Pigmentation today

ByBy

Fat’heya ZahranFat’heya Zahran

Professor, Cairo University Professor, Cairo University

ByBy

Fat’heya ZahranFat’heya Zahran

Professor, Cairo University Professor, Cairo University

Non MelanoticNon Melanotic Non MelanoticNon Melanotic

LocalizedLocalized DiffuseDiffuse

MelanoticMelanotic MelanoticMelanotic

Localized:Localized: Ectodermal alteration Ectodermal alteration

Acanthosis NigericansAcanthosis Nigericans Increased melanin production:Increased melanin production:

Café au lait spots Café au lait spots e.g. polyostotic fibrous dysplasia e.g. polyostotic fibrous dysplasia and multiple neurofibromatosisand multiple neurofibromatosis..

Smoker’s melanosisSmoker’s melanosis Lichen planusLichen planus Local irritation.Local irritation.

Melanocyte proliferation:Melanocyte proliferation: NaeviNaevi Melanoma/malignant melanomaMelanoma/malignant melanoma Lentigo Lentigo e.g. peutz Jegher’s syndromee.g. peutz Jegher’s syndrome

Drug-Induced.Drug-Induced.

Localized:Localized: Ectodermal alteration Ectodermal alteration

Acanthosis NigericansAcanthosis Nigericans Increased melanin production:Increased melanin production:

Café au lait spots Café au lait spots e.g. polyostotic fibrous dysplasia e.g. polyostotic fibrous dysplasia and multiple neurofibromatosisand multiple neurofibromatosis..

Smoker’s melanosisSmoker’s melanosis Lichen planusLichen planus Local irritation.Local irritation.

Melanocyte proliferation:Melanocyte proliferation: NaeviNaevi Melanoma/malignant melanomaMelanoma/malignant melanoma Lentigo Lentigo e.g. peutz Jegher’s syndromee.g. peutz Jegher’s syndrome

Drug-Induced.Drug-Induced.

Diffuse:Diffuse: Racial pigmentation (basilar melanosis)Racial pigmentation (basilar melanosis) Metabolic pigmentationMetabolic pigmentation

HemochromatosisHemochromatosis PorphyriaPorphyria Pellagra Pellagra

EndocrineEndocrine Addison’s diseaseAddison’s disease HyperpituitrismHyperpituitrism

AutoimmuneAutoimmune HIV melanosisHIV melanosis Lung/pancreas malignancyLung/pancreas malignancy Drug-inducedDrug-induced

Drugs causing melanin formation Drugs causing melanin formation e.g. ACTH, busulfane.g. ACTH, busulfan Drugs forming complex with melanin Drugs forming complex with melanin e.g. minocycline.g. minocyclin Drug deposited in skin and mucous membrane Drug deposited in skin and mucous membrane e.g. silver & golde.g. silver & gold

Diffuse:Diffuse: Racial pigmentation (basilar melanosis)Racial pigmentation (basilar melanosis) Metabolic pigmentationMetabolic pigmentation

HemochromatosisHemochromatosis PorphyriaPorphyria Pellagra Pellagra

EndocrineEndocrine Addison’s diseaseAddison’s disease HyperpituitrismHyperpituitrism

AutoimmuneAutoimmune HIV melanosisHIV melanosis Lung/pancreas malignancyLung/pancreas malignancy Drug-inducedDrug-induced

Drugs causing melanin formation Drugs causing melanin formation e.g. ACTH, busulfane.g. ACTH, busulfan Drugs forming complex with melanin Drugs forming complex with melanin e.g. minocycline.g. minocyclin Drug deposited in skin and mucous membrane Drug deposited in skin and mucous membrane e.g. silver & golde.g. silver & gold

Non MelanoticNon Melanotic

Lipopigments:Lipopigments: Lipochrome Lipochrome

(carotene)(carotene) Lipofuscin Lipofuscin Fordyce’s Fordyce’s

granulesgranules

Lipopigments:Lipopigments: Lipochrome Lipochrome

(carotene)(carotene) Lipofuscin Lipofuscin Fordyce’s Fordyce’s

granulesgranules

RBCS:RBCS: ExtravasationExtravasation Qualitative changes in HbQualitative changes in Hb Pigments resulting from Pigments resulting from

RBC destructionRBC destruction

RBCS:RBCS: ExtravasationExtravasation Qualitative changes in HbQualitative changes in Hb Pigments resulting from Pigments resulting from

RBC destructionRBC destruction

Vascular lesions:Vascular lesions: HemangiomasHemangiomas Kaposi’s sarcomaKaposi’s sarcoma Varices Varices Hereditary hemorrhagic Hereditary hemorrhagic

telangiectasiatelangiectasia

Vascular lesions:Vascular lesions: HemangiomasHemangiomas Kaposi’s sarcomaKaposi’s sarcoma Varices Varices Hereditary hemorrhagic Hereditary hemorrhagic

telangiectasiatelangiectasia

Chromogenic Chromogenic bacteriabacteria

Black hairy Black hairy tongue tongue

Chromogenic Chromogenic bacteriabacteria

Black hairy Black hairy tongue tongue

Heavy metals Heavy metals intoxication intoxication

Heavy metals Heavy metals intoxication intoxication

Acanthosis NigericansAcanthosis Nigericans Unusual dermatosis characterized by skin Unusual dermatosis characterized by skin

hyperkeratosis and melanin pigmentation and hyperkeratosis and melanin pigmentation and white oral lesion.white oral lesion.

