Melanosis gingival: diagnóstico y terapéutica de su implicación estética. Revisión de la literatura / Gingival Melanosis: Diagnosis and Therapy of Its Aesthetic Involvement. Literature Review

ABSTRACT: Gingival hyperpigmentation is produced by excessive melanin deposit, generating a dark gum coloring. Although it does not constitute a health issue, in some cases it usually represents an aesthetic problem that can affect psychologically, for which there are currently several treatment alternatives such as: surgery with scalpel, laser therapy, abrasion, cryosurgery, electrosurgery, among others. The aim of this literature review was to analyze the available information about gingival melanosis and the therapeutics that can be applied to improve the appearance of patients with this condition. Articles in English and Spanish, published during the period 2000-2020 in the PubMed, Medline, Scielo, Cochrane and Lilacs databases, were reviewed. It was concluded that the selection of the technique will depend on each particular case, however, the laser is the most relevant.

RESUMEN: La hiperpigmentación gingival se produce por el depósito excesivo de melanina, generando una coloración oscura de la encía. Aunque no constituye un inconveniente para la salud, en algunos casos suele representar un problema estético que puede afectar psicológicamente, por lo cual, en la actualidad existen diversas alternativas de tratamiento como: cirugía con bisturí, terapia láser, abrasión, criocirugía, electrocirugía, entre otros. El objetivo de esta revisión de la literatura fue analizar la información disponible acerca de la melanosis gingival y la terapéutica que puede ser aplicada para mejorar el aspecto de los pacientes con esta condición. Se revisaron artículos en inglés y español, publicados durante el período 2000-2020 en las bases de datos PubMed, Medline, Scielo, Cochrane y Lilacs. Se concluyó que la elección de la técnica dependerá de cada caso en particular, sin embargo, el láser es el más destacado.

Symmetrical acral keratoderma revisited: proposal for a new term, 'pigmented carpotarsal hyperkeratosis'.

First reported from Taiwan mistakenly as acral acanthosis nigricans in 1991, pigmented carpotarsal hyperkeratosis or hyperkeratosis nigricans carpi et tarsi displays a peculiar distribution of velvety brown-grey hyperpigmented plaques symmetrically on the flexural side of the wrists and ankles and on the dorsal sides of the hands and feet. A marked epidermal hyperkeratosis with typically mild acanthosis and papillomatosis is observed in histology. Whitish maceration upon perspiration or water exposure, with exacerbation in summer but remission in winter, is common. The association with obesity, endocrine disorders, atopic dermatitis, ichthyosis or malignancy is unknown. Familial occurrence and hereditary patterns are ill-defined. There is preliminary evidence indicating a pathogenic role of missense mutation in the transcription factor 4 gene. Treatment is empirical, with good outcome with topical retinoids and keratolytic agents. Recurrence is common, and long-term prognosis is unclear. To be distinguished are acral acanthosis nigricans, palmoplantar keratoderma of the Nagashima type, palmoplantar keratoderma of the Bothnian type and aquagenic palmoplantar keratoderma. Most reported cases are from Southern China and are predominantly observed in men between the ages of 20 and 40 years. The currently used term 'symmetrical acral keratoderma' is non-specific and misleading and may lead to global unawareness, underreporting or misdiagnosis of this phenomenon. Further genetic and molecular studies are required to clarify its pathogenesis and relation to palmoplantar keratoderma.

Macular pigmentation of uncertain aetiology revisited: two case reports and a proposed algorithm for clinical classification.

Ashy dermatosis, erythema dyschromicum perstans, lichen planus pigmentosus and idiopathic eruptive macular pigmentation are various types of acquired macular hyperpigmentation disorders of the skin described in literature. However, a global consensus on the definitions of these entities is lacking. We report two cases of acquired macular (hyper)pigmentation of uncertain aetiology diagnosed as ashy dermatosis and attempt to clarify the various confusing nosologies based on existing literature. We infer that acquired small and large macular pigmentation of uncertain aetiology should be considered separate from that associated with lichen planus. We also propose a diagnostic algorithm for patients with acquired macular hyperpigmentation.

Classification by causes of dark circles and appropriate evaluation method of dark circles.

