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Psychosocial impact on patients with hyperpigmented lesions.

Over the centuries, all cultures showed a preference for lighter skin; "porcelain complexion" was considered a sign of nobility. Integumentary pallor or I--II skin phototype, especially in women, was associated with finesse, fragility, youth, or health, and thus, besides isolation in closed environments or specific clothing--long clothes, gloves, umbrellas, designed to protected them from solar radiations--they used to apply different ointments for skin bleaching, and many of these "beauty solutions" were extremely toxic.

Nevertheless, the prestige of spectral and fragile fair skin complexion faded away slowly, but surely, along with the exploitation of solar rays in lupus vulgaris, gout, rheumatism and severe eczema improvement, in early 1900s. In mid 1920s, "sun baths" began to extend beyond sanatoria, thus marking the beginning of pigmented, tanned complexion, which would become the symbol of sex appeal, healthy and dynamic life style.

Regardless of the integumentary pigment, the goal was the same: integumentary uniformity and healthy, young skin.

The skin, an organ with high accessibility, can host significant pigment modifications, with major psychosocial impact on patients, due to the evolution potential of some lesions or to the aesthetic discomfort caused by persistent/permanent lesions.

Cutaneous hyperpigmentations are the result of melanin pigment excess, histologically localized in the epidermis or dermis, most often manifested secondary to quantitative disorders (increase in melanin production--hypermelanocytosis) and occasionally to qualitative disorders (increase in melanocytes activity--hypermelaninoses).

The most accurate classification and compression criteria for hypermelanoses are etiological: genetic hyperpigmentations associated with endocrinopathies, metabolic disease, postinflammatory or infectious pathologies associated to chemical or physical agents (either irritants or medication-related) or associated to tumours, systemic and idiopathic pathologies. From a clinical viewpoint, hypermelanoses may look like circumscribed lesions, diffuse reticular ones, linear or generalized, most often localized and predominantly in areas of the body physiologically pigmented (folds) or in areas exposed to light.

A. Genetic Cutaneous Hyperp igmentation s:

They might look like circumscribed or diffuse, congenital or acquired, isolated or multiple lesions.

Circumscribed lesions: 1. Freckles: they are spots with dimensions ranging from 1 to 3 mm, well-defined, round, brownish, acquired in the first three--five years of life, as a result of melanogenesis stimulation or the increase in melanosomes melanized on keratocytes by the sun rays. They are localized on the photo-exposed area, in persons with I--II skin photo-types, blond or red-haired persons, on the face area, posterior thorax and the back of the hands. They grow in intensity under the influence of solar radiations and they can diminish in dimensions and pigmentation during winter.

2. "Cafe au lait" spots: they are spots ranging with dimensions from 0.5 to 20 cm, well defined, with homogeneous colour, light brown; spread anywhere on integumentary area, but avoiding the mucous membrane. They can be present at birth in 10 20 % of the kids, growing in dimensions and in number over the years.

The presence of at least six lesions on the clinical exam, with > 1.5 cm in diameter, may raise the suspicion of neurofibromatosis type I in children over five. On children under five, five or more "cafe au lait" spots with > 0.5 cm in diameter suggest neurofibromatosis type I diagnosis (Crowe Sign--lesions with 1-4 cm in diameter, localized in the armpit area--specific to neurofibromatosis). Lesions similar to "cafe au lait" spots are also present in tuberous sclerosis, Albright syndrome and Warson Syndrome.

3. Pigmentary naevus: benign tumour spots resulted from the growth of nevus cells on the epidermis. They are classified into jonctional nevi (the growth of nevocytes on the inferior layers of epidermis and at the dermal-epidermal junction), intradermal nevi (dermic nevus growth) and compound nevi (nevus nests localized at the dermal-epidermal jonction and at the dermal area). They are pigmentary lesions ranging from light brown to dark brown, well defined, with various shapes and lengths: flat, macular, papular, nodular, papillomatous, verrucous and pilose. They can be congenital or acquired.

Congenital forms are divided according to their dimensions into: small congenital nevi < 1.5 cm, large ones 1.5-20 cm, gigantic ones > 20 cm; they are, usually, ma cular at birth, barely visible postpartum, intensely pigmented on certain areas such as the scalp. Over the years, they modify their size and their character by becoming verrucous, rugous, nodular or developing hypertrichosis, and by that causing a great prejudice especially to children, teenagers and young adults.

