Hyperpigmented macules and papules on trunk and extremities

Presenter: Aleksandra Brown, DO

Dermatology Program: POH/Botsford

Program Director: Annette LaCasse, DO

Submitted on: October 5, 2011

CHIEF COMPLAINT: Rash x 1 year

CLINICAL HISTORY: A 23-year-old female presents for evaluation of multiple hyperpigmented macules and papules on her thighs, arms, chest, and abdomen. They have been present for approximately one year and are mildly pruritic. A review of systems reveals fatigue for two weeks. She has no significant past medical history and family history is non-contributory. She does report an allergy to bee stings.

PHYSICAL EXAM:
Physical exam reveals scattered 2-5 mm orange to tan colored macules and papules on her bilateral thighs, upper extremities, abdomen, and chest. These lesions show dermatographism with positive Darier’s sign. Hyperpigmentation of the lesions is persistent with diascopy. No hepatosplenomegaly or lymphadenopathy are palpable.

LABORATORY TESTS:

The serum tryptase level was 70.3 ng/ml initially and 57.1 ng/ml on a repeat one week later (normal less than 11.5 ng/ml). CBC was within normal limits.

DERMATOHISTOPATHOLOGY:

3 mm punch biopsy demonstrated superficial perivascular infiltrate of lymphocytes around slightly ectatic vessels. A toluidine blue stain showed significantly increased mast cells within the papillary dermis. The above is consistent with urticaria pigmentosa, macular type.