Slate Gray Perioral Pigmentation in a Boy
Year: 2025
Type: article
Abstract: Dear Editor, A 7-year-old boy was brought to the dermatology clinic for evaluation of dark brown to grayish peri-oral pigmentation. The pigmentation was asymptomatic, insidious in onset, and gradually progressive over the past few months. Medical history was unremarkable, with no significant past illnesses or allergies. Upon examination, dark brown to gray macules and patches were observed over the perioral and mental region [Figure 1]. No signs of inflammation were noted. On dermatoscopic examination, grayish-brown pigment dots forming a broken reticular network were seen [Figure 2]. Histopathology showed epidermal atrophy, vacuolar degeneration of the basal layer, variable lichenoid infiltrate, and pigment incontinence [Figure 3]. The patient was started on topical tacrolimus and is currently under follow-up. Based on clinical, dermoscopic, and histopathological findings, a diagnosis of lichen planus pigmentosus (LPP) was arrived at. The child was started on topical steroids and is currently under follow-up with mild improvement after 2 months.Figure 1: A 7-year-old boy with dark brown to grayish, peri-oral pigmentationFigure 2: Dermatoscopic image showing grayish-brown pigment dots forming a broken reticular network (Dermlite IV, polarized, ×10)Figure 3: Histopathology image showing vacuolar degeneration of the basal layer; variable lichenoid infiltrate and epidermal atrophy (H and E, ×20)Pediatric LPP is rare, mainly affecting children of Indian or Middle Eastern descent.[1] A study of 21 cases of pediatric LPP found 95.8% to be in children of skin color, with an average age of 10.7 years (range 5-16 years).[2] LPP typically affects the head and neck, but an inverse variant exists. Slate gray perioral and periorbital pigmentation distinguishes LPP from pigmented cosmetic dermatitis.[3] LPP may be linked to autoimmune disorders like lichen planus, vitiligo, and hypothyroidism, suggesting an autoimmune role. Interestingly, pediatric LPP manifests in a Blaschkoidal pattern, indicating a genetic predisposition.[4] LPP lesions initially appear as small, ill-defined oval-to-round macules, later merging to create extensive pigmented areas. The pigmentation ranges from slate-gray to brownish-black, typically uniform within a patient. Distinguishing mildly pruritic brown macules in children involves considering conditions such as LPP, postinflammatory hyperpigmentation, fixed drug eruption, lichenoid drug eruption, erythema dyschromica perstans (EDP), and terra firma-forme dermatosis. EDP presents as slate gray macules with an erythematous halo on the trunk and limbs, showing epidermal vacuolization and mild perivascular inflammatory infiltrates on histopathology. It is grouped under acquired dermal macular hyperpigmentation, along with LPP and pigmented contact dermatitis.[5] Lip licker’s dermatitis in young children, often linked with atopy, leads to chronic redness, dryness, and scaling around the lips, sometimes beyond the vermillion border. Histopathology reveals spongiosis with epidermal neutrophils, swollen capillaries in the subepidermal dermis, and perivascular lymphocytic infiltrates. Dermatoscopy shows serocrusts, uneven dotted vessels, and a dull red backdrop. Our patient had no history of atopy. Pediatric LPP is rare, demanding a high clinical suspicion and reliance on dermatoscopy for initial differentiation. Biopsy remains the universally accepted gold standard for definitive diagnosis. Dermatoscopically, LPP features pigment dots, globules, and blotches, with owl-eye-like structures (which consist of a central brown dot surrounded by a hyperpigmented halo) and an exaggerated pseudoreticular pattern.[6] Histopathologically, it exhibits a lichenoid infiltrate, basal cell vacuolization, and melanin incontinence. Rarely, apoptotic keratinocytes are identified.[5] Therapeutically, outcomes are often suboptimal, with topical corticosteroids and tacrolimus as primary treatments. Narrowband ultraviolet B treatment has shown success in pediatric cases of LPP inversus.[7] The rarity of pediatric LPP, varied clinical manifestations, and possible autoimmune links emphasize the need for increased awareness and precise diagnosis. Further research is crucial to uncover genetic and immunological aspects, leading to more effective therapeutic strategies, especially in pediatric cases. Declaration of consent The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Authors: Manavi Gupta, Apoorva Sharma, Debajyoti Chatterjee, Keshavamurthy Vinay
Language: English
Subfield: Cell Biology
Domain: Life Sciences
Open Access status: diamond
OpenAlex ID: W4408957657