BACKGROUND: Dark circles refer to a symptom that present darkness under the eyes. Because of improvement in the quality of life, the dark circles have been recognized as one of major cosmetic concerns. However, it is not easy to classify the dark circles because they have various causes. METHODS: To select suitable instruments and detailed evaluation items, the dark circles were classified according to the causes through visual assessment, Wood's lamp test, and medical history survey for 100 subjects with dark circles. After the classification, were newly recruited for instrument conformity assessment. Through this, suitable instruments for dark circle evaluation were selected. We performed a randomized clinical trial for dark circles, a placebo-controlled double-blind study, using effective parameters of the instruments selected from the preliminary test. RESULTS: Dark circles of vascular type (35%) and mixed type (54%), a combination of pigmented and vascular types, were the most common. Twenty four subjects with the mixed type dark circles applied the test product (Vitamin C 3%, Vitamin A 0.1%, Vitamin E 0.5%) and placebo on randomized split-face for 8 weeks. The effective parameters (L*, a, M.I., E.I., quasi L*, quasi a* and dermal thickness) were measured during the study period. Result showed that the L* value of Chromameter(®) , Melanin index (M.I.) of Mexameter(®) and quasi L* value obtained by image analysis improved with statistical significance after applying the test product compared with the placebo product. CONCLUSION: We classified the dark circles according to the causes of the dark circles and verified the reliability of the parameter obtained by the instrument conformity assessment used in this study through the efficacy evaluation. Also based on this study, we were to suggest newly established methods which can be applied to the evaluation of efficacy of functional cosmetics for dark circles.

Influence of Environmental Tobacco Smoke on Gingival Pigmentation in Schoolchildren.

PURPOSE: To examine the relationship between environmental tobacco smoke (ETS) and oral pigmentation in schoolchildren. MATERIALS AND METHODS: Oral photographs of 117 systemically healthy, nonsmoking children and young adults (aged 10 to 21 years) were randomly selected from two rural schools. Closed-ended questionnaires were designed for this age group and used to record answers given by the subjects. The subjects were divided into two groups based on age: group 1 (10 to 14 years) and group 2 (15 to 21 years). There were 58 subjects in group 1 and 59 in group 2. Gingival pigmentation was classified using the Melanin Index Score (MIS) into MIS-0 (no pigmentation), MIS-1 (solitary unit(s) of pigmentation in papillary gingiva) and MIS-2 (continuous band extending from 2 neighbouring solitary units). RESULTS: In group 1, 17.24% of subjects displayed MIS-0 compared to only 5.08% in group 2. The difference between the groups was found to be statistically significant according to Student's t-test (p < 0.001). In group 2, 38.98% of subjects showed MIS-2 as compared to only 17.24% subjects in group 1. CONCLUSION: Despite the relatively small sample size, the results of the present study confirmed previously reported findings that ETS has an influence on both the prevalence and the severity of gingival pigmentation.

The biology of hyperpigmentation syndromes.

Hyperpigmentation is a key feature in a variety of inherited and acquired syndromes. Nonetheless, determining the exact diagnosis only on the clinical phenotype can be challenging, and a detailed search for associated symptoms is often of crucial importance. As pigmentation pathways are regulated by complex signaling transduction cascades (e.g. MSH/cAMP, KIT signaling pathways), the underlying defects leading to elevated melanin production are numerous. With regard to treatment, limited therapeutic options exist, each with specific side effects. In acquired hyperpigmentation, the melanin deposition may, however, be reversible after adequate therapy of the underlying disorder or even disappear spontaneously. In this review, we provide an overview of the biology of hyperpigmentation syndromes classified according to the main underlying defect that deregulates physiological melanogenesis. The identification of novel genes or key players involved in hyperpigmentary disorders is becoming increasingly important in view of the development of safer and more efficient treatments.

Linear atrophoderma of Moulin: a distinct entity?

