Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letters to the Editor - Letter in Response to Previously Published Articles
doi: 10.4103/ijdvl.IJDVL_373_18
PMID: 30460929

Everything is in the name: Macular hyperpigmentation of uncertain etiology or acquired dermal macular hyperpigmentation of varied etiologies?

Anuradha Bishnoi, Keshavamurthy Vinay, Sendhil Muthu Kumaran, Davinder Parsad
 Department of Dermatology Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Keshavamurthy Vinay
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
Published: 21-Nov-2018
How to cite this article:
Bishnoi A, Vinay K, Kumaran SM, Parsad D. Everything is in the name: Macular hyperpigmentation of uncertain etiology or acquired dermal macular hyperpigmentation of varied etiologies?. Indian J Dermatol Venereol Leprol 2019;85:85-87
Copyright: (C)2019 Indian Journal of Dermatology, Venereology, and Leprology


He, who steals my purse, steals trash, but he that filches from me my good name robs me of that which enriches him not, and makes me poor indeedWilliam Shakespeare

We read with interest the letter by Gupta and Sharma on the controversies surrounding the nomenclature of ashy dermatosis, erythema dyschromicum perstans, lichen planus pigmentosus and pigmented cosmetic dermatitis.[1] The interest in cutaneous disorders characterized by brownish-slate gray-purplish black hyperpigmentation on face, neck, flexures and trunk, associated with interface dermatitis and pigment incontinence, and a virtually nonexistent prior clinical inflammatory phase is increasing. Though described as early in 1959 as los cenicientos by Ramirez, followed by ashy dermatosis,[2] lichen planus pigmentosus,[3] pigmented contact dermatitis and pigmented cosmetic dermatitis[4] in 1970s, these disorders were considered enigmatic and there were only a few published studies till recently, when the interest in these entities has renewed and multiple studies have been published in this regard, the important ones being dermatoscopic evaluation,[5] role of patch testing[6] and providing a novel scoring system.[7] Our center has been actively involved in describing the epidemiology, clinical features, risk factors, disease associations, dermatoscopy and treatment of these disorders.[8],[9],[10],[11] In this context, we would like to convey our viewpoint on the controversies surrounding the nosology of these overlapping dermatoses.

In general, name introduces the readers and researchers to an entity, and should convey the important and salient defining features of a dermatosis. It can raise the interest or kill the spirit. In 2016, Chandran and Kumarasinghe had first proposed the term “acquired macular (hyper) pigmentation of uncertain etiology” for a group of disorders characterized by “acquired macular hyperpigmentation” with small and large macules associated with evidence of current or resolved interface dermatitis with pigment incontinence histopathologically, without any clinically evident prior inflammatory skin lesions.[12] Gupta and Sharma have reiterated the same terminology as “macular hyperpigmentation of uncertain etiology,” but omitted the term “acquired.” Given the clinicopathological and dermatoscopic overlap amongst these disorders, we support their view of bringing these disorders under one roof and our opinion has been firmly echoed in our previous studies.[5],[7],[9],[13]

But, we differ on the choice of nomenclature for the umbrella term and prefer the name “acquired dermal macular hyperpigmentation of varied etiologies” to “macular hyperpigmentation of uncertain etiology.” The clinical differentials of macular hyperpigmentation are multiple and include fixed drug eruptions, melasma, ochronosis, macular amyloidosis, drug-induced and post inflammatory hyperpigmentation, nevus of Ota and other dermal melanocytoses, many of which have uncertain etiology. The name “macular hyperpigmentation of uncertain etiology,” therefore, could misguide the readers about all possible dermatoses that could be encompassed in this term.

To the contrary, the term acquired dermal macular hyperpigmentation of varied etiologies divulges details about the origins and natural history (acquired), localization (dermal) and character (macular) of the hyperpigmentation, and therefore, is more informative and does justice to the scientific literature described so far in the context of these disorders without increasing more paradigms, besides signifying their treatment-resistant nature that stems from localization of pigment inside dermis. Many triggering factors and associations have been described in the etiopathogenesis of lichen planus pigmentosus, ashy dermatosis and pigmented contact/cosmetic dermatitis including genetic predisposition to lichen planus, type 4 hypersensitivity reaction to amla oil and mustard oil, trauma, friction, hepatitis C infection, influence of sex hormones and contact allergens such as para-phenylenediamine.[14] A recent study by Sharma et al. reported patch test positivity in 17/50 (34%) patients diagnosed as “lichen planus pigmentosus” and the authors opined that there is a “probable role of allergens in causing lichen planus pigmentosus on the face.”[6] Thus, the words “varied etiologies” provide more rationale to the etiopathogenesis of these disorders than “uncertain etiology.”