Nevus spilus--rare entity, considered congenital, changing at puberty, characterized by a brownish macula, homogenous coloured, resembling "cafe au lait" macula, developing lentigo-like lesions or brownish papules throughout the area; they entail minimum risk of becoming malign.

Particular forms:

Halo nevus (Sutton)--pigmentary nevus single/multiple, frequently met in children or teenagers, with a peripheral acromic halo. A similar disorder is the Meyerson nevus, whose peripheral halo is inflammatory and intensely pruriginous.

Becker nevus--acquired cutaneous pigmentation, rarely congenital, initially pale, growing in dimensions and intensity due to sun exposure, associated with the increase in receptivity for androgynous hormones. This theory is supported by the subsequent characteristics: hypertrichosis, dermal thickening, sebaceous glands hypertrophy, and acne. It is unilaterally distributed most frequently on the superior thorax and shoulder. It has been reportedly associated with ipsilateral anomalies like mammary hyperplasia, supernumerary nipple, aplasia of the pectoralis, lipoatrophy, shortage of ipsilateral inferior member, spina bifida, and anomalies specific to Becker nevus syndrome.

Spitz-Allen juvenile melanoma: pigmentary nevus that shows upon birth/first years of life, frequently localized on the face, clinically characterized by a nodular area, protruding, homogeneous pigmented, with benign progress, but exceptionally malignization potential.

Hyperpigmented dermal lesions are considered to be the result of dermal melanocytes stored into the dermis during foetal life.

Mongolian spot--macular lesion, congenital, diffuse, with more or less homogeneous colour, grey-bluish, round-oval, approximately 10 cm in size, frequently localized on the lumbo-sacral area.

It is frequently met in black people and Asians, with regression course in the first decade, rarely persisting during adulthood.

Blue nevus--benign tumour lesion, congenital, approximately 1 cm in size, most often localized on the face area, but also on the members. Lesions larger than 1 cm, specific to cellular blue nevus; it has degenerative potential.

Ota nevus--pigmented, unilaterally macules, with heterogeneous colour, with a deep bluish spot, diffuse and another one, superficially, reticular and brownish in colour, localized on the eyelids, conjunctive tissue, sclera or the pathway of trigeminal nerve.

Ito nevus--hyperpigmentation clinically resembling Ota nevus, but with acromioclavicular and deltoid occurrence. 4. Familial lentiginosis--clinically characterized by lentigines--small macules < 5 mm, brownish, resulted from the increase in epidermal melanocytes. It is associated with increased occurrence of cardiovascular diseases, endocrinological diseases and gastrointestinal neoplasm. They occur in Corney complex, Peutz-Jeghers syndrome, LEOPARD syndrome, LaugierHunziker disease and Bannayan-Riley-Ruvalcaba syndrome.

Linear lesions:

1. Incontinentia pigmenti: rare multisystemic disease, with a 4-stage evolution: erythemato-bullous, verrucous, hyperpigmentary, hypopigmentary/ atrophies. Stage 3 is characterized by the presence of linear or swirl pigmentations, grey/greybrownish, parallel to Blaschko lines, frequently localized on the torso and the base of members. They tend to regress gradually from childhood to adolescence, and they might be replaced with hypopigmentary lesions/atrophies (the only signs of this disease in adults).

2. Epidermal nevus: cutaneous lesion derived from the pluripotent cells of basal layer of epidermis, clinically characterized by hyperpigmentary papules, hyperkeratosis well-defined, coalescent into linear lesions, parallel to Blaschko lines, localized on the torso, neck, flexural areas, frequently they are unilateral (nevus unius lateralis) or bilaterally (hystrix epidermal nevus). Epidermal nevus syndrome is defined in association with neurologic anomalies or musculoskeletal anomalies.

3. Reticular lesions:

1. Gougerot and Carteaud papillomatosis: multiple hyperpigmented papules, brownish, 4-5 cm in size, hyperkeratosic, with the tendency of central confluation and peripheral reticular disposition, localized on the presternal area, interscapular area and upper abdomen.

2. Congenital dyskeratosis: genodermatosis with onset during adolescence, characterized by the triad: reticular hyperpigmentation (creases, neck and genital area), mucosal leukoplakia and nail dystrophy. It can be associated with poikiloderma, tardive pancytopenia, multisystemic affection: testicular atrophy, pulmonary fibrosis, liver cirrhosis.

