Minocycline-induced hyperpigmentation resolves during oral isotretinoin therapy.(CASE REPORTS)

Abstract

Although disfiguring hyperpigmentation is a well-defined complication of minocycline therapy, modalities to reverse the phenomenon are unpredictable. We report a case of minocycline-induced, blue-black pigmentation in a 23-year-old Hispanic man, which resolved after treatment with oral isotretinoin for acne vulgaris.

Introduction

Minocycline is a widely prescribed, broad-spectrum antibiotic for the treatment of acne. Cutaneous hyperpigmentation induced by minocycline is a well-recognized, infrequent adverse effect. (1-18) The pigmentation generally associated with long-term and/or high-dose therapy may persist for years. The Q-switched ruby laser, (19-22) the Q-switched neodymium (Nd):YAG laser, (23,24) and Q-switched alexandrite laser (25,26) have successfully removed minocycline-induced hyperpigmentation. The following report describes a patient with profound, minocycline-induced, blue-black hyperpigmentation, initially of the face and neck progressing to the trunk and extremities, which resolved after treatment of acne vulgaris with oral isotretinoin.

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Case Report

A 23-year-old Hispanic male presented in September 2002 with deep blue-black hyperpigmentation on sun exposed areas of the face and neck that had persisted for 11 months. In 2001, the patient sought treatment for acne that dated to his early teenage years. Minocycline, 100 mg daily, was initiated and 2 to 3 months later, the patient noticed the appearance of blue-black pigmentation on his face. The facial discoloration intensified during the ensuing 3 months while his acne did not improve. At the time minocycline was discontinued, the patient had received a cumulative dose of 18 to 20 grams. Oral erythromycin, 500 mg daily, was substituted. One year after discontinuing minocycline therapy, the patient was referred to one of the authors (SRC) for consultation regarding the treatment of cystic acne in the setting of facial hyperpigmentation.

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At the time of his first visit, the patient described his general health as excellent. He reported childhood asthma that was quiescent for many years and no known allergies to medication. Other than unspecified cold remedies, he had not taken any oral medications prior to minocycline. Related to his work as a model and actor, he described a year-round pursuit of the "perfect tan." The only abnormal findings were macular patches of homogenous deep blue-black pigmentation and cystic acne nodules restricted to the face and neck (Figure 1). There was no mucosal, ocular, dental, nail plate, or nail bed dyspigmentation. The patient had a Fitzpatrick type IV complexion with a moderate tan.

Based on the history and clinical findings, the patient was advised to discontinue erythromycin, avoid tetracycline and its derivatives, and use sunscreen. A trial of oral isotretinoin, 100 mg/day (1.5 mg/kg), was initiated for acne. Topical hydroquinone was suggested for hyperpigmentation. After 5 months of treatment, the facial discoloration faded but remained perceptible; hydroquinone was discontinued and never used subsequently. In January 2003, recalcitrant cystic …