With multiple studies in tow, the future of these enigmatic disorders seems hopeful and we could start contributing to it by devising and following a uniform nomenclature, which could be improved further as more research unfolds. A consistent terminology shall maintain constancy in the reporting of clinical trials and facilitate communication among researchers. Although moving forward and embracing new terminologies comes along with continued research, one should, nevertheless, remember the significant and unrelenting contribution of Ramirez, Bhutani and Nakayama to “acquired dermal macular hyperpigmentation,” in particular, regarding the initial events in the intricate pathogenesis of these complex disorders. Because the end result in the form of dermal hyperpigmentation is similar in all of these, remembering the semantics shall guide further research in the initiating and perhaps, the most important events in the natural history of these disorders, where novel therapeutics and preventive measures could act.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Gupta V, Sharma VK. Ashy dermatosis, lichen planus pigmentosus and pigmented cosmetic dermatitis: Are we splitting the hair? Indian J Dermatol Venereol Leprol 2018;84:470-4.
[Google Scholar]
Bhutani LK. Ashy dermatosis or lichen planus pigmentosus: What is in a name? Arch Dermatol 1986;122:133.
[Google Scholar]
Bhutani LK, Bedi TR, Pandhi RK, Nayak NC. Lichen planus pigmentosus. Dermatologica 1974;149:43-50.
[Google Scholar]
Nakayama H, Harada R, Toda M. Pigmented cosmetic dermatitis. Int J Dermatol 1976;15:673-5.
[Google Scholar]
Vinay K, Bishnoi A, Parsad D, Saikia UN, Sendhil Kumaran M. Dermatoscopic evaluation and histopathological correlation of acquired dermal macular hyperpigmentation. Int J Dermatol 2017;56:1395-9.
[Google Scholar]
Sharma VK, Gupta V, Pahadiya P, Vedi KK, Arava S, Ramam M. Dermoscopy and patch testing in patients with lichen planus pigmentosus on face: A cross-sectional observational study in fifty Indian patients. Indian J Dermatol Venereol Leprol 2017;83:656-62.
[Google Scholar]
Vinay K, Dabas G, Parsad D, Kumaran MS. A novel scale for measurement of acquired dermal macular hyperpigmentation severity. J Eur Acad Dermatol Venereol 2018;32:e251-3.
[Google Scholar]
Kanwar AJ, Dogra S, Handa S, Parsad D, Radotra BD. A study of 124 Indian patients with lichen planus pigmentosus. Clin Exp Dermatol 2003;28:481-5.
[Google Scholar]
Kumaran MS, Razmi TM, Vinay K, Parsad D. Clinical, dermoscopic, and trichoscopic analysis of frontal fibrosing alopecia associated with acquired dermal macular hyperpigmentation: A cross sectional observational case-control study. J Am Acad Dermatol 2018;79:588-91.
[Google Scholar]
Sindhura KB, Vinay K, Kumaran MS, Saikia UN, Parsad D. Lichen planus pigmentosus: A retrospective clinico-epidemiologic study with emphasis on the rare follicular variant. J Eur Acad Dermatol Venereol 2016;30:e142-4.
[Google Scholar]
Muthu SK, Narang T, Saikia UN, Kanwar AJ, Parsad D, Dogra S. Low-dose oral isotretinoin therapy in lichen planus pigmentosus: An open-label non-randomized prospective pilot study. Int J Dermatol 2016;55:1048-54.
[Google Scholar]
Chandran V, Kumarasinghe SP. Macular pigmentation of uncertain aetiology revisited: Two case reports and a proposed algorithm for clinical classification. Australas J Dermatol 2017;58:45-9.
[Google Scholar]
Kumaran MS, Dabas G, Parsad D, Vinay K. Lichen planus pigmentosus – An appraisal. Int J Dermatol 2018;57:748-50.
[Google Scholar]
Robles-Méndez JC, Rizo-Frías P, Herz-Ruelas ME, Pandya AG, Ocampo Candiani J. Lichen planus pigmentosus and its variants: Review and update. Int J Dermatol 2018;57:505-14.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections