Pigmentary demarcation lines associated with pregnancy

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  • Pigmentary demarcation lines associated with pregnancy

    T. Nakama,* K. Hashikawa,* M. Higuchi,* N. Ishii,* M. Miyasato, T. Hamada* and T. Hashimoto*

    *Department of Dermatology, Kurume University School of Medicine; and Miyasato Dermatology Clinic, Kurume, Japan

    doi:10.1111/j.1365-2230.2009.03247.x

    Summary We report three cases of pigmentary demarcation lines associated with pregnancy. Inaddition, we reviewed 19 cases including our 3 cases, which were reported in Japan.

    Most cases occurred during the latter period of pregnancy (after the seventh month),

    and the pigmentation faded spontaneously or disappeared a few months after delivery

    in all cases except one. Pigmentary demarcation lines are classified into five groups

    (types AE). Of the 19 cases we reviewed, 2 cases showed lines of both types A and B,

    whereas all the other cases showed type B lines. Although there have only been 29

    cases of pigmentary demarcation lines associated with pregnancy reported to date,

    before ours, we experienced 3 cases within 3 months, therefore it is possible that many

    such cases are overlooked. Pigmentary demarcation lines are mainly a cosmetic

    problem. Two of our three cases presented to obstetricians initially. We suggest that

    dermatologists should be aware that pigmentary demarcation lines may be associated

    with pregnancy.

    Pigmentary demarcation lines are visible boundaries on

    the skin found in restricted areas of the trunk and limbs,

    and have clear borders of abrupt transition betweenmore

    deeply pigmented skin and areas of lighter pigmentation.

    They are commonly seen in Japanese and black popula-

    tions, and have a female gender predilection.1,2 Matsum-

    oto3 first described pigmentary demarcation lines in 14

    Japanese cases and considered that they correspond to

    Voigts lines. They are classified into five groups (types

    AE), and it has been reported that cases associated with

    pregnancy are almost exclusively type B.2,4 We present

    three cases of pigmentary demarcation lines associated

    with pregnancy in Japanese women that we examined

    between August and October 2006.

    Report

    Patient 1 was a 33-year-old primigravida, who pre-

    sented with pigmentation extending from both buttocks

    to the posterior areas of both thighs. She initially

    presented to an obstetrician and was later referred to us

    in August 2006. She had noticed the asymptomatic

    pigmentation during the ninth month of pregnancy. On

    physical examination, she was found to have defined

    pigmentation from the lower half of the buttocks down

    to the posterolateral thighs, which was clearly demar-

    cated from the normally pigmented skin (Fig. 1). The

    Figure 1 Patient 1. Defined pigmentation from the lower half of

    the buttocks down to the posterolateral thighs.

    Correspondence: Dr Takekuni Nakama, Department of Dermatology,

    Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka

    8300011, Japan.

    E-mail: takekuni@med.kurume-u.ac.jp

    Conflict of interest: none declared.

    Accepted for publication 27 August 2008

    Clinical dermatology Concise report Clinical and Experimental Dermatology

    2009 The Author(s)Journal compilation 2009 British Association of Dermatologists Clinical and Experimental Dermatology, 34, e573e576 e573

  • pigmentation was bilateral and symmetrical. Two weeks

    after delivery, the pigmentation began to fade, and it

    had disappeared 3 months later.

    Patient 2 was a 31-year-old primigravida, who

    presented initially to a obstetrician and was referred to

    us in October 2006 because of pigmentation on the

    posterior areas of both legs, which developed during the

    ninth month of pregnancy. On examination, we found

    erythematous pigmentation symmetrically distributed

    from the posterolateral thighs down to the upper third of

    the calves, and also distributed over the lower third of

    the calves (Fig. 2a,b). A month after delivery, the

    erythematous pigmentation began to disappear sponta-

    neously, but was still faintly visible 3 months after

    delivery.

    Patient 3 was a 24-year-old primigravida, who

    presented in October 2006 with erythematous pigmen-

    tation on the posterior areas of both legs. She had first

    noticed asymptomatic erythematous pigmentation on

    the posterior areas of both thighs during the eighth

    month of pregnancy. The erythematous pigmentation

    spread down to the posterior areas of the lower legs

    1 month later. Physical examination revealed an ery-

    thematous pigmentation, which extended from both

    buttocks to cover almost all the posterior legs (Fig. 3a).