Types:Types: Benign formBenign form

Associated with insulin resistant diabetes (defect in Associated with insulin resistant diabetes (defect in insulin receptors).insulin receptors).

Insulin will bind to receptor for ILGF → growth of the Insulin will bind to receptor for ILGF → growth of the cells instead of glucose utilization → hyperkeratosis, cells instead of glucose utilization → hyperkeratosis, acanthosis and papillomatosis.acanthosis and papillomatosis.

Malignant formMalignant form Internal malignancy releases certain peptides→ stimulate Internal malignancy releases certain peptides→ stimulate

melanin production.melanin production.

Unusual dermatosis characterized by skin Unusual dermatosis characterized by skin hyperkeratosis and melanin pigmentation and hyperkeratosis and melanin pigmentation and white oral lesion.white oral lesion.

Types:Types: Benign formBenign form

Associated with insulin resistant diabetes (defect in Associated with insulin resistant diabetes (defect in insulin receptors).insulin receptors).

Insulin will bind to receptor for ILGF → growth of the Insulin will bind to receptor for ILGF → growth of the cells instead of glucose utilization → hyperkeratosis, cells instead of glucose utilization → hyperkeratosis, acanthosis and papillomatosis.acanthosis and papillomatosis.

Malignant formMalignant form Internal malignancy releases certain peptides→ stimulate Internal malignancy releases certain peptides→ stimulate

melanin production.melanin production.

Acanthosis NigericansAcanthosis Nigericans

These lesions have the colour of coffee and cream that These lesions have the colour of coffee and cream that varies from small to large diffuse macule.varies from small to large diffuse macule.

They are found in two rare conditions; They are found in two rare conditions; neurofibromatosis and polyostotic fibrous dysplasia.neurofibromatosis and polyostotic fibrous dysplasia.

(A) Multiple neurofibromatosis (Von Recklinghausen’s (A) Multiple neurofibromatosis (Von Recklinghausen’s disease of skin)disease of skin)

It is an inherited autosomal dominant condition It is an inherited autosomal dominant condition which is characterized by proliferation of fibrous which is characterized by proliferation of fibrous element of nerve sheath and cafe au lait element of nerve sheath and cafe au lait pigmentation.pigmentation.

Café au lait pigmentationCafé au lait pigmentation

Clinical FeaturesClinical Features(1) Multiple nodules: (1) Multiple nodules:

Sessile or pedunculated, superficial or deep Sessile or pedunculated, superficial or deep nodules that mainly affect the trunk. nodules that mainly affect the trunk. Malignant transformation to neurogenic Malignant transformation to neurogenic sarcoma is common in 5 % of cases. The sarcoma is common in 5 % of cases. The lesion may involve the whole body causing lesion may involve the whole body causing cosmetic problem.cosmetic problem.

Tongue involvement results in multiple Tongue involvement results in multiple nodules due to proliferation of fibrous nodules due to proliferation of fibrous element of lingual nerve. In addition, element of lingual nerve. In addition, macroglossia, scrotal tongue and enlarged macroglossia, scrotal tongue and enlarged fungiform papillae had been reportedfungiform papillae had been reported

Multiple Multiple NeurofibromatosisNeurofibromatosis

Sessile Nodules with Café au Sessile Nodules with Café au Lait PigmentationLait Pigmentation

(2) Neurologic manifestation:(2) Neurologic manifestation:

Centrally located lesions within bone cavities are Centrally located lesions within bone cavities are

associated with neurological manifestations such as associated with neurological manifestations such as

pain, deafness, seizures, mental retardation and pain, deafness, seizures, mental retardation and

headache.headache.

Mandibular nerve involvement can be detected Mandibular nerve involvement can be detected

radiographically as radiolucent area and is radiographically as radiolucent area and is

associated with lip numbness and pain.associated with lip numbness and pain.

(3) Café au lait pigmentation.(3) Café au lait pigmentation.

(2) Neurologic manifestation:(2) Neurologic manifestation:

Centrally located lesions within bone cavities are Centrally located lesions within bone cavities are

associated with neurological manifestations such as associated with neurological manifestations such as

pain, deafness, seizures, mental retardation and pain, deafness, seizures, mental retardation and

headache.headache.

Mandibular nerve involvement can be detected Mandibular nerve involvement can be detected

radiographically as radiolucent area and is radiographically as radiolucent area and is

associated with lip numbness and pain.associated with lip numbness and pain.


