Drug-induced oral pigmentation
Additional mechanisms include the deposition of chelated metabolites of the medication in the oral mucosa (such as with clofazimine) and/or iron / hemosiderin deposition following medication-related damage to dermal vasculature.
While drug-induced oral pigmentation is generally diffuse discoloration, fixed drug eruptions occurring orally tend to be more demarcated, slate-brown colored macules, often with accompanying genital lesions. The most common offending agents are clotrimazole and tetracycline.
Other medications implicated in drug-induced pigmentation include zidovudine (AZT), chlorpromazine, ketoconazole, busulfan, doxorubicin, bleomycin, cyclophosphamide, 5-fluorouracil, nicotine, heroin, nitrogen mustard, phenothiazines, arsenic, silver, gold, lead, Premarin, clofazimine, and more recently imatinib mesylate.
For a discussion addressing multiple possible etiologies of oral mucosal pigmentation (physiologic, exogenous and endogenous substances, systemic disease), see Multifocal or diffuse mucosal pigmentation.
T50.995A – Adverse effect of other drugs, medicaments and biological substances, initial encounter
403663003 – Drug-induced oral pigmentation
- Physiologic pigmentation (multifocal or diffuse mucosal pigmentation) – Diffuse and bilateral, childhood onset.
- Peutz-Jeghers syndrome (periorificial lentiginosis) – Multiple diffuse and bilateral macules on the lips, oral / intranasal / conjunctival / rectal mucosa; childhood onset.
- Cronkhite-Canada syndrome – Nonfamilial gastrointestinal polyposis syndrome with associated cutaneous hyperpigmented macules, onychodystrophy, and alopecia.
- Scurvy – Ecchymosis, sometimes dusky purple discoloration of the gingiva, with intraoral swelling and hemorrhage.
- Primary hypoadrenalism (Addison disease) – Diffuse blue-black streaks or patches on oral mucosa and tongue in addition to hyperpigmentation, particularly in sun-exposed areas and flexural creases; also with fatigue, hypotension, electrolyte abnormalities.
- Cushing disease
- Kaposi sarcoma – Bilateral brown to purple plaques / nodules in human immunodeficiency virus (HIV)-positive individuals; ulcerative and necrotic in advanced stages.
- Elevated heavy metal levels (lead, bismuth, silver, mercury, gold, arsenic; see multifocal or diffuse mucosal pigmentation) – Blue-black discoloration along the gingival margin.
- Post-inflammatory pigmentation – Hyperpigmented lesions at sites of previous inflammatory or traumatic lesions or adjacent to active lesions (eg, lichen planus, pemphigus, pemphigoid).
- Smoker's melanosis – Brown-black lesions on the anterior labial and buccal mucosa in smokers.
- Hemangioma – Red-bluish / purple lesion, flat or slightly raised, blanches with pressure, most commonly on tongue.
- Varix – Bluish / purple, irregular elevation, blanches with pressure, commonly on ventral tongue; if it does not blanch with pressure, it may contain a thrombus.
- Hemorrhagic lesion – Nonblanching macule, papule, or petechiae; may be ecchymotic.
- Melanotic macule – Usually less than 1 cm, well demarcated, light or dark brown; more common in women and young adults. Though benign, should consider biopsy to rule out melanoma.
- Pigmented nevi – Brown or blue macule or papule commonly on the palate. Though benign, should consider biopsy to rule out melanoma.
- Melanoma – Brown or black patch with irregular borders, rapidly growing and more ulcerated as it advances; commonly on the palate, followed by the gingiva.
- Oral melanoacanthoma – Similar presentation to oral melanoma; however, occurs more commonly in young female patients with darker skin phototypes.
- Amalgam tattoo – Blue-black area; usually follows accidental placement of dental filling into the oral mucosa.