    Histopathological examination of a skin biopsy showed

    slight lymphocyte infiltration around vessels in the

    upper dermis and mild basal layer hyperpigmentation.

    A few days after delivery, the erythematous pigmenta-

    tion began to disappear rapidly and had almost disap-

    peared a month later (Fig. 3b).

    None of the three patients had any problems

    throughout their pregnancy and delivery.

    Pigmentary demarcation lines are areas of pigmenta-

    tion that appear as lines due to differences in melano-

    cyte distribution. They were classified into four groups

    by Miura in 1951,1 and were later classified into five

    groups by Selmanowitz and Krivo in 1975.2 Type A are

    lines on the upper anterior arms across the pectoral area

    (subtypes IIV), type B are lines over the posteromedial

    area of the legs, type C are lines on the sternal area

    (subtypes I and II), type D are lines over the postero-

    medial spine, and type E are hypopigmented streaks

    extending from the mid third of the clavicle to the

    periareolar skin (found in black populations). Cases of

    type A are often found in Japanese patients. Ito5

    reported that 130 cases of type A (4.3%) were found

    among 3021 Japanese (1509 males, 1512 females) and

    the frequency was considerably higher in females (118

    cases) than in males (12 cases). The frequency in black

    populations is higher than in Japanese populations.

    James et al.4 reported that 70% of black adults, both

    (a)

    (b)

    Figure 2 Patient 2. Erythematous pigmentation from (a) the

    posterolateral thighs down to the upper lower third of the calves;

    and (b) in the lower lower third of the calves.

    2009 The Author(s)e574 Journal compilation 2009 British Association of Dermatologists Clinical and Experimental Dermatology, 34, e573e576

    Three cases of pigmentary demarcation lines associated with pregnancy T. Nakama et al.

  • men and women, had this condition, with types A and B

    being present in over 50% of women, and type C being

    most prevalent in men. Furthermore, type B lines were

    observed among 14% of black women during preg-

    nancy.

    Recently, several cases associated with pregnancy

    have been reported in Japan. Firstly, James et al.6

    reported two cases of pigmentary demarcation lines

    associated with pregnancy in 1984, and to date, there

    have been 29 reports (besides ours). In 2005, Matsuda

    et al.7 reported statistics on 13 cases associated with

    pregnancy in Japan. We added another three cases

    from two reports, and our own three cases, making a

    total of 19 cases, which we examined statistically

    (Table 1).

    Of these 19 cases, 11 cases were primigravidas and

    their progress since then is unknown. In one case

    (patient 6), pigmentary demarcation lines occurred

    during all three of her pregnancies. In other cases, the

    skin condition occurred only once in two or three

    pregnancies. In most cases, pigmentary demarcation

    lines occurred during the latter period after seventh

    month of pregnancy. In regard to types, two cases (4

    and 13) had both type A and type B lines; all other cases

    had type B. Two cases that James et al.6 reported also

    had type B. The pigmentation faded spontaneously or

    disappeared a few months after delivery in all cases

    except one (patient 5), whose final outcome was

    unknown.

    (a) (b)

    Figure 3 Patient 3. (a) Erythematous pigmentation from the but-

    tocks down to the lower limbs. (b) A month after delivery, the

    erythematous pigmentation almost disappeared. (*scar due to skin

    biopsy).

    Table 1 Case reports of pigmentary

    demarcation lines associated with preg-

    nancy in Japan.

    Patient

    Age,

    years

    Pregnancies

    (occurrences

    of PDL)

    Month of

    pregnancy

    in which

    PDL occurred Type

    Outcome after

    delivery

    1* 33 1 (1) 9 B Disappeared 3 months later

    2* 31 1 (1) 9 B Faded 1 month later

    3* 24 1 (1) 8 B Faded a few days

    4 27 2 (1) 8 A, B Faint pigmentation remained

    1 year later

    5 30 Unknown (1) 9 B Unknown

    6 32 3 (3) 6 B Disappeared a few months later

    7 26 1 (1) 9 B Disappeared 1 month later

    8 34 2 (1) 8 B Disappeared 2 months later

    9 26 2 (1) 9 B Disappeared 1 month later

    10 23 2 (1) 8 B Disappeared 2 months later

    11 32 1 (1) 4 B Disappeared 4 months later

    12 27 3 (1) 7 B Disappeared 4 months later

    13 26 1 (1) 7 A, B Disappeared 2 months later

    14 25 1 (1) 8 B Disappeared 3 months later

    15 34 3 (1) 6 B Disappeared 7 months later

    16 34 1 (1) 9 B Faded 2 months later

    179 29 1 (1) 8 B Faded 3 months later

    1810 24 1 (1) 7 B Disappeared 1 month later

    1910 35 1 (1) 7 B Disappeared 2 months later

    PDL, pigmentary demarcation lines Modified from reports by Matsuda et al.7 *Our threepatients presented in this report.

