Revista SPDV 71(1) 2013; Fred Bernardes Filho, Maria Victória Pinto Quaresma Santos,Felipe Nazareth de Matos Pinto
de Carvalho, et al.;
Ashy dermatosis caused by antidepressants.
Caso Clínico
DERMATOSE CINZENTA ASSOCIADA COM USO ORAL DE
ANTIDEPRESSIVO
Fred Bernardes Filho, MD1, Maria Victória Pinto Quaresma Santos, MD2,Felipe Nazareth de Matos Pinto de Carvalho,
MD3, Paulo Henrique Cordeiro de Oliveira4, Marco Antônio Bianco de Soto4, Fernanda da Fonseca Oliveira4, Franciely
Silva4, Carlos Gustavo Carneiro de Castro, MD5
1
Pós Graduando de Dermatologia / Graduated in Dermatology, no Instituto de Dermatologia Professor Rubem David
Azulay da Santa Casa da Misericórdia do Rio de Janeiro (IDPRDA - SCMRJ) - Rio de Janeiro (RJ), Brazil
2
Pós Graduanda de Dermatologia / Graduated in Dermatology, no Instituto de Dermatologia Professor Rubem David
Azulay da Santa Casa da Misericórdia do Rio de Janeiro (IDPRDA - SCMRJ) - Rio de Janeiro (RJ), Brazil
3
Pós Graduando de Dermatologia / Graduated in Dermatology, na Universidade Federal do Rio de Janeiro (UFRJ) -
Rio de Janeiro (RJ), Brazil
4
Acadêmicos deMedicina /Medical Academic, da Universidade do Grande Rio (UNIGRANRIO), Rio de Janeiro (RJ),
Brazil
5
Dermatologista Especialista / Specialist of Dermatology, pela Sociedade Brasileira de Dermatologia (SBD) e
Associação Médica Brasileira (AMB)
Trabalho realizado em clínica particular / Study performed at a private clinic.
RESUMO – Dermatose cinzenta ou eritema discrômico persistente (EDP) é uma síndrome clínica de classificação
controversa. A condição é rara no Brasil. Foi descrita inicialmente em El Salvador, mas também tem sido encontra-
da em vários países da América do Sul e em outras regiões do mundo. Sua etiologia é desconhecida, porém alguns
autores acreditam que ela representa uma apresentação difusa de erupção medicamentosa fixa, enquanto outros a
consideram como uma variante do líquen plano pigmentoso por apresentar achados histopatológicos semelhantes.
Clinicamente apresenta-se com lesões na forma de numerosas máculas cinza de tamanhos variados. Não há trata-
mento eficaz até o momento, no entanto, os benefícios foram relatados com o uso de clofazimina. Neste relato de
caso, os autores descrevem um caso de ashy dermatose associada ao uso de inibidores específicos da recaptação da
serotonina.
PALAVRAS-CHAVE – Dermatose cinzenta; Eritema; Hiperpigmentação; Líquen plano.
ASHY DERMATOSIS ASSOCIATED WITH ORAL ANTIDEPRESSANTS
ABSTRACT – Ashy dermatosis or erythema dyschromicum perstans (EDP) is a clinical syndrome with a controversial
classification. The condition is rare in Brazil. It was initially reported in El Salvador but has also been found in several
South American countries and in other regions of the world. Its etiology is unknown; however, some authors believe
that it represents a diffuse presentation of fixed drug eruption, while others consider it to be a variant of lichen planus
pigmentosus in view of the similar histopathological findings. Clinically, the condition presents with lesions in the form
of numerous gray macules of varying sizes. There is no effective treatment to date; however, benefits have been repor-
ted with the use of clofazimine. In this report, the authors describe a case of ashy dermatosis associated with the use of
serotonin-specific reuptake inhibitors.
KEY-WORDS – Skin diseases; Erythema; Hyperpigmentation; Drug eruptions; Lichen planus.
Conflitos de interesse: Os autores declaram não possuir conflitos de interesse.
No conflicts of interest.
85
Revista SPDV 71(1) 2013; Fred Bernardes Filho, Maria Victória Pinto Quaresma Santos,Felipe Nazareth de Matos Pinto de Carvalho, et al.;
Ashy dermatosis caused by antidepressants.
Caso Clínico
Suporte financeiro: O presente trabalho não foi suportado por nenhum subsídio ou bolsa.
No sponsorship or scholarship granted.
Direito à privacidade e consentimento escrito / Privacy policy and informed consent: Os autores declaram que
pediram consentimento ao doente para usar as imagens no artigo.
The authors declare that the patient gave written informed consent for the use of its photos in this article.