))BB ( (Polyostotic Fibrous DysplasiaPolyostotic Fibrous Dysplasia

Unilateral bone involvementUnilateral bone involvement Most bones are intactMost bones are intact Skin café au lait spotsSkin café au lait spots No endocrinal disturbanceNo endocrinal disturbance

Unilateral bone involvementUnilateral bone involvement Most bones are intactMost bones are intact Skin café au lait spotsSkin café au lait spots No endocrinal disturbanceNo endocrinal disturbance

Jaffe typeJaffe typeJaffe typeJaffe type Albright syndromeAlbright syndromeAlbright syndromeAlbright syndrome

Unilateral Unilateral Most bones are affectedMost bones are affected Café au lait spotsCafé au lait spots Endocrinal disturbance is present:Endocrinal disturbance is present:

ParathyroidParathyroid ThyroidThyroid PituitaryPituitary Gonads (precocious puberty)Gonads (precocious puberty)

Unilateral Unilateral Most bones are affectedMost bones are affected Café au lait spotsCafé au lait spots Endocrinal disturbance is present:Endocrinal disturbance is present:

ParathyroidParathyroid ThyroidThyroid PituitaryPituitary Gonads (precocious puberty)Gonads (precocious puberty)

Albright SyndromeAlbright Syndrome

Oral Findings:Oral Findings: Slowly progressive expansion of jaw bone:Slowly progressive expansion of jaw bone:

Jaw bone is replaced by fibrous tissue and the Jaw bone is replaced by fibrous tissue and the cortex becomes thin leading to pathologic cortex becomes thin leading to pathologic fracturefracture

Radiographically the lesion may show one of Radiographically the lesion may show one of these patterns:these patterns: Ground glass radio-opaque pattern Ground glass radio-opaque pattern Mottled radiolucent & radio-opaque patternMottled radiolucent & radio-opaque pattern Unilocular or multilocular radiolucencv Unilocular or multilocular radiolucencv

Oral Findings:Oral Findings: Slowly progressive expansion of jaw bone:Slowly progressive expansion of jaw bone:

Jaw bone is replaced by fibrous tissue and the Jaw bone is replaced by fibrous tissue and the cortex becomes thin leading to pathologic cortex becomes thin leading to pathologic fracturefracture

Radiographically the lesion may show one of Radiographically the lesion may show one of these patterns:these patterns: Ground glass radio-opaque pattern Ground glass radio-opaque pattern Mottled radiolucent & radio-opaque patternMottled radiolucent & radio-opaque pattern Unilocular or multilocular radiolucencv Unilocular or multilocular radiolucencv

It is basilar melanosis that occurs in some It is basilar melanosis that occurs in some smokers where tobacco smoke products smokers where tobacco smoke products stimulate synthesis of melanin.stimulate synthesis of melanin.

It appears as diffuse brown flat macules, It appears as diffuse brown flat macules, mainly on anterior labial gingiva in mainly on anterior labial gingiva in cigarette smokers and on palate in pipe cigarette smokers and on palate in pipe smokers but may also appear on cheek and smokers but may also appear on cheek and lip mucosa.lip mucosa.

It is basilar melanosis that occurs in some It is basilar melanosis that occurs in some smokers where tobacco smoke products smokers where tobacco smoke products stimulate synthesis of melanin.stimulate synthesis of melanin.

It appears as diffuse brown flat macules, It appears as diffuse brown flat macules, mainly on anterior labial gingiva in mainly on anterior labial gingiva in cigarette smokers and on palate in pipe cigarette smokers and on palate in pipe smokers but may also appear on cheek and smokers but may also appear on cheek and lip mucosa.lip mucosa.

Smoker’s MelanosisSmoker’s Melanosis

Smoker’s MelanosisSmoker’s Melanosis

Lichen planus is dermatologic disease Lichen planus is dermatologic disease which is characterized by white papules, which is characterized by white papules, erosive and atrophic areas. Rarely erosive and atrophic areas. Rarely erosive or papular form may be erosive or papular form may be associated with diffuse melanosis.associated with diffuse melanosis.

This increase in melanogenesis may be This increase in melanogenesis may be stimulated by infiltrate of T-lymphocytes stimulated by infiltrate of T-lymphocytes

Lichen planus is dermatologic disease Lichen planus is dermatologic disease which is characterized by white papules, which is characterized by white papules, erosive and atrophic areas. Rarely erosive and atrophic areas. Rarely erosive or papular form may be erosive or papular form may be associated with diffuse melanosis.associated with diffuse melanosis.

This increase in melanogenesis may be This increase in melanogenesis may be stimulated by infiltrate of T-lymphocytes stimulated by infiltrate of T-lymphocytes

Pigmented Lichen PlanusPigmented Lichen Planus

Pigmented Lichen PlanusPigmented Lichen Planus

Definition:Definition:

It is benign proliferation of melanocytes It is benign proliferation of melanocytes that appears after birth and during that appears after birth and during childhood, reaching certain size then childhood, reaching certain size then remains static.remains static.


It is benign proliferation of melanocytes It is benign proliferation of melanocytes that appears after birth and during that appears after birth and during childhood, reaching certain size then childhood, reaching certain size then remains static.remains static.

Clinical Features:Clinical Features:(i) Nevocellular nevi(i) Nevocellular nevi:: Junctional nevi:Junctional nevi:

Nevus cells maintain their location at the junction of the Nevus cells maintain their location at the junction of the epithelium and connective tissue.epithelium and connective tissue.

They are flat, brown round and oval lesions.They are flat, brown round and oval lesions. Compound nevi:Compound nevi:

Nevus cells proliferate down into the connective tissue.Nevus cells proliferate down into the connective tissue. They are dome-shaped, brown lesions.They are dome-shaped, brown lesions.

