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Year : 2017  |  Volume : 8  |  Issue : 5  |  Page : 367-370  

Idiopathic eruptive macular pigmentation in an Indian male

1 Department of Dermatology and Venereology, All Institute of Medical Sciences, New Delhi, India
2 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India
3 Department of Pathology, All Institute of Medical Sciences, New Delhi, India

Date of Web Publication15-Sep-2017

Correspondence Address:
Sweta Subhadarshani
Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi - 110 049
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/idoj.IDOJ_274_16

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How to cite this article:
Subhadarshani S, Singh A, Ramateke PP, Verma KK. Idiopathic eruptive macular pigmentation in an Indian male. Indian Dermatol Online J 2017;8:367-70

How to cite this URL:
Subhadarshani S, Singh A, Ramateke PP, Verma KK. Idiopathic eruptive macular pigmentation in an Indian male. Indian Dermatol Online J [serial online] 2017 [cited 2022 Jan 18];8:367-70. Available from: https://www.idoj.in/text.asp?2017/8/5/367/214712


We report a 24-year-old man who presented with asymptomatic dark brown lesions over the face and trunk of 20 years duration. They appeared spontaneously without any preceding erythema or topical/systemic therapy. The lesions started insidiously and gradually progressed over a period of 3 years followed by a quiescent phase of around 16 years and aggravation 1 year before presenting to us. The general physical and systemic examination was unremarkable. Cutaneous examination revealed multiple brownish-gray to dark, discrete, round-to-oval, barely elevated plaques of size 0.5 to 2 cm [Figure 1]a and [Figure 1]b. Most of the lesions had a velvety texture. Palms and soles were spared. He also had mild acanthosis nigricans of bilateral axillae [Figure 1]c. The mucosae, hair, and nails were normal. Darier's sign was negative. Hematological and biochemical investigations including fasting blood sugar. glycosylated hemoglobin, and fasting insulin levels were normal. Skin biopsy showed irregular acanthosis, papillomatosis [Figure 2], keratin horn formation, and basal layer hyperpigmentation [Figure 3]. The upper dermis showed sparse superficial lymphohistiocytic infiltrate. Few melanophages were seen in the papillary dermis. The mast cell number was normal on hematoxylin and eosin stain. A diagnosis of idiopathic eruptive macular pigmentation (IEMP) was made based on characteristic clinical and histopathological features.
Figure 1: (a) Multiple hyperpigmented plaques on the trunk. (b) Close up picture showing velvety hyper pigmented plaque. (c) Acanthosis nigricans in axilla

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Figure 2: Skin biopsy H&E stain showing irregular acanthosis, papillomatosis, keratin horn formation, and basal layer hyperpigmentation

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Figure 3: Skin biopsy H&E stain showing prominent basal layer hyper pigmentation

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The patient was started on topical tretinoin 0.05% application once daily for 2 months without much improvement, following which it was discontinued.

IEMP is a rare disorder of pigmentation of unknown etiology. It was first described by Degos et al.[1] in 1978, and since then, less than 50 cases have been reported. Joshi et al.[2] have reported the largest series of 48 cases. IEMP is self-resolving and has been reported to disappear spontaneously in months to years. An unusual case IEMP lasting for 21 years in a 24-year-old woman was characterized by several periods of spontaneous resolution followed by recurrences.[3]

The diagnostic criteria for IEMP were given by Sanz de Galdeano et al. in 1996 which includes (a) Eruption of brownish, nonconfluent, asymptomatic macules involving the trunk, neck, and proximal extremities in children and adolescents; (b) absence of preceding inflammatory lesions; (c) no previous drug exposure; (d) basal layer hyperpigmentation of the epidermis and prominent dermal melanophages without visible basal layer damage or lichenoid inflammatory infiltrate; (e) normal mast cell count (4).[4] Our patient fulfilled all these criteria.

Recently, lesions occurring in a Christmas tree pattern [5] and limited to flexures [6] have been described. The differential diagnosis include lichen planus pigmentosus (LPP), erythema dyschromicum perstans (EDP), fixed drug eruption, and mastocytosis. However, none of these have velvety lesions. In IEMP, a preceding cause is absent and Darier's sign is negative. The disease occurs primarily during childhood and adolescence usually without a history of erythema or drug medication unlike FDE. LPP is characterized by hyperpigmented, dark-brown macules in sun-exposed areas and flexural folds whereas EDP has hyperpimented macules surrounded by erythema.

