Pigmentary demarcation lines associated with pregnancy* wi l l i am D. James, Major, M e , USA, Monte S. Meltzer, Major, MC, USA, Marshall A. Guill, Lieutenant Colonel, MC,** USA, T imothy G. Berger, Major, MC, USA, and Orlando G. Rodman, Colonel, MC, USA Washington, DC

Pigmentary demarcation lines are borders of abrupt transition between more deeply pigmented skin and that of lighter pigmentation. Two patients developed these lines on the lower extremities during pregnancy. (J AM ACAD DERMATOL 11:438-440, 1984.)

Pigmentary demarcat ion lines are borders of ab- rupt transition be tween more deeply pigmented skin and that o f l ighter pigmentation. They are most commonly described on the anterior brachial surfaces of the arms of Japanese and black per- sons, t-~ although five separate areas o f the body are associated with these distinctive pigmentary findings. 5,t~ A variety of alterations in skin pig- mentation are commonly seen with pregnancy; however, changes that occur in pigmentary de- marcation lines have not hitherto been reported.

CASE REPORTS C a s e 1

A 27-year-old black woman, first seen 3 months postpartum, noted changes in the skin color of both legs during the fifth month of her otherwise normal preg- nancy. The patient stated that she did not have this pigmentary pattern before pregnancy; this statement was corroborated by her mother. She also noted the appearance of linea nigra and hyperpigmentation of the

From the Dermatology Service, Department of Medicine, Walter Reed Army Medical Center.

Accepted for publication Feb, 13, 1984. Reprint requests to: Dr, William D. James, Dermatology Service,

Walter Reed Army Medical Center, Washington, DC 20307. *The opinions expressed are those of the authors and are not to be

construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

**Dr. Guill is with the Dermatology Service, Eisenhower Army Medical Center, Fort Gordon, GA 30805.

438

areolae and nipples during pregnancy, but these changes spontaneously resolved.

On examination a striking dark pigmentation of the posteroIateral thighs was present that was sharply de- lineated from what the patient stated to be her normal lighter pigmentary pattern medially. The line of demar- cation began at mid perineum, progressed to a point at the inner quarter of the popliteal fossa, curved to the medial calf, and stopped at the inner base of the heel (Fig. 1). The lines were bilateral and symmetrical. She also had bilateral pigmentary demarcation lines of the anterior arms. These were less dramatic in appearance, and the patient was not aware of them prior to our examination. These pigmentary patterns remain un- changed 8 months postpartum.

Case 2

A 24-year-old white woman presented to the Der- matology Clinic in her immediate postpartum period, complaining of streaks down her legs. The streaks were of cosmetic concern but were otherwise asymptomatie. She had observed increased pigment in a linear distri- bution on the posterior aspect of her legs during the last trimester of a normal pregnancy. She had noticed no other areas of pigmentary change.

Examination revealed hyperpigmented skin of the posterolateral thighs that was sharply demarcated from the normally pigmented skin of the inner thigh. The lines of demarcation followed the course described previously in Case 1 (Fig. 2). Biopsy of the hy- perpigmented skin showed mild basal layer hyperpig- mentation.

Volume 1 l Number 3 September, 1984

Pigmentao, demarcation lines with pregnancy 439

Fig. 1. Case 1. Pigmentary demarcation line extending down posteromedial aspect of leg.

Fig. 2. Case 2. Pigmentary demarcation line of lower extremities.

COMMENT

Matzumoto ~ described pigmentary demarcation lines of the upper and lower limbs of Japanese persons in 1913; these studies have been con- firmed and expanded by several other authors. 2-'~ The five presently recognized types of pigmentary demarcation lines are summarized in Table I.

The best characterized and most common types are types A and C, both of which occur in nearly one third of the persons who are screened. 5 The relative frequency of the pigmentary lines seen in our patients has not been reported to date. It is of great interest that these lines have been described only in Japanese and black persons. Our Case 2 is unique in that clearly visible pigmentary demarca- tion lines appeared in a white woman.

Most reports of the more thoroughly studied upper extremity lines (type A) show a higher inci- dence among women compared to men; the inci- dence in women increases with age. a-5 Accentua-

Table I. Presently recognized types of pigmentary demarcation lines

Type ] Location

A B C D E

Upper anterior arms across pectoral area Lower posteromedial limb Pre- and parasternal area Posteromedial area of spine Bilateral chest marking from mid third

of clavicIe to periareolar skin

tion of preexisting lines or appearance of new lines during pregnancy, such as those described in the patients presented in this report, may be a possible explanation for this increase.