Intradermal/intramucosal nevi:Intradermal/intramucosal nevi: Nevus cells are localized in connective tissue.Nevus cells are localized in connective tissue. They appear as elevated brown nodules.They appear as elevated brown nodules.

(ii)(ii) Blue nevi: Blue nevi: The nevus cells reside deeply in connective tissue. On skin they The nevus cells reside deeply in connective tissue. On skin they

appear blue in colour because the overlying vessels dampen the appear blue in colour because the overlying vessels dampen the brown colour of melanin.brown colour of melanin.

Clinical Features:Clinical Features:(i) Nevocellular nevi(i) Nevocellular nevi:: Junctional nevi:Junctional nevi:

Nevus cells maintain their location at the junction of the Nevus cells maintain their location at the junction of the epithelium and connective tissue.epithelium and connective tissue.

They are flat, brown round and oval lesions.They are flat, brown round and oval lesions. Compound nevi:Compound nevi:

Nevus cells proliferate down into the connective tissue.Nevus cells proliferate down into the connective tissue. They are dome-shaped, brown lesions.They are dome-shaped, brown lesions.

Intradermal/intramucosal nevi:Intradermal/intramucosal nevi: Nevus cells are localized in connective tissue.Nevus cells are localized in connective tissue. They appear as elevated brown nodules.They appear as elevated brown nodules.

(ii)(ii) Blue nevi: Blue nevi: The nevus cells reside deeply in connective tissue. On skin they The nevus cells reside deeply in connective tissue. On skin they

appear blue in colour because the overlying vessels dampen the appear blue in colour because the overlying vessels dampen the brown colour of melanin.brown colour of melanin.

Raised painless sessile or pedunculated.Raised painless sessile or pedunculated. If melanomas become painful, with increased If melanomas become painful, with increased

pigmentation, bleeding or ulceration this may pigmentation, bleeding or ulceration this may be a sign of malignancy.be a sign of malignancy.

Malignant melanoma is a rare neoplasma of Malignant melanoma is a rare neoplasma of the oral cavity.the oral cavity.

Most commonly found on the palate and Most commonly found on the palate and anterior labial gingiva.anterior labial gingiva.

Raised painless sessile or pedunculated.Raised painless sessile or pedunculated. If melanomas become painful, with increased If melanomas become painful, with increased

pigmentation, bleeding or ulceration this may pigmentation, bleeding or ulceration this may be a sign of malignancy.be a sign of malignancy.

Malignant melanoma is a rare neoplasma of Malignant melanoma is a rare neoplasma of the oral cavity.the oral cavity.

Most commonly found on the palate and Most commonly found on the palate and anterior labial gingiva.anterior labial gingiva.


It is an autosomal dominant syndrome It is an autosomal dominant syndrome

that is characterized by multiple that is characterized by multiple

intestinal polyposis and melanotic intestinal polyposis and melanotic

macules mainly on the face and oral macules mainly on the face and oral

cavitycavity

Peutz-Jegher’s SyndromePeutz-Jegher’s Syndrome

Clinical Features:Clinical Features: Brown Pigmentation:Brown Pigmentation:

Multiple melanotic macules appearing as freckles, Multiple melanotic macules appearing as freckles, mainly perioral, perinasal and perioccular.mainly perioral, perinasal and perioccular.

Melanotic macules are present intraoral, mainly on Melanotic macules are present intraoral, mainly on palate and lip.palate and lip.

Intestinal polyposis:Intestinal polyposis: Polyposis of small intestine may result in abdominal Polyposis of small intestine may result in abdominal

pain, hemorrhage or intestinal obstruction .pain, hemorrhage or intestinal obstruction . Malignant transformation can occur.Malignant transformation can occur. Intestinal polyps are better to be diagnosed by Intestinal polyps are better to be diagnosed by

barium enema.barium enema.

Clinical Features:Clinical Features: Brown Pigmentation:Brown Pigmentation:

Multiple melanotic macules appearing as freckles, Multiple melanotic macules appearing as freckles, mainly perioral, perinasal and perioccular.mainly perioral, perinasal and perioccular.

Melanotic macules are present intraoral, mainly on Melanotic macules are present intraoral, mainly on palate and lip.palate and lip.

Intestinal polyposis:Intestinal polyposis: Polyposis of small intestine may result in abdominal Polyposis of small intestine may result in abdominal

pain, hemorrhage or intestinal obstruction .pain, hemorrhage or intestinal obstruction . Malignant transformation can occur.Malignant transformation can occur. Intestinal polyps are better to be diagnosed by Intestinal polyps are better to be diagnosed by

barium enema.barium enema.

Peutz-Jegher’s SyndromePeutz-Jegher’s Syndrome

It is basilar melanosis that evolves in It is basilar melanosis that evolves in childhood, commonly in dark-skinned childhood, commonly in dark-skinned individuals.individuals.

It appears as multiple, diffuse flat It appears as multiple, diffuse flat brown macules, mainly on gingiva, brown macules, mainly on gingiva, labial and cheek mucosa.labial and cheek mucosa.

It is basilar melanosis that evolves in It is basilar melanosis that evolves in childhood, commonly in dark-skinned childhood, commonly in dark-skinned individuals.individuals.

