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E-IJD CORRESPONDENCE
Year : 2016  |  Volume : 61  |  Issue : 1  |  Page : 127
Pigmentary demarcation lines in pregnancy


1 Department of Dermatology, S H Medical Centre, Kottayam, Kerala, India
2 Department of Dermatology, Government Medical College, Kottayam, Kerala, India

Date of Web Publication15-Jan-2016

Correspondence Address:
Veena Chandran
Department of Dermatology, S H Medical Centre, Kottayam, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.174202

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How to cite this article:
Chandran V, Kurien G, Mohan V. Pigmentary demarcation lines in pregnancy. Indian J Dermatol 2016;61:127

How to cite this URL:
Chandran V, Kurien G, Mohan V. Pigmentary demarcation lines in pregnancy. Indian J Dermatol [serial online] 2016 [cited 2019 Sep 18];61:127. Available from: http://www.e-ijd.org/text.asp?2016/61/1/127/174202


Sir,

Pigmentary demarcation lines (PDL) are abrupt lines of transition from deeply pigmented areas to lightly pigmented areas in the skin. Eight different types are described in the literature. Type B PDL have been reported over the legs during pregnancy, and regress after delivery. [1] We are reporting a case with PDL related to pregnancy in Indian skin.


   Case Report Top


A 27-year-old woman came on postpartum day 4 with hyperpigmentation on the posterior aspect of both lower limbs and outer aspect of upper limbs. She started noticing these changes during the last trimester of pregnancy and it became more prominent after her delivery. Her antenatal period was uneventful except for hyperemesis gravidarum and intake of medroxyprogesterone tablets for 1 week during the initial part of pregnancy. The baby was delivered vaginally in occipitoposterior position. On examination, there were well-demarcated areas of hyperpigmentation on the flexoral aspect of both lower limbs which were diagnosed as Type B PDL [Figure 1]. Similar well-demarcated pigmentation was noticed on the anterolateral aspects of both arms suggestive of Type A PDL [Figure 2].
Figure 1: Type B PDL in the patient

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Figure 2: Type A PDL in the patient

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Type B PDL are reported commonly in association with pregnancy. Type B is the most common type of PDL in pregnancy. [2] These lines are very common in blacks. Seventy-nine percent of black female adults have at least one type of pigmentary demarcation line, with types A and B being present in over 50% of the cases. [2] There are also many reports of Type B PDL in Japanese and Caucasians. [3],[4] Gupta et al. reported a pregnant woman from India, who presented with Type B PDL and generalized cutaneous hyperemia. [5] Kumari et al. reported a case with Type A PDL alone and another case with Type B PDL alone in pregnancy. [6] To the best of our knowledge, ours is the first report of a case having both Type A and Type B PDL in pregnancy from India. There are only few previous reports of concomitant occurrence of Type A and Type B PDL in pregnancy from outside India. [3],[7]

Miura described PDL to correspond to axial lines of Sherrington. These virtual lines, well studied by neurologists, correspond to a subset of lines of Voigt, which separate dermatomes arising from nonconsecutive dorsal roots. [8] Pigmentation has neural control and differences in pigmentation noted across these lines may correspond to the absence of overlap between neural territories controlled by different homoeobox genes. [9] As per the axial-neural theory by Maleville, PDL may become apparent only when subtle variation in pigmentation is apparent between two contiguous dermatomes originating from noncontiguous dorsal roots. The prominence of these embryonic demarcated lines in different areas may be influenced by neural, hormonal and genetic factors. In pregnancy, increase in hormones such as melanocyte-stimulating hormone may trigger the inconspicuous melanocytes more in some of these demarcated areas supplied by specific peripheral nerves leading to prominence of PDL (including Type A and B as in our case). [3]

Since prominence of Type B PDL is more associated with pregnancy, local factors in the pelvis like compression and neurogenic inflammation of nerve roots S1 and S2 by enlarging uterus may be a significant contributing factor for Type B PDL as reported by previous authors. [10] We are postulating that sacral nerve root compression which is more common in occipitoposterior deliveries might have added to aggravation of PDL on lower limbs in our patient after delivery. PDL on the face are fairly common in the Indian population especially among the females. [11] We speculate that Type B PDL also may not be rare in Indian skin type and large population-based surveys are required.

 
   References Top

1.
James WD, Meltzer MS, Guill MA, Berger TG, Rodman OG. Pigmentary demarcation lines associated with pregnancy. J Am Acad Dermatol 1984;11:438-40.  Back to cited text no. 1
[PUBMED]    
2.
James WD, Carter JM, Rodman OG. Pigmentary demarcation lines: A population survey. J Am Acad Dermatol 1987;16:584-90.  Back to cited text no. 2
[PUBMED]    
3.
Nakama T, Hashikawa K, Higuchi M, Ishii N, Miyasato M, Hamada T, et al. Pigmentary demarcation lines associated with pregnancy. Clin Exp Dermatol 2009;34:e573-6.  Back to cited text no. 3
    
4.
Ruiz-Villaverde R, Blasco Melguizo J, Naranjo-Sintes R. Pigmentary demarcation lines in a pregnant Caucasian woman. Int J Dermatol 2004;43:911-2.  Back to cited text no. 4
[PUBMED]    
5.
Gupta LK, Kuldeep CM, Mittal A, Paliwal V, Singhal H, Agarwal K, et al. Pigmentary demarcation lines in pregnancy. Indian J Dermatol Venereol Leprol 2005;71:292-3.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Kumari R, Laxmisha C, Thappa DM. Pigmentary demarcation lines associated with pregnancy. J Cosmet Dermatol 2006;5:169-70.  Back to cited text no. 6
[PUBMED]    
7.
Arunachalam M, Bruscino N, Bassi A, Difonzo E. Type A and B pigmentary demarcation lines in a white, pregnant woman- a rare observation? Eur J Dermatol 2011;21:787-8.  Back to cited text no. 7
[PUBMED]    
8.
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 medial regions. Tohoku J Exp Med 1951;54:135-40.  Back to cited text no. 8
[PUBMED]    
9.
Maleville J, Taïeb A. Pigmentary demarcation lines as markers of neural development. Arch Dermatol 1997;133:1459.  Back to cited text no. 9
    
10.
Klein FH, Alves RH, Souza AH. Case for diagnosis. An Bras Dermatol 2013;88:465-7.  Back to cited text no. 10
    
11.
Somani VK, Razvi F, Sita VN. Pigmentary demarcation lines over the face. Indian J Dermatol Venereol Leprol 2004;70:336-41.  Back to cited text no. 11
[PUBMED]  Medknow Journal  


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