Pigmentary changes are seen in up to 90% of pregnant womenT: hyperpigmentation of the linea nigra, genitalia, areolae and nipples, freckles, and nevi are all seen. Melasma occurs in 70% of preg- nant women and usually regresses after delivery .7

440 James et at

Journal of lhe American Academy 0i"

Dermatology

Alterations of pigmentary demarcation lines with pregnancy have not been previously reported. 6

The demarcation lines we photographically document closely correspond to lines described by Voigt as delineating boundaries of the areas supplied by the main cutaneous nerve stems, a's'9 They do not correspond to either Blaschko's lines (derived from his study of numerous linear nevoid disorders) or dermatomal lines. 9

In summary, our report documents the new ap- pearance of pigmentary demarcation lines (type B) of the lower extremities of two women during pregnancy. It also documents the existence of these lines in a white woman. Further studies should be done to quantify the relative incidence of lower limb pigmentary demarcation lines in dif- ferent racial populations and to determine the fre- quency of darkening or new appearance of these lines with pregnancy. Better long-term follow-up of the latter cases will allow more precise determi- nation Of prognosis for what may be a disturbing cosmetic problem.

A D D E N D U M

Fulk TM reported a marked increase in pigmentary demarcat ion lines during pregnancy. Fig. 6 in his arti- cle showed them to be type B lines in a black woman.

REFERENCES 1. Matzumoto S: Ober eine eigentfimliche Pigmentwr-

teilung an den Voigtschen Linien (Beitrag zur kenntnis der Voigtschen Grenzen). Arch Derm Syph(Berl) 118: 157-164, 1913.

2. Futcher PH: A peculiarity of pigmentation of the upper arm of Negroes. Science 88:570-571, 1938.

3. Ito K: The peculiar demarcation of pigmentation along the so-called Voigt's line among the Japanese. Dermatd Int 4:45-47, 1965.

4. Vollum DI: Skin markings in Negro children from West Indies. Br J Dermatol 86:260-263, 1972.

5. Selmanowitz VJ, Krivo JM: Pigmentary demarcation lines. Br J Dermatol 93:371-377, 1975.

6. Miura O: On the demarcation lines of pigmentation ob- served among the Japanese, on inner sides of their ex- tremities and on anterior and posterior sides of their me- dial regions. Tohoku J Exp Med 54:135-140, 1951.

7. Scoggins RB: Skin changes and diseases in pregnancy,in Fitzpatrick TB, Eisen A, Wolff K, editors: Dermatology in general medicine. New York, 1979, McGraw-Hilt Book Co., p. 1363.

8. Siemans HW: General diagnosis and therapy of skin dis- eases. Chicago, 1958, The University of Chicago Press, p. 139.

9. Jackson R: The lines of Blaschko: A review and recon- sideration. Br J Dermatol 95:349-360, 1976.

10. Fulk CS: Primary disorders of hyperpigmentation. J AM ACAD DERMATOL 10:1-16, 1984.

A B S T R A C T S

Terry's nails: Revised definition and new correlations

Holzberg M, Walker HK: Lancet 1:896-899, 1984

One hundred-twenty-nine of 512 (25.2%) consecutive hospital inpatients were found to have Terry's nails as defined by a white or light pink proximal nail and a distal pink to brown transverse band 0.5 to 3.0 mm wide. There was a statistically significant association with cirrhosis, congestive heart failure, adult-onset diabetes mellitus, and age. His- !opathologically, the nail abnormality was due to distal telangiectasias.

J . G , S .

Circadian urticaria: Another Campylobacter association

Bretag AH, Archer RS, Atkinson HM, Woods WH: Lancet 1:954, 1984

Urticarial episodes occurring in the evening associated with positive fecal cultures for Campytobacter organisms are

reported. Occurrence of circadian urticaria warrants seach for Campylobacter in the stool.

J.G.S.

Fatal hepatitis associated with ketoconazole therapy

Duarte PA, Chow CC, Simmons F, Ruskin J: Arch Intern Med 144:1069-1970, 1984

A fatal case of hepatic necrosis in a 67-year-old worna~ who received ketoconazole, 200 mg daily for 2 months, is reported.

J.G.S~

Selective alopecia with mitoxantrone

Arl in ZA, Friedland ML, Atamer MA: N Engl J Med 310:1464, 1984

The drug mitoxantrone, used in treatment of breast cancer, lymphoma, and leukemia, produced a selective loss of white hair in two patients.

J.G.$.