It appears as multiple, diffuse flat It appears as multiple, diffuse flat brown macules, mainly on gingiva, brown macules, mainly on gingiva, labial and cheek mucosa.labial and cheek mucosa.

Physiologic Pigmentation Physiologic Pigmentation ((Racial PigmentationRacial Pigmentation))

Racial PigmentationRacial Pigmentation

Hemochromatosis (Hemochromatosis (Bronze DiabetesBronze Diabetes))

Primary : Primary : Disorder of inborn error of iron metabolism secondary to Disorder of inborn error of iron metabolism secondary to

increased intestinal iron absorption.increased intestinal iron absorption. Secondary:Secondary:

Due to increased iron intake or increased destruction of Due to increased iron intake or increased destruction of RBCs.RBCs.

Excess iron is deposited in various tissue and Excess iron is deposited in various tissue and organs:organs: In the liver producing liver cirrhosis.In the liver producing liver cirrhosis. In the pancreas producing diabetes mellitus.In the pancreas producing diabetes mellitus. In the adrenal gland inducing Addison’s disease. In the adrenal gland inducing Addison’s disease. In the heart inducing heart failure. In the heart inducing heart failure. In the skin producing pigmentation .In the skin producing pigmentation .

Primary : Primary : Disorder of inborn error of iron metabolism secondary to Disorder of inborn error of iron metabolism secondary to

increased intestinal iron absorption.increased intestinal iron absorption. Secondary:Secondary:

Due to increased iron intake or increased destruction of Due to increased iron intake or increased destruction of RBCs.RBCs.

Excess iron is deposited in various tissue and Excess iron is deposited in various tissue and organs:organs: In the liver producing liver cirrhosis.In the liver producing liver cirrhosis. In the pancreas producing diabetes mellitus.In the pancreas producing diabetes mellitus. In the adrenal gland inducing Addison’s disease. In the adrenal gland inducing Addison’s disease. In the heart inducing heart failure. In the heart inducing heart failure. In the skin producing pigmentation .In the skin producing pigmentation .

PorphyriasPorphyrias Hereditary diseases caused by abnormalities in the pathway Hereditary diseases caused by abnormalities in the pathway

of heme biosynthesis, resulting in over production of of heme biosynthesis, resulting in over production of porphyrins and porphyrin precursors.porphyrins and porphyrin precursors.

Two types are characterized by skin pigmentation:Two types are characterized by skin pigmentation: Cutaneous hepatic porphyria “Porphyria cutenea tarda”Cutaneous hepatic porphyria “Porphyria cutenea tarda”

Starts as erythema and progresses to vesicles that become confluent Starts as erythema and progresses to vesicles that become confluent to form bullae, that heal by scar with skin hyperpigmentation.to form bullae, that heal by scar with skin hyperpigmentation.

Congenital erythropoietic porphyria:Congenital erythropoietic porphyria: Excessive formation of porphyrin in bone marrow leads to its Excessive formation of porphyrin in bone marrow leads to its

deposition on the skin producing photosensitivity → vesicular and deposition on the skin producing photosensitivity → vesicular and bullous reaction on the light exposed skin.bullous reaction on the light exposed skin.

Vesicles contain serous fluid with red fluorescence.Vesicles contain serous fluid with red fluorescence. Healing is by scars and red brown hyperpigmentation.Healing is by scars and red brown hyperpigmentation. Urine is red in colour.Urine is red in colour. Lavender teeth: due to incorporation of porphyrins in decidous and Lavender teeth: due to incorporation of porphyrins in decidous and

permanent teethpermanent teeth

Hereditary diseases caused by abnormalities in the pathway Hereditary diseases caused by abnormalities in the pathway of heme biosynthesis, resulting in over production of of heme biosynthesis, resulting in over production of porphyrins and porphyrin precursors.porphyrins and porphyrin precursors.

Two types are characterized by skin pigmentation:Two types are characterized by skin pigmentation: Cutaneous hepatic porphyria “Porphyria cutenea tarda”Cutaneous hepatic porphyria “Porphyria cutenea tarda”

Starts as erythema and progresses to vesicles that become confluent Starts as erythema and progresses to vesicles that become confluent to form bullae, that heal by scar with skin hyperpigmentation.to form bullae, that heal by scar with skin hyperpigmentation.

Congenital erythropoietic porphyria:Congenital erythropoietic porphyria: Excessive formation of porphyrin in bone marrow leads to its Excessive formation of porphyrin in bone marrow leads to its

deposition on the skin producing photosensitivity → vesicular and deposition on the skin producing photosensitivity → vesicular and bullous reaction on the light exposed skin.bullous reaction on the light exposed skin.

Vesicles contain serous fluid with red fluorescence.Vesicles contain serous fluid with red fluorescence. Healing is by scars and red brown hyperpigmentation.Healing is by scars and red brown hyperpigmentation. Urine is red in colour.Urine is red in colour. Lavender teeth: due to incorporation of porphyrins in decidous and Lavender teeth: due to incorporation of porphyrins in decidous and

permanent teethpermanent teeth

PellagraPellagra It is niacin (Nicotinic acid) deficiency.It is niacin (Nicotinic acid) deficiency. It progresses through: It progresses through:

Dermatitis with melanin pigmentation of the Dermatitis with melanin pigmentation of the exposed skin surfaces (hands, feet and face).exposed skin surfaces (hands, feet and face).

