, scarring or milia were present.


Laboratory investigations

The routine blood and urinalysis and serology including ANA and anti ds DNA were unremarkable.

The patient did not give her consent for the biopsy, so the lesions were not biopsied.

Vitiligo and solar lentigenes

The differential diagnoses included discoid lupus erythematosus, actinic lichen planus, fixed drug eruption, depigmentation following exposure to phenolic cleaners or bleaching agents and post inflammatory hypo and hyperpigmentation.

Reasons Presented

To know the comments of other dermatologists regarding the possible etiology of a localised mottled eruption especially involving the sun exposed areas


What caused the hyperpigmented lesions? Could our colleagues help me understand the simultaneous eruption of the depigmented and hyperpigmented lesions.


1. Sethuraman G, D'Souza M, Thappa DM. Localized dyschromatosis. J Dermatol. 2001 Jun;28(6):332-4.

2. Aloi F, Solaroli C, Giovannini E. Actinic lichen planus simulating melasma. Dermatology. 1997;195(1):69-70.

3. Yashar SS, Lim HW. Classification and evaluation of photodermatoses. Dermatol Ther. 2003;16(1):1-7.

Comments from Faculty and Members

Thomas Jayakar MD, PhD , Professor of Dermatology, Chennai, India on Feb 28, 2005

I had seen this picture earlier from Dr. Janjua.
I was favoring a diagnosis of actinic lichen planus as well as an LE/LP overlap. The side view picture shows telangiectasia over the malar region. We should probably keep in mind photo-induced poikiloderma.
A biopsy with immunofluorescence study will be the final court of appeal. I wish Dr. Janjua could coax the patient to agree for a biopsy. Best wishes to VGR-D

Raafa Hayani MD, Baghdad, Iraq on Feb 28, 2005

The hyperpigmented lesions are looking violaceous so the exclusion of actinic lichen planus via biopsy is mandatory.The hypopigmented skin are looking otherwise completely normal with involvement of area near orifices which support the diagnosis of vitiligo whether due to external cause like phenolic compound or internal causes. We see many cases of DLE with postinflamatory vitiligo like leukoderma but the skin is not looking normal like this and if the photos are not so clear the possibility of LP DLE overlap is good and still biopsy is important.

Walter and Dorinda Shelley, M.D., Professors of Dermatology, Medical College of Ohio, Toledo, OH, USA on Feb 28, 2005.

Here is our take on this patient:

1) Looks like DLE - but if nothing is palpable, it is probably vitiligo.

2) The distribution is striking and suggests underlying peridontal or tooth disease of lower jaw. She needs comprehensive dental exam and

3) Where did the lesions start? Lips? (consider HSV) Below ears? (chronic ear infection) Scalp line, anterior or posterior? (look at throat).

4) Follow the trail of infection and TREAT - suggest 4 week trials with Augmentin, doxycycline, Flagyl, and Zovirax.

Richard Sontheimer M.D., Professor and Vice-Chairman, Department of Dermatology, Fleischaker Endowed Chair in Dermatology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA on Feb 28, 2005

I would be interested in knowing more about the duration of this eruption. If it has been present for a long period of time I would more strongly consider a burned out case of cutaneous LE or LE/lichen planus overlap. Some forms of cutaneous LE can resolve with non-atrophic vitiligo-like depigmentation (eg, SCLE and superficial forms of discoid LE). In addition, I think that the association between the hyperpigmentation and hypopigmentation also suggest cutaneous LE. On the forhead and scalp, several areas of hypopigmentation appear to be immediately bordered by hyperpigmentation. This arrangement of pigmentary changes is very characteristic of cutaneous LE (i.e., peripheral postinflammatory hyperpigmentation surrounding central postinflammatory hypopigmentation). I would also be interested in knowing whether she might have any of the follicular changes in her external auditory canals that are often seen in cutaneous LE patients having involvement of the face and scalp (perifollicular hyperpigmentation, patulous follicules, keratin plugged follicles). I would consider a skin biopsy mandatory in this case.

Khaled El-Hoshy MD, Troy, Michigan, USA on Feb 28, 2005

Consider actinic lichen planus, topical steroids and sunscreen usage may be of help.

Abir Saraswat MD, Lucknow, India on Mar 1, 2005

The predominantly periorificial distribution is reminiscent of vitiligo, as is the sharply demarcated depigmented patch on the chin, which does not have any hyperpigmented border or scarring. the involvement of scalp and hairline and sparing of the most convex parts of the face makes a primary photosensitive eruption unlikely. Keeping in mind the violaceous macules (?papules), coexisting vitiligo / Lichen planus is my first possibility. A biopsy from the lesions at the hairline should be not too disfiguring.

Additional image posted on March 2, 2005

Omid Zargari MD, Assistant Professor of Dermatology, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran on Mar 2, 2005

To me it looks like DLE (or LE/LP overlap). Pigmentary changes are not uncommon in DLE, especially in dark skin people.

Khalifa Shaquie MD, PhD, Professor of Dermatology, College of Medicine, University of Baghdad, Baghdad, Iraq on Mar 3, 2005

On careful examination of the rash, we can notice both lichenoid eruption and leucoderma on the face of outdoor worker. So both problems could be triggered by sunlight. Regarding lichenoid rash is strongly suggestive lichen planus actinicus after excluding the thiazides intake that can cause lichenoid solar rash. Lichen planus actinicus is a common problem in Middle East and India and no problem to establish right clinical diagnosis. Post-inflammatory leucoderma can happen at the lesions of LP actinicus but in the present case the leucodermas are unrelated and go beyond the LP rash. So accordingly the white milky spots are ordinary vitiligo which accidently occured in combination with LP actinicus and both are induced by autoimmune reaction. Psoralen drugs should not be used in treatment of vitiligo otherwise will exacerbate LP actinicus. So the management needs avoidance of sunlight exposure with sunsreen and corticosteroid, both topical and systemic for both vitiligo and LP. In addition we can use topical 5% iodine tincture or 5% lactic solution 3 times weekly for vitiligo as additional remedy.

Sunil Dogra MD, Dept. of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India on Mar 7, 2005

Lesions particularly over the forehead are violaceous and depigmented macules and patches over lips and ear are characteristic of vitiligo. No scarring and lack of hyperpigmentation at borders or center of these dipigmented patches or any other epidermal change make DLE to be very unlikely. I wil consider the possibility of LP(actinic?) and vitiligo overlap. Biopsy from forehead papule should resolve issue.

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