3. Naegeli-Franceschetti-Jadassohn syndrome: autosomal dominant disease, rare, characterized by reticular hyperpigmentation, brown/grey-brownish, frequently localized on the abdomen, periocular and perioral area. It is often associated with adermatoglyphia, hypohidrosis, palmoplantarkeratoderma/diffuse, nail dystrophies, dental anomalies.

4. Reticulate pigmentary dermopathy: genodermatosis characterized by reticular hyperpigmentation, persistent in teenagers, most frequently localized on the torso, proximal area of limbs, associated with onicodistrophy, non-scarring alopecia, axial.

5. Dowling-Degos disease: autosomal dominant pathology, affecting teenagers and young adults, clinically characterized by reticular hyperpigmentation, with axial onset, with further extension on intergluteal, flexural and submammary areas, neck and torso. It is frequently associated with follicular hyperkeratosis, pimples, acneiform scarring, hidradenitis suppurativa.

6. Reticulate acropigmentation of Kitamura: genodermatosis characterized by reticulate and atrophic hyperpigmented macules, with childhood onset and initially localized on the acral area--face and back of the hands, with further evolution during adolescence, aggravated by sun exposure. Dyskeratosis: clinically characterized by hypopigmented, as well as hyperpigmented lesions.

1. Hereditary symmetric dyskeratosis: symmetric dyskeratosis on distal extremi ties, frequent in Asian people. It affects the mucous tissues and its onset is at the age of six.

2. Hereditary universal dyskeratosis: pervasive or localized hypo--and hyperpigmented macules localized on the torso, without affecting mucous tissues and its onset is at the age of six.

3. Xeroderma pigmentosum: hypo--hyperpigmentation macules developed mostly on sun-exposed areas, with malign evolution potential.

B. Cutaneous hyperpigmentation associated with endocrinopathy:

1. Addison disease, Cushing syndrome, hyperthyroidism, Nelson syndrome are all endocrinopathies characterized on cutaneous level by diffuse pervasive hyperpigmentations, higher in intensity on sunexposed areas (face, neck, back of the hands), traumatized areas, areas exposed to pressure, scared areas and flexural areas.

2. Melisma: chronic disease characterized by hyperpigmented plaques, with irregular shapes, with various colours ranging from fawn to brown, evenly spread on centrofacial, malar and mandibular areas. These pigmentations are specific to pregnancy, oral contraceptives and pronounced by sun exposure.

C. Metabolic cutaneous hyperpigmentations:

In patients with diabetes, along with an increased number of vitiligo, there have been recorded hyperpigmented plaques, asymptomatic, irregular in shape, light brown, still not clarified completely, most frequently localized on calf areas, lesions specific to acanthosis nigricans and localized in the axial, inguinal and laterocervical areas.

In patients with porphyria cutanea tarda diagnosis, the hyperpigmentation is brown, diffuse, pronounced in sun-exposed areas; hemochromatosis--early and progressive hyperpigmentation due to melanin and iron deposit, mostly in the flexural area, scares, sun-exposed areas and genital organs.

D. Infectious and post inflammatory cutaneous hyperpigmentations:

These are the results of melanic pigment, secondary to all acute, chronic or infectious inflammatory pathologies, most frequently met in patients with dark skin.

The most frequent conditions are associated with acne syndrome (scars and residual hyperpigmentations with significant psycho-emotional and social impact), atopic dermatitis, all forms of intertigo (favoured by perspiration and microbial spectrum, erythrasma, hidradenitis suppurativa (healing phase with hypertrophic and hyperpigmented scarring), pigmented lichen planus (frequently met in teenagers/adults with skin type III--IV, with hyperpigmented lesions, symmetric, localized on creases and sun exposed areas).

Fox Fordice disease--inflammatory pathology of apocrine glands, frequent in women between 15 and 35, clinically characterized by follicular papules, coalescent, yellow/yellow-brownish, hyperkeratosic, most often localized on the axillary, genital, areola areas and with second manifestation of liquefaction due to persistent and intense itching.