Recebido/Received – Novembro/November 2012; Aceite/Accepted – Dezembro/December 2012
Correspondência:
Dr. Fred Bernardes Filho
Rua Marquês de Caxias, 9 Centro
24030-050 Niterói, RJ, Brazil
Tel.: +55 21 25426658
Fax: + 55 21 25444459
E-mail: [email protected]
INTRODUCTION Fixed drug eruption is an acute drug reaction that
improves following withdrawal of the causative drug,
Ashy dermatosis or erythema dyschromicum perstans leaving a residual hyperpigmentation. Several drugs
(EDP) is a hypermelanotic disorder first described by Ra- may induce fixed pigmented erythema, including chlor-
mirez in 1957. It is characterized by bluish-grey macules mezanone, penicillin, acetylsalicylic acid, diclofenac,
that develop on the skin of healthy individuals1,2. It is a indomethacin, mefenamic acid, ibuprofen, nimesulide,
controversial entity, with some authors considering EDP clarithromycin, levamisole, phenobarbital and sulfame-
to represent a variant of lichen planus pigmentosus in thoxazole-trimethoprim, among others7.
view of the overlapping clinical and histologic features In ashy dermatosis, clinical differential diagnoses
of these two conditions. However, according to the lite- include, principally, a fixed drug eruption with multiple
rature, there are significant clinical differences between lesions and postinflammatory hyperpigmentation se-
these two dermatoses, giving strength to the hypothesis condary to a lichenoid drug eruption, pityriasis rosea,
that they represent two separate conditions3,4. small plaque parapsoriasis, Addison's disease, hemo-
Ashy dermatosis occurs predominantly in dark skin- chromatosis, lichen planus and erythema multiforme.
ned individuals, principally women. It affects individuals Less common conditions that should be included in a
of all ages. Most patients present with slowly progres- differential diagnosis are macular forms of urticaria pig-
sing gray, brownish-gray or bluish-gray macules and mentosa, pinta and leprosy2,7.
patches. The presence of an active red border or a pe- Up to the present date, a rigorous epidemiologic
ripheral erythematous margin of 1-2mm in diameter is study examining potential triggers has yet to be perfor-
uncommon. The most commonly affected sites are the med. Furthermore, the possibility has been raised that
neck, face, trunk and proximal arms, with distribution some patients with multiple fixed drug eruptions may
being usually symmetric. No reticular pattern or pruritus be misdiagnosed as having EDP, emphasizing the need
is found with ashy dermatosis. Although the condition to carefully review all medications, including over-the-
may clear up spontaneously, particularly in prepubertal -counter drugs and herbal remedies.
children, the lesions usually follow a chronic and insi-
dious course and persist for years in adults. Lichen pla-
nus pigmentosus is characterized by papules, a reticular CASE REPORT
pattern and occasional pruritus, with the lesions affec-
ting sun-exposed and flexural areas. These two derma- A 60-year-old Latin-American woman presented at
toses are histologically similar; however, according to an outpatient clinic with dark spots on her abdomen
the literature, hyperkeratosis, hypergranulosis and li- that had been present for the preceding 8 months. The
chenoid infiltrate are absent in ashy dermatosis2-6. lesions had gradually progressed to her forehead, back,
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Revista SPDV 71(1) 2013; Fred Bernardes Filho, Maria Victória Pinto Quaresma Santos,Felipe Nazareth de Matos Pinto de Carvalho, et al.;
Ashy dermatosis caused by antidepressants.
Caso Clínico
arms and legs. The patient denied itching, numbness or
scaling on the lesions. She also reported having been
in treatment for hypothyroidism for the past 15 years
and for depression for the past year. Depression was
initially treated with fluoxetine, this medication being re-
placed by paroxetine hydrochloride after 6 months. The
patient’s family history revealed nothing of significance.
Dermatological examination showed numerous con-
fluent bluish-gray macules of varying sizes and shapes
located on the patient’s neck, abdomen, back and right
arm (Figs. 1, 2 and 3). No peripheral erythematous ring
was present in the lesions. The diagnostic hypotheses
taken into consideration were fixed drug eruption, ashy
dermatosis and lichen planus. An incisional biopsy was Fig 3 - Numerous confluent bluish-gray macules of varying
performed on a lesion located on the right arm. His- sizes and shapes located on the arm.
topathology revealed necrotic keratinocytes, pigmenta-
ry incontinence, melanophages and mild perivascular
mononuclear infiltrate (Fig. 4). Based on the association
of the clinical manifestations and histopathological fin-
dings, a diagnosis of erythema dyschromicum perstans
Fig 1 - Numerous confluent bluish-gray macules of varying
sizes and shapes located on the neck.
Fig 4 - Necrotic keratinocytes, pigmentary incontinence,
Fig 2 - Numerous confluent bluish-gray macules of varying melanophages and mild superficial perivascular mononu-
sizes and shapes located on the abdomen. clear infiltrate.
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Revista SPDV 71(1) 2013; Fred Bernardes Filho, Maria Victória Pinto Quaresma Santos,Felipe Nazareth de Matos Pinto de Carvalho, et al.;
Ashy dermatosis caused by antidepressants.
Caso Clínico
was established. The patient was advised to discontinue REFERENCES
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