Dementia (impaired memory) Dementia (impaired memory) Diarrhea, Diarrhea, Death (if untreated)Death (if untreated)

Oral manifestations:Oral manifestations: Stomatitis, Glossitis, Acute necrotizing ulcerative Stomatitis, Glossitis, Acute necrotizing ulcerative

gingivitis, Sialorrhea, Angular cheilosis, Herpes gingivitis, Sialorrhea, Angular cheilosis, Herpes labialis, Deminution of taste sensation.labialis, Deminution of taste sensation.

It is niacin (Nicotinic acid) deficiency.It is niacin (Nicotinic acid) deficiency. It progresses through: It progresses through:

Dermatitis with melanin pigmentation of the Dermatitis with melanin pigmentation of the exposed skin surfaces (hands, feet and face).exposed skin surfaces (hands, feet and face).

Dementia (impaired memory) Dementia (impaired memory) Diarrhea, Diarrhea, Death (if untreated)Death (if untreated)

Oral manifestations:Oral manifestations: Stomatitis, Glossitis, Acute necrotizing ulcerative Stomatitis, Glossitis, Acute necrotizing ulcerative

gingivitis, Sialorrhea, Angular cheilosis, Herpes gingivitis, Sialorrhea, Angular cheilosis, Herpes labialis, Deminution of taste sensation.labialis, Deminution of taste sensation.

Bronzing of skin and patchy melanosis of Bronzing of skin and patchy melanosis of the oral mucous membrane are features of the oral mucous membrane are features of adrenal cortex insufficiency (adrenal cortex insufficiency (Addison’s Addison’s diseasedisease) or hyperfunction of pituitary ) or hyperfunction of pituitary gland (gland (due to increased ACTHdue to increased ACTH).).

The oversecretion of ACTH results in The oversecretion of ACTH results in melanosis since it is a hormone that have melanosis since it is a hormone that have stimulating properties on melanocytes. stimulating properties on melanocytes.

Endocrinopathic PigmentationEndocrinopathic Pigmentation

HIV positive patients show HIV positive patients show hyperpigmentation of the nails and mucous hyperpigmentation of the nails and mucous membrane. The etiology is unknown but membrane. The etiology is unknown but may be due to the destruction of adrenal may be due to the destruction of adrenal cortex (cortex (Addison’s diseaseAddison’s disease).).

It appears as diffuse flat brown macules, It appears as diffuse flat brown macules, mainly on buccal and labial mucosa.mainly on buccal and labial mucosa.

HIV Oral MelanosisHIV Oral Melanosis

HIV Oral MelanosisHIV Oral Melanosis

LipopigmentsLipopigments Lipochrome: “Carotene”Lipochrome: “Carotene”

Carotenes are yellow or red fat soluble pigments found in Carotenes are yellow or red fat soluble pigments found in carrots, tomatoes, sweet potatoes, green leafy plants, milk, carrots, tomatoes, sweet potatoes, green leafy plants, milk, body fat and egg yolk.body fat and egg yolk.

Carotenes found in plants consist mainly of two molecules Carotenes found in plants consist mainly of two molecules of vitamin A, Joined by a double bond . Orally ingested of vitamin A, Joined by a double bond . Orally ingested carotenes are broken down by Carotenase enzyme into carotenes are broken down by Carotenase enzyme into vitamin A, the main storage of vitamin A is in the liver.vitamin A, the main storage of vitamin A is in the liver.

Excessive intake of carotene results in Excessive intake of carotene results in carotenemiacarotenemia The resultant yellow colour of skin is known as The resultant yellow colour of skin is known as

((carotenodermiacarotenodermia).). Carotene is water insoluble so Carotene is water insoluble so can not reach the eyecan not reach the eye..

Lipochrome: “Carotene”Lipochrome: “Carotene” Carotenes are yellow or red fat soluble pigments found in Carotenes are yellow or red fat soluble pigments found in

carrots, tomatoes, sweet potatoes, green leafy plants, milk, carrots, tomatoes, sweet potatoes, green leafy plants, milk, body fat and egg yolk.body fat and egg yolk.

Carotenes found in plants consist mainly of two molecules Carotenes found in plants consist mainly of two molecules of vitamin A, Joined by a double bond . Orally ingested of vitamin A, Joined by a double bond . Orally ingested carotenes are broken down by Carotenase enzyme into carotenes are broken down by Carotenase enzyme into vitamin A, the main storage of vitamin A is in the liver.vitamin A, the main storage of vitamin A is in the liver.

Excessive intake of carotene results in Excessive intake of carotene results in carotenemiacarotenemia The resultant yellow colour of skin is known as The resultant yellow colour of skin is known as

((carotenodermiacarotenodermia).). Carotene is water insoluble so Carotene is water insoluble so can not reach the eyecan not reach the eye..

Lipochrome PigmentsLipochrome Pigments

Sebaceous glands:Sebaceous glands: Yellowish white spots on skin or mucous Yellowish white spots on skin or mucous

membrane occur due to ectopic collection membrane occur due to ectopic collection of sebaceous glands.of sebaceous glands.