    2009 The Author(s)Journal compilation 2009 British Association of Dermatologists Clinical and Experimental Dermatology, 34, e573e576 e575

    Three cases of pigmentary demarcation lines associated with pregnancy T. Nakama et al.

  • The aetiology of pigmentary demarcation lines is

    unknown. It has been suggested that the peripheral

    nerves originating from the S1 and S2 levels of the

    spinal nerves are compressed by the enlarged uterus in

    the latter period of pregnancy and obstruct the inner-

    vated cutaneous microvasculature to induce the skin

    symptoms with resultant pigmentation.1,8 However,

    only a few cases have shown both type A and type B.

    Furthermore, although we performed a histological

    examination of a skin biopsy specimen from only one

    case, that biopsy showed infiltration of only a few

    lymphocytes around vessels in the upper dermis and

    mild basal layer hyperpigmentation, and there were no

    findings of circulatory obstruction. These findings were

    similar to the previous reports that examined biopsies

    histopathologically. Furthermore, all the cases of pig-

    mentary demarcation lines associated with pregnancy

    faded spontaneously and disappeared after delivery.

    Types A and B are boundary lines corresponding to

    Voigts lines, which delimit the distribution of peripheral

    nerves. Based on the previous studies and our results, we

    suggest that there are clinically inconspicuous melano-

    cytes in areas of specific peripheral nerves, and hyper-

    pigmentation of the specific areas is triggered by the

    increase in hormones such as melanocyte-stimulating

    hormone during pregnancy.

    There have only been 29 reported cases of pigmentary

    demarcation lines associated with pregnancy before our

    cases (16 in Japan), but we found 3 cases within

    3 months, suggesting that many cases may be over-

    looked. Pigmentary demarcation lines are usually asymp-

    tomatic and the pigmentation disappears spontaneously

    after the delivery. In addition, two of our three cases

    presented to obstetricians and were only later referred to

    the dermatologists, thus this maymean low awareness of

    this condition among dermatologists. Dermatologists

    should be alert to the presence of pigmentary demarca-

    tion lines associated with pregnancy.

    References

    1 Miura O. On the demarcation lines of pigmentation

    observed among the Japanese, on inner sides of their

    extremities and on anterior and posterior sides of their

    medical resions. Tohoku J Exp Med 1951; 54: 13540.

    2 Selmanowitz VJ, Krivo JM. Pigmentary demarcation lines.

    Br J Dermatol 1975; 93: 3717.

    3 Matsumoto S. Pigmentary demarcation lines correspond to

    Voigts lines. Kyoto J Med 1913; 10: 195207.

    4 James WD, Colonel L, Carter JM et al. Pigmentary demar-

    cation lines: a population survey. J Am Acad Dermatol

    1987; 16: 58490.

    5 Ito K. The peculiar demarcation of pigmentation along the

    so-called Voigts line among the Japanese. Dermatologia Int

    1965; 4: 457.

    6 James WD, Meltzer MS, Guill MA et al. Pigmentary

    demarcation lines associated with pregnancy. J Am Acad

    Dermatol 1984; 11: 43840.

    7 Matsuda S, Oniki S, Kunisada M et al. Pigmentary demar-

    cation lines associated with pregnancy: a case report. Jpn J

    Dermatol 2005; 115: 117580.

    8 Ozawa H, Rokugo M, Aoyama H. Pigmentary demarcation

    lines of pregnancy with erythema. Dermatology 1993; 187:

    1346.

    9 Kon A, Hanada K, Sato S. Pigmentary demarcation lines

    associated with pregnancy. Rinsho Derma (Tokyo) 2002;

    44: 82930.

    10 Yamasaki H, Mizuno A, Hamakawa Y et al. Pigmentary

    demarcation lines associated with pregnancy. Pract

    Dermatol 2005; 27: 397400.

    2009 The Author(s)e576 Journal compilation 2009 British Association of Dermatologists Clinical and Experimental Dermatology, 34, e573e576

    Three cases of pigmentary demarcation lines associated with pregnancy T. Nakama et al.

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