Histologically, an atrophic epidermis, a vacuolar alteration of the basal cell layer with a scarce lymphohistiocytic lichenoid infiltrate and pigment incontinence are seen in LPP. In EDP, slate gray macules with rim of erythema without any predilection for photoexposed sites are seen and pigment is also present in deep dermis. However, in IEMP, there is absence of lichenoid infiltrate or basal cell damage and mast cells are normal in number. There is acanthosis, basal layer hyperpigmentation, and dermal melanophages. The histopathological finding “pigmented papillomatosis,” which is a characteristic feature reported in a series of nine cases from India was present in our case too.[7] Emphasis has been laid on the histological presence of pigmented papillomatosis to be a diagnostic criteria for IEMP [Table 1].[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18]
Table 1: Cases published till date with histological emphasis on pigmented papillomatosis

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This case is reported for its rarity with an objective to increase its awareness among dermatologists and pathologists. Although it has been called as eruptive acanthosis nigricans in view of clinical and histological similarity, there was no metabolic derangement in our patient. He had associated acanthosis nigricans of axillae which may suggest a possible relationship between these disorders. The clinical course of our patient was different as he never had spontaneous resolution but his disease stopped progressing followed by a sudden aggravation 16 years later.

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   References Top

Degos R, Civatte J, Belaich S. La pigmentation maculeuse eruptive idiopathique. Ann Dermatol Venerol 1978;105:177-82.  Back to cited text no. 1
Joshi RS, Rohatgi S. Idiopathic eruptive macular pigmentation: A critical review of published literature and suggestions for revision of criteria for diagnosis. Indian J Dermatol Venereol Leprol 2015;81:576-80.  Back to cited text no. 2
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Mehta S, Aasi S, Cole R, Chu P, Weinberg JM. Idiopathic eruptive macular pigmentation: A case of 21 years' duration. J Am Acad Dermatol 2003;49(Suppl):S280-2.  Back to cited text no. 3
Sanz de Galdeano C, Léauté-Labrèze C, Bioulac-Sage P, Nikolic M, Taïeb A. Idiopathic eruptive macular pigmentation: Report of five patients. Pediatr Dermatol 1996;13:274-7.  Back to cited text no. 4
Oiso N, Kawada A. Idiopathic eruptive macular pigmentation following a Christmas tree pattern. J Dermatol 2013;40:934-5.  Back to cited text no. 5
Kim EH, Lee ES, Kim YC, Kang HY. A case of idiopathic eruptive macular pigmentation limited to flexural areas. Ann Dermatol 2008;20:98-101.  Back to cited text no. 6
Joshi R, Palwade PK. Idiopathic eruptive macular pigmentation or acanthosis nigricans? Indian J Dermatol Venereol Leprol 2010;76:591.  Back to cited text no. 7
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Milobratovic D, Djordjevic S, Vukicevic J, Bogdanovic Z. Idiopathic eruptive macular pigmentation associated with pregnancy and Hashimoto thyroiditis. J Am Acad Dermatol 2005;52:919-21.  Back to cited text no. 8
Joshi R. Idiopathic eruptive macular pigmentation withpapillomatosis: Report of nine cases. Indian J Dermatol Venereol Leprol 2007;73:402-5.  Back to cited text no. 9
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Grover S, Basu A. Idiopathic eruptive macular pigmentation: Report on two cases. Indian J Dermatol 2010;55:277-8.  Back to cited text no. 10
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Verma S, Thakur BK. Idiopathic eruptive macular pigmentation with papillomatosis. Indian Dermatol Online J 2011;2:101-3.  Back to cited text no. 11
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Begum A, Ramchandra BV, Kumar A. Idiopathic eruptive macular pigmentation. Indian J Paediatr Dermatol 2014;15:114-6.  Back to cited text no. 12
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Herd TJ, Wright TS. Idiopathic eruptive macular pigmentationinvolving the distal extremities: A case report. Pediatr Dermatol 2014;31:e52-4.  Back to cited text no. 13
Wei-Feng Z, Ai-E X, Jun-Fan C. Idiopathic eruptive macular pigmentation in a Chinese child. Indian Dermatol Online J 2015;6:274-6.  Back to cited text no. 14
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Fu CL, Hu YF, Song YZ. Idiopathic eruptive macular pigmentation in a child with citrin deficiency. Pediatr Int 2016;58:902-5.  Back to cited text no. 15
Tsai WC, Lan J, Lee CH. Progression of Idiopathic Eruptive Macular Pigmentation in a Girl from Childhood to Adolescence: Case Report and Literature Review. Pediatr Dermatol 2016;33:e299-302.  Back to cited text no. 16
Pang YZ, Koh WL, Ang CC. Idiopathic eruptive macular pigmentation with papillomatosis (IEMPP): A controversial entity. Dermatol Online J 2016;22.  Back to cited text no. 17
Misri RR, Khurana VK, Thole AV, Nagad MB. Idiopathic eruptive macular pigmentation with papillomatosis: An unfamiliar entity. Indian J Dermatol 2016;61:581.  Back to cited text no. 18
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