It may occur in:It may occur in: Oral cavity → Fordyce’s granulesOral cavity → Fordyce’s granules Nipple → Montogomry tuberclesNipple → Montogomry tubercles Upper eye lid → Mebomian glands.Upper eye lid → Mebomian glands.

The lipopigment is the colouring matter of The lipopigment is the colouring matter of the sebum and fatty tissues.the sebum and fatty tissues.

Fordyce’s GranulesFordyce’s Granules

Pigmentation Related to RBCsPigmentation Related to RBCs

Extravasation:Extravasation: May be due to trauma, bleeding May be due to trauma, bleeding

tendency and B.V. abnormality.tendency and B.V. abnormality. Extravasated RBCs are red in colour Extravasated RBCs are red in colour

then turn brown due to degradation of then turn brown due to degradation of Hb into hemosidrin (Hb into hemosidrin (localized iron localized iron overloadoverload). ).

Extravasation:Extravasation: May be due to trauma, bleeding May be due to trauma, bleeding

tendency and B.V. abnormality.tendency and B.V. abnormality. Extravasated RBCs are red in colour Extravasated RBCs are red in colour

then turn brown due to degradation of then turn brown due to degradation of Hb into hemosidrin (Hb into hemosidrin (localized iron localized iron overloadoverload). ).

PetechiaePetechiae

Qualitative Changes in Hb:Qualitative Changes in Hb: Reduced hemoglobin-reduced hemoglobin is Reduced hemoglobin-reduced hemoglobin is

associated with cyanosis and bluish associated with cyanosis and bluish discoloration of the skin and oral mucosa, discoloration of the skin and oral mucosa, secondary to heart and lung disease due to secondary to heart and lung disease due to over extraction of oxygen from hemoglobin.over extraction of oxygen from hemoglobin.

Carboxy hemoglobin- carboxy hemoglobin is Carboxy hemoglobin- carboxy hemoglobin is pink (cherry red) color, due to inhalation of pink (cherry red) color, due to inhalation of carbon monoxide.carbon monoxide.

Qualitative Changes in Hb:Qualitative Changes in Hb: Reduced hemoglobin-reduced hemoglobin is Reduced hemoglobin-reduced hemoglobin is

associated with cyanosis and bluish associated with cyanosis and bluish discoloration of the skin and oral mucosa, discoloration of the skin and oral mucosa, secondary to heart and lung disease due to secondary to heart and lung disease due to over extraction of oxygen from hemoglobin.over extraction of oxygen from hemoglobin.

Carboxy hemoglobin- carboxy hemoglobin is Carboxy hemoglobin- carboxy hemoglobin is pink (cherry red) color, due to inhalation of pink (cherry red) color, due to inhalation of carbon monoxide.carbon monoxide.

Pigmentation due to RBCs destruction:Pigmentation due to RBCs destruction:

HbHb

GlobinGlobinGlobinGlobinHemeHemeHemeHeme

Proto-porphyrinProto-porphyrinProto-porphyrinProto-porphyrinFeFe++++FeFe++++

Iron overload:Iron overload: LocalizedLocalized GeneralizedGeneralized

Porphyria:Porphyria: HepaticHepatic ErythropoieticErythropoietic

22 +2 +2ββ chains chains22 +2 +2ββ chains chains

ThalassemiaThalassemia

Sickle cell Sickle cell anemiaanemia

Jaundice:Jaundice: HemolyticHemolytic ObstructiveObstructive Hepatocellular Hepatocellular

JaundiceJaundice A common manifestation of liver disease due to an increase A common manifestation of liver disease due to an increase

of the yellow pigment bilirubin in the blood & tissue fluid.of the yellow pigment bilirubin in the blood & tissue fluid. A yellow tint appears in the sclera and is followed by yellow A yellow tint appears in the sclera and is followed by yellow

coloration of the skin and mucous membrane.coloration of the skin and mucous membrane. Etiology:Etiology:

Hemolytic jaundiceHemolytic jaundice: Excessive production of bilirubin due : Excessive production of bilirubin due to abnormally RBCs.to abnormally RBCs.

Hepatocellular JaundiceHepatocellular Jaundice: e.g. Infective hepatitis with wide : e.g. Infective hepatitis with wide spread damage of the liver with consequent disorganization spread damage of the liver with consequent disorganization of its structure. of its structure.

Extrahepatic (obstructive) JaundiceExtrahepatic (obstructive) Jaundice: Due to obstruction of : Due to obstruction of the bile duct system by gall stones or by carcinoma of the the bile duct system by gall stones or by carcinoma of the head of pancreas.head of pancreas.

A common manifestation of liver disease due to an increase A common manifestation of liver disease due to an increase of the yellow pigment bilirubin in the blood & tissue fluid.of the yellow pigment bilirubin in the blood & tissue fluid.

A yellow tint appears in the sclera and is followed by yellow A yellow tint appears in the sclera and is followed by yellow coloration of the skin and mucous membrane.coloration of the skin and mucous membrane.

