5. pigmented lesions

what are the 10 categories of pigmented lesions discussed?

• amalgam tattoo

• medication induced pigmentation

• systemic metallic intoxications

• oral melanotic macule

• post inflammatory hypermelanosis

• oral melanocanthosis

• syndromes and systemic causes of pigmentation

• melanotic neuroectodermal tumor of infancy 

• nevus

• melanoma 

what are the categories for differential diagnosis?

• developmental

• reactive

• autoimmune/immune-mediated

• infectious

• metabolic/systemic

• neoplastic

• premalignant/malignant

what are five sources of pigment?

• melanin (melanocytes)

• vascular structures

• saliva/mucin

• cystic fluid (pathology)

• foreign material

what are the two main categories of pigmented lesions?

non-melanin associated and melanin associated

what category of pigmented lesions?

• exogenous

• endogenous

non-melanin associated 

what category of pigmented lesion?

• developmental

• reactive/inflammatory

• infectious

• autoimmune and immune mediated

• metabolic/systemic

• neoplastic

• premalignant/malignant

melanin-associated

which category of non-melanin associated pigmented lesions?

• amalgam tattoo (focal argyrosis)

• graphite and other foreign body tattoos

• medication-induced pigmentation 

exogenous

amalgam tattoo aka

focal argyrosis (silver, looks blue)

which pigmented lesion?

clinical features

• Asymptomatic, localized

• Blue-gray macule

• Gingiva/alveolar ridge mucosa (50%)➔ buccal mucosa ➔floor of mouth

• Localized around areas with: (blank) restoration

amalgam tattoo (exogenous, non-melanated)

which pigmented lesion

amalgam tattoo

amalgam tattoo,

L: purple epithelial lining and the pink the middle is the scar you can see through epithelium (graphite won’t do this)

which pigmented lesion histopathological features?

• pigmented fragments

• staining of reticulin fibers

• large fragments surrounded by fibrosis 

amalgam tattoo (exogenous, non-melanated)

what can be done to treat amalgam tattoo?

laser

graphite and other foreign body tattoos (non-melanated, exogenous)

where does tattoo pigmentation housed?

in macrophages

which pigmented lesion etiopathogenesis?

• Accumulation of melanin

  • Increase in melanin production (more like accumulation of med or agent itself and iron)

  • Decrease in melanin clearance

• Accumulation of medication (ie. antimalarial for lupus)

• Synthesis of special pigments (I.e. Lipofuscin)

• Deposition of iron

medication-induced (non-melanated, exogenous)

clinical features of which pigmented lesion?

• diffuse, painless, symmetric bluish-gray macule

• melanonychia (nail bands) and skin lesions

medication-induced pigmentation

amalgam tattoos appear where 50% of the time?

gingiva/alveolar ridge mucosa

unlike amalgam tattoos where do medication-induced pigmentations occur?

on palate and usually larger

medication-induced

what are the medications associated w hyperpigmentation?

• minocycline

• antimalarials

• clofazimine

• tranquilizers

• hormones

• heavy metals

• amiodarone

which medication proposed source of pigmentation: hyperproduction of melanin, complex w iron, or stained bone?

minocycline

which medication proposed source of pigmentation: hyperproduction of melanin?

antimalarials and hormones

which medication proposed source of pigmentation: chelated metabolites of med?

clofazimine

which medication proposed source of pigmentation: med/metabolites and/or accumulation of melanin?

tranquilizers

which medication proposed source of pigmentation: granules of metal distributed throughout blood vessels?

heavy metals

which medication proposed source of pigmentation: increased production of lipofuscin?

amiodarone 

imatinib-induced hyperpigmentation

what is the worry with pigmented lesions?

melanoma 

medication-induced pigmented lesion

pt also has pigmented lesions in vestibule, on palate, tori, etc

medication-induced pigmented lesion

medication-induced pigmented lesion can appear on skin

amalgam tattoo

antimalaria for immune related purposes, milatinab or quinone

no scarring unlike amalgam tattoo

bluestain = iron, medication-induced pigmented lesion

the most common meds to cause drug-induced gingival pigmentation include all except:

A. minocycline

B. chloroquine (malaria)

C. cyclophosphamide (leukemia, lymphoma immunosuppressant)

D. corticosteroids

E. azidothymidine (AZT, HIV antiviral)

D. corticosteroids

what is heavy metal toxicity and what are the relevant metals?

Pigmentation of marginal gingiva, tongue tremor, metallic taste, excessive salivation, trichotillomania, bruxism

• Lead, mercury, silver, bismuth, gold

heavy metal toxicity, leeches through saliva and GCF

coated (hairy) tongue

• non-melanated

• exogenous: accumulation of keratin build on the filiform papillae; color from trapping of bacteria, yeast, or debris

coated (hairy) tongue

what are the two types of non-melanated endogenous pigmented lesions?

hemosiderin and bilirubin 

what is hemosiderin?

a brown-yellow pigment that accumulates in tissues when red blood cells break down. It is composed of iron oxide and protein. 

what is bilirubin?

a yellowish pigment formed when old red blood cells are broken down. It is a waste product that is processed by the liver and excreted in bile, which gives feces their color

hemosiderin

hemosiderin

bilirubin (liver, bile - also in blood and when levels too high = jaundice)