Linear atrophoderma of Moulin (LAM) is a rare dermatologic disorder characterized by a hyperpigmented atrophoderma that consistently follows the lines of Blaschko. There are many clinical and histologic similarities between LAM, atrophoderma of Pasini and Pierini (APP), and morphea, and whether LAM represents part of a disease spectrum or its own distinct entity is debated. This case of a 16-year-old boy with LAM supports the hypothesis that LAM, APP, and morphea are a spectrum of disorders rather than unique entities. Although the patient's overall clinical picture supports a diagnosis of LAM with hyperpigmented, depressed lesions following the lines of Blaschko and perivascular lymphocytic infiltrate on biopsy, the bilateral presentation typical of APP, collagen entrapment of eccrine ducts typical of morphea, and changes in dermal collagen illustrate features spanning all three disorders, suggesting a relationship between these conditions that represents a spectrum of disease. Furthermore, a review of all reported cases of LAM in the literature suggests an evolving definition beyond what Moulin and colleagues originally described, including features related to those of APP and morphea.

Hyperpigmentation: types, diagnostics and targeted treatment options.

BACKGROUND: Pigment formation is highly complex. It is involved in inflammation, sun protection and many other processes. For practical purposes, such as exposure time for sun tanning, six skin types are distinguished according to Fitzpatrick, listed in decreasing lightness. The hyperpigmentation commonly occurs in Fitzpatrick skin types III to VI and can have a considerable impact on quality of life. MATERIAL & METHODS: In this article we will give an overview of normal variations of pigmentation and the most often common pigment abnormalities. It also reviews diagnostics and the current targeted treatment options of epidermal and dermal pigmentation. RESULTS: There are multiple hyperpigmented skin lesions, classification of pigmentation is based on histology or Woods light examination. Bleaching agents with phenolic compounds with non-phenolic agens as follow-up therapy appears to be the most beneficial treatment options for the hyperpigmentation. CONCLUSIONS: The effective treatment of pigment disorders is characterized by influence of melanin formation, but the therapy should be based on a the correct diagnosis and always targeted to the other histopathological processes in the skin. The Woods light examination shows clinical aspect of the lesions and may be helpful in the determination of the diagnosis.

Reticulate pigmentary disorders.

Reticulate pigmentary disorders is a term that is loosely defined to include a spectrum of acquired and congenital conditions with different morphologies. The presentations vary from the reticular or net like pattern to the" freckle like" hyper and hypopigmented macules that are usually restricted to the true genetic "reticulate" pigmentary disorders. There is little clarity on this topic and related terms, in major dermatology textbooks. Hence, to harmonize the different entities we feel that the term "mottled pigmentation" could be used to include reticulate pigmentary disorders (acquired and congenital), dyschromasias and the disorders with a reticular pattern. The genetic reticulate pigmentary disorders can also be classified according to the gene loci which in the majority of cases are localized to keratin 5/14. A more useful clinical method of classification is based on the regional distribution, which includes facial, truncal, acral or flexural types. In this review we will largely focus on the inherited reticulate pigmentary disorders.

Normal and abnormal skin color.

The varieties of normal skin color in humans range from people of "no color" (pale white) to "people of color" (light brown, dark brown, and black). Skin color is a blend resulting from the skin chromophores red (oxyhaemoglobin), blue (deoxygenated haemoglobin), yellow-orange (carotene, an exogenous pigment), and brown (melanin). Melanin, however, is the major component of skin color ; it is the presence or absence of melanin in the melanosomes in melanocytes and melanin in keratinocytes that is responsible for epidermal pigmentation, and the presence of melanin in macrophages or melanocytes in the dermis that is responsible for dermal pigmentation. Two groups of pigmentary disorders are commonly distinguished: the disorders of the quantitative and qualitative distribution of normal pigment and the abnormal presence of exogenous or endogenous pigments in the skin. The first group includes hyperpigmentations, which clinically manifest by darkening of the skin color, and leukodermia, which is characterized by lightening of the skin. Hypermelanosis corresponds to an overload of melanin or an abnormal distribution of melanin in the skin. Depending on the color, melanodermia (brown/black) and ceruloderma (blue/grey) are distinguished. Melanodermia correspond to epidermal hypermelanocytosis (an increased number of melanocytes) or epidermal hypermelanosis (an increase in the quantity of melanin in the epidermis with no modification of the number of melanocytes). Ceruloderma corresponds to dermal hypermelanocytosis (abnormal presence in the dermis of cells synthesizing melanins) ; leakage in the dermis of epidermal melanin also exists, a form of dermal hypermelanosis called pigmentary incontinence. Finally, dyschromia can be related to the abnormal presence in the skin of a pigment of exogenous or endogenous origin.

Periorbital hyperpigmentation in Asians: an epidemiologic study and a proposed classification.