E. Physic hyperpigmentations: due to cumulative effect, solar radiation exposure causes senile lentigo, actinic keratosis or photosensitivity caused by perfumes and cosmetic compounds (Riehl's melanosis, poikiloderma of Civatte) or furocoumarins from certain plants (phytophotodermatitis).

Chronic exposure to heat or trauma causes erythema ab igne, characterized at first by erythematous lesions, with further hyperpigmentation in brown, with reticular aspect, after repeated exposures.

Cumulative exposure to X-rays causes hyperpigmentations of irradiation point.

F. Chemical hyperpigmentations caused by either chronic exposure to certain substances, such as arsenic (hyperpigmentation of the photo exposed, traumatized areas) or due to systemic/topic drugs: fixed drug eruption (cyclines, barbiturates and sulfonamides), pseudoacanthosis nigricans (corticoids, tars, nicotinic acid and insulin), flagellate pigmentation (bleomycin), supravenous serpentine hyperpigmentation (vinblastine, bleomycin, 5-FLU).

G. Tumour cutaneous hyperpigmentation:

1. Acanthosis nigricans: malign disorder associated to abdominal tumour, especially gastric ones, clinically characterized by hyperpigmented plaques/placards, symmetric, black, with a diminished colour intensity towards peripheral area, covering integument most often consistently thickened and natural skin squaring accentuated, sometimes in association with giant papillomatosis, which causes pseudo-tumour aspect localized in the axillary and inguinal areas, inner thighs, cervical area, elbows and knees.

2. Malignant melanoma: malign tumour with melanocytar origin, localized anywhere in the cutaneous and mucous areas, with severe evolution and increased lethal risk due to early metastasis.

Diffuse dermatitis--manifested in association to malignant melanoma metastasis.

H. Hyperpigmentations associated with autoimmune and systemic disease: characterized by residual lesions from the bullous or evolving pathologies spectrum or lupus erythematosus systemic lesions and scleroderma.

I. Idiopathic cutaneous hyperpigmentation:

1. Prurigo pigmentosa: idiopathic pathology frequent in teenagers, characterized by inflammatory eruption, pruriginous, papulous, papulovesicular, localized in the back of the torso, neck, presternal area, followed by a regression of inflammatory process, hyperpigmented macules, reticular distribution, grey-brownish.

2. Erythema dyscromicum perstans: circumscribed macules/plaques, grey-brownish, asymptomatic, with dimensions ranging from 0.5 to 3 cm, round/ovals or irregular contour, initially erythematous, protruding, elevated and soft on touch. During the next several months, they tend to regress. It is most frequently met in young women, with skin type III--IV, localized on the cervical area, neck, face and proximal area of limbs.

Numerous studies showed that 30-40% of patients with cutaneous disorders, especially chronic ones, manifest mental disorders and psychosocial deficiencies. The presence of these pathologies bears a great impact on every aspects of life: schooling, professional performances, human relationships, self-esteem, sexual life and free time.

The bidirectional relationship "mind--body", and subsequently the skin, is supported by the presence of two kinds of cutaneous conditions. The first is named "psychophysiological condition", comprising defined pathologies, exacerbated by or stress supported. The second one with the same frequency in dermatological practice is characterized by cutaneous scarring with negative impact on patients' psychological state of mind.

As far as cutaneous hyperpigmentations are concerned, these two should not be neglected due to their psychosocial impact. Independent of the matter, pigmented lesions, unique and multiple, often with no associated subjective symptoms (for example: pigmentary nevi), are able to raise some concerns in certain patients. They also tend to become obsessive, due to their clinical and histopathological evolutions.

Secondary hyperpigmentations, resulted from coexistent or residual disorders, are visible indications of an active pathologic process, possibly evolving/degenerative, or they represent the sign of a pre-existing condition. Besides the aesthetic prejudice, all these might cause anxiety, depression, compulsive-obsessive disorders, suicidal thoughts, as well as lower adherence to treatment.

Psychosocial impact determination in patients with cutaneous hyperpigmentations must rely on certain aspects like gender, age, localization and the bidirectional relationship of cutaneous condition and the psychological component.

Lesions displayed in exposed areas (face, neck, hands, upper side of the anterior torso, genital organs) significantly increase the risk of psychiatric disorders.