Etiology:Etiology: Hemolytic jaundiceHemolytic jaundice: Excessive production of bilirubin due : Excessive production of bilirubin due

to abnormally RBCs.to abnormally RBCs. Hepatocellular JaundiceHepatocellular Jaundice: e.g. Infective hepatitis with wide : e.g. Infective hepatitis with wide

spread damage of the liver with consequent disorganization spread damage of the liver with consequent disorganization of its structure. of its structure.

Extrahepatic (obstructive) JaundiceExtrahepatic (obstructive) Jaundice: Due to obstruction of : Due to obstruction of the bile duct system by gall stones or by carcinoma of the the bile duct system by gall stones or by carcinoma of the head of pancreas.head of pancreas.

JaundiceJaundice

HemangiomaHemangioma

Unilateral portwine stain of face Unilateral portwine stain of face Sturge-Weber syndrome (heamangioma)Sturge-Weber syndrome (heamangioma)

Varices (varicositis)Varices (varicositis)

Kaposi SarcomaKaposi Sarcoma

Kaposi SarcomaKaposi Sarcoma

Multifocal smooth, red Multifocal smooth, red raised neoplasm, raised neoplasm, characterized by characterized by proliferation of blood proliferation of blood vessels.vessels.

Site: head, neck, tip of Site: head, neck, tip of nose & intra-orally the nose & intra-orally the palate is commonly palate is commonly involved in AIDS patient.involved in AIDS patient.

Exogenous pigmentations include:Exogenous pigmentations include: Black hairy tongueBlack hairy tongue Tattoo:Tattoo: Amalgam, graphite tattoo. Amalgam, graphite tattoo. Metallic intoxication: lead, mercury, Metallic intoxication: lead, mercury,

bismuth. bismuth.

Exogenous PigmentationsExogenous Pigmentations

Black Hairy TongueBlack Hairy Tongue

Exogenous pigmentationExogenous pigmentation(1) Amalgam tattoo(1) Amalgam tattooEtiologyEtiology Amalgam tattoo is due to iatrogenic factors. For Amalgam tattoo is due to iatrogenic factors. For

example:example: Dentist’s bur loaded with small fragment of amalgam Dentist’s bur loaded with small fragment of amalgam

particles that accumulate during removal of amalgam may particles that accumulate during removal of amalgam may accidentally introduce the metal flecks into the oral accidentally introduce the metal flecks into the oral mucosa.mucosa.

Metal particles may fall unnoticed into extraction socket.Metal particles may fall unnoticed into extraction socket.

Clinical FeaturesClinical Features Grey or black macule on gingiva, palate or buccal Grey or black macule on gingiva, palate or buccal

mucosa.mucosa. Amalgam tattoo is not harmful so its removal is not Amalgam tattoo is not harmful so its removal is not

required.required.Biopsy is necessary if the lesion arises at areas distant from Biopsy is necessary if the lesion arises at areas distant from

any restoration to exclude melanomaany restoration to exclude melanoma

Amalgam TattooAmalgam Tattoo

(2) Graphite tattoo(2) Graphite tattoo It is due to traumatic implantation of graphite It is due to traumatic implantation of graphite

from lead pencil, commonly seen on palate.from lead pencil, commonly seen on palate. The patient may not recall the injury since the The patient may not recall the injury since the

event usually occurs during grade school.event usually occurs during grade school.

(3) Metallic intoxication(3) Metallic intoxication High levels of heavy metals or metal salts may High levels of heavy metals or metal salts may

result in metallic intoxication.result in metallic intoxication. The exposure of the body to heavy metals may be The exposure of the body to heavy metals may be

either:either: Occupational hazard: as workers in lead factories.Occupational hazard: as workers in lead factories. Therapeutic hazard: as certain drugs, that contain salts Therapeutic hazard: as certain drugs, that contain salts

of heavy metals (bismuth, gold, mercuryof heavy metals (bismuth, gold, mercury..

Clinical FeaturesClinical Features Systemic symptoms of toxicity including:Systemic symptoms of toxicity including:

Behavioral change.Behavioral change. Intestinal pain.Intestinal pain. Neurological disorder.Neurological disorder.

Oral featuresOral features Grey to black pigmentation that outlines the Grey to black pigmentation that outlines the

gingiva like “eyeliner”. The heavy metal tends gingiva like “eyeliner”. The heavy metal tends to extravasate from vessels in foci of increased to extravasate from vessels in foci of increased ability such as inflamed tissue. Thus the free ability such as inflamed tissue. Thus the free marginal gingiva is the most commonly affected marginal gingiva is the most commonly affected site.site.

Clinical FeaturesClinical Features Systemic symptoms of toxicity including:Systemic symptoms of toxicity including:

Behavioral change.Behavioral change. Intestinal pain.Intestinal pain. Neurological disorder.Neurological disorder.

Oral featuresOral features Grey to black pigmentation that outlines the Grey to black pigmentation that outlines the

gingiva like “eyeliner”. The heavy metal tends gingiva like “eyeliner”. The heavy metal tends to extravasate from vessels in foci of increased to extravasate from vessels in foci of increased ability such as inflamed tissue. Thus the free ability such as inflamed tissue. Thus the free marginal gingiva is the most commonly affected marginal gingiva is the most commonly affected site.site.

MercurialismMercurialism

Lipochrome PigmentsLipochrome Pigments

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