BACKGROUND: Periorbital hyperpigmentation (POH) presents with a dark area surrounding the eyelids. It is an ill-defined condition, and the pathogenesis can be multifactorial. OBJECTIVE: This epidemiologic study was conducted to assess the prevalence of periorbital hyperpigmentation in Singapore in an attempt to propose a classification. MATERIALS AND METHODS: One thousand consecutive patients attending the general dermatology clinic at the National Skin Center were enrolled in the study to assess for POH, of whom 200 with POH were examined and investigated to define the cause of POH. The possible causes were determined according to a detailed history, clinical examination, and assessment by three dermatologists. The extent of the POH was measured using a mexameter. RESULTS: The commonest form of POH was the vascular type (41.8%), followed by constitutional (38.6%), postinflammatory hyperpigmentation (12%), and shadow effects (11.4%). The vascular type was seen predominantly in Chinese, whereas as the constitutional type was most common in Indians and Malays. CONCLUSION: The vascular form of POH was the predominant type. We propose a comprehensive classification for POH that we hope will influence the choice of treatment modalities used in managing POH in the future.

Familial progressive hypermelanosis in Indian monozygotic twins.

Familial hyperpigmentation, or melanosis universalis hereditaria, is a rare hyperpigmentary disorder with onset in infancy. Here, we describe monozygotic twins with similar pattern of progressive hyperpigmentation with onset in early neonatal period without any family history. Histopathological examination showed increased melanin throughout the epidermis. Although hereditary defects may influence melanogenesis resulting in a pigmentary anomaly, the pathogenesis of hyperpigmentation in this case remains unclear.

Bluish pigmentation of face and sclera.

Was this a case of Addison's disease, hemochromatosis, or melanoma? Or did one of the patient's medications have something to do with it?

Pigmentary disorders in Latin America.

Pigmentary disorders with hypopigmentation/depigmentation or hyperpigmentation may have special manifestations in Latin America. Most pigmentary disorders are commonly observed in all areas of Latin America, but a few are particularly seen in tropical and subtropical regions. In most pigmentary disorder ailments described, multiple factors involved in their pathogenesis are known, but etiology remains elusive. Some pigmentary disorders have peculiar clinical expressions and, in spite of being restricted to certain geographical areas, they may be observed in other world areas because of frequent traveling of affected patients. Therapy of most of these ailments is difficult or remains unknown.

Pigmentary disorders in China.

Because variations in the degrees of pigmentation occur in various regions of the body, there are different pigmentary diseases in various ethnic groups. We usually divide the disorders of melanin pigmentation into two types: hypermelanosis and hypomelanosis. These disorders may be due to genetic and environmental factors. Pigmentary disorders are more visible on the Chinese skin and are of great cosmetic concern to patients. In this article we introduce characteristic pigmentary disorders in China.

Association of lip pigmentation with smoking and gingival melanin pigmentation.

OBJECTIVE: We investigated the association of lip pigmentation with smoking and melanin pigmentation in the gingiva. DESIGN: Case-control study. SETTING: Health check-up in an institute. SUBJECTS AND METHODS: Photos of 213 males employed in an institution were assessed in terms of pigmentation in lip and gingiva. MAIN OUTCOME MEASURES: Prevalence and scores of lip and gingival pigmentation and smoking status. RESULTS: Among subjects displaying lip and gingival pigmentation, 73% and 87% respectively, were current smokers, whereas 33% and 27% of individuals lacking pigmentation were current smokers respectively. Odds ratios of current smoking relative to lip and gingival pigmentation were 5.6 (95% confidence interval: 2.8-11.1) and 17.0 (8.1-36.0) respectively. Daily consumption, duration of smoking and lifetime exposure exhibited significant correlation with scores of lip and gingival pigmentation (P<0.0001). Odds ratios increased in lip and gingival pigmentation upon exposure. In current smokers, scores of lip and gingival pigmentation demonstrated meaningful correlation (P<0.0001); moreover, 95% of participants with lip pigmentation were positive for gingival pigmentation. CONCLUSION: These results indicated the presence of a striking association between smoking and pigmentation in the lip and gingiva, which was stronger with respect to gingival pigmentation. Health professionals could educate smokers, utilizing visible symptoms in the lip and gingiva.