pigmentary demarcation lines associated with pregnancy

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. In

addition, 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 A–E). 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 between more

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

Voigt’s lines. They are classified into five groups (types

A–E), 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

830–0011, Japan.

E-mail: [email protected]

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, e573–e576 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 I—IV), 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.


e574 Journal compilation � 2009 British Association of Dermatologists • Clinical and Experimental Dermatology, 34, e573–e576

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





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



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

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



PDL, pigmentary demarcation lines Modified from reports by Matsuda et al.7 *Our three

patients presented in this report.


Journal compilation � 2009 British Association of Dermatologists • Clinical and Experimental Dermatology, 34, e573–e576 e575


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

Voigt’s 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 may mean 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: 135–40.

2 Selmanowitz VJ, Krivo JM. Pigmentary demarcation lines.

Br J Dermatol 1975; 93: 371–7.

3 Matsumoto S. Pigmentary demarcation lines correspond to

Voigt’s lines. Kyoto J Med 1913; 10: 195–207.

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

cation lines: a population survey. J Am Acad Dermatol

1987; 16: 584–90.

5 Ito K. The peculiar demarcation of pigmentation along the

so-called Voigt’s line among the Japanese. Dermatologia Int

1965; 4: 45–7.

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

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

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

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134–6.

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pigmentary demarcation lines associated with pregnancy

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