Studies showed a rate two times higher of psychiatric and behavioural disorders (anxiety, frustration, anger, isolation, aggression) in children with hyperpigmentation lesions, during schooling period, an impact also present and increased in family members who see themselves helpless and who tend to blame themselves. Children tend to internalize stereotypes and negative reactions received from the outside environment (offends, avoidance, disapproval as far as interacting and group activities are concerned). All these experiences will shape their cognitive structures associated with self-image and personality, leading to severe cases of embarrassment, self-isolation, denying participation in any group activity.

Adolescence is an important stage in individual development, characterized by numerous biological, physical, moral and psychological changes. This is the time when physical appearance--and, consequently, the way they are perceived and accepted by others--represents a crucial factor for teenagers' emotional and motivational development. The most powerful impact, in terms of dermatological pathologies, is carried by acne. Constant accentuations of acne, as well as disfiguring post-acne lesions (scarring and hyperpigmentations), can trigger severe psychic and behavioural disorders, like anxiety, depression, decreased quality of life, academic results decrease, self-esteem decrease, social phobia, anorexia, and self-harming ideas in the worst case scenario. Behavioural and psychoemotional reactions to body image issues in relation to exterior cutaneous lesions, and in the age context are even more frequent, hard to control, manage and with a higher suicidal risk.

Another important aspect of cutaneous scarring is the relationship between acne and the psychological state of mind. Furthermore, psychological factors like emotional stress, anxiety, lead to acne increase. Several hypotheses posit that certain stress hormones, such as glucocorticoids hormones are released in higher quantities along with psychological stress, consequently creating a vicious circle.

In adults, cutaneous scarring consequences manifest themselves both on socioeconomic and psychosocial level. Patients are interested in the aesthetic aspect, sex appeal, human interaction abilities, as well as the possibility to achieve their professional goals or to work in areas involving human contact.

The constancy of these issues will lower self-esteem and distort self-image; it will also entail professional motivation loss, avoidance of situations and activities that involve skin exposure, addictions. All the aforementioned aspects can lead to the development of depression and major anxiety, aggressiveness and uncontrolled autolytic actions.

Moreover, bearing a social stigma entails other consequences such as unemployment and costs for treatments meant to solve aesthetic prejudice (that often do not show expected results, thus increasing the psychoemotional stress in patients).

Correspondence: Dan vAtA

Dermatology Discipline "Grigore T. Popa" University of Medicine and Pharmacy Iasi No. 2 Str. Vasile Conta, Iasi, Romania

Tel.: +40 741 084 264 E-mail: dan.vata@umfiasi.ro

Submission: June, 10th, 2016 Acceptance: July, 22nd, 2016

ACKNOWLEDGMENTS AND DISCLOSURES

Authors state that there are no declared conflicts of interests regarding this paper.

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Laura Statescu--M. D., Ph. D., Senior Dermatologist at "St. Spiridon" Emergency Hospital Iasi, Teaching Assistant at "Grigore T. Popa" University of Medicine and Pharmacy, Dermatology Discipline, Iasi, Romania

Madalina Bejan--Resident Dermatologist at "St. Spiridon" Emergency Hospital Iasi, Romania

Elena Andrese--M. D., Dermatologist, Teaching Assistant at "Grigore T. Popa" University of Medicine and Pharmacy, Dermatology Discipline, Iasi, Romania

Adriana Patrascu--M. D., Dermatologist at CMI Lauderma Iasi, Romania

Dan Vata--M. D., Ph. D., Senior Dermatologist at "St. Spiridon" Emergency Hospital Iasi, Lecturer at "Grigore T. Popa" University of Medicine and Pharmacy, Dermatology Discipline, Iasi, Romania

Tatiana Taranu--M. D., Ph. D., Senior Dermatologist at CFR Hospital Iasi; Associate Professor at "Grigore T. Popa" University of Medicine and Pharmacy, Faculty of Dental Medicine, Iasi, Romania

Laura Gheuca Solovastru--M. D., Ph. D., Senior Dermatologist at "St. Spiridon" Emergency Hospital Iasi; Professor at "Grigore T. Popa" University of Medicine and Pharmacy, Dermatology Discipline, Iasi, Romania
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Author:Statescu, Laura; Bejan, Madalina; Andrese, Elena; Patrascu, Adriana; Vaja, Dan; Taranu, Tatiana; Ghe
Publication:Bulletin of Integrative Psychiatry
Article Type:Report
Date:Sep 1, 2016
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