A 66-year-old white woman presented for an evaluation of her skin. Informed consent was obtained from the patient for being included in the study. Additional informed consent was obtained from all patients for which identifying information is included in this article. The patient’s past medical history was significant for systemic lupus erythematosus and myasthenia gravis. Since 1980, the patient has been treated with hydroxychloroquine at a daily dose of 400 mg.\nThere was diffuse hyperpigmentation. The patient’s forehead, face, neck, v-area of the upper central chest, and upper back were black (Figs. , ), and her right upper chest was blue (Figs. , ). Hyperpigmentation was absent from her oral mucosa and nails.\nFive years earlier, the patient had visited a new clinician on a Friday afternoon. The patient’s clinician misinterpreted her black and blue dyschromia to be trauma-induced and had notified Adult Protective Services. The following Monday morning, a worker from the agency was at her home to investigate the family for elder abuse. Eventually the situation was resolved and the family was cleared of all suspicion of elder abuse.\nDuring her current cutaneous evaluation, a skin biopsy from the area of blue dyschromia on the patient’s right upper chest was performed. Microscopic examination showed both intracellular and extracellular yellow-to-brown granules scattered throughout the reticular dermis. Pigmented granules were seen between the collagen bundles with some accentuation around eccrine glands. The granules stained positively for both Fontana Masson and Perl’s stains.\nCorrelation of the patient’s medical history, clinical presentation, and pathology findings confirmed the diagnosis of hydroxychloroquine-induced hyperpigmentation.
A 65-year-old retired male (Fitzpatrick phototype II) previously healthy except for a distant history of basal cell carcinoma presented to our dermatology clinic with a two-day duration of a rash. The lesions were first noticed on his chest, upper extremity and back []. The rash was extremely pruritic resulting in insomnia for the previous 2 nights which went unrelieved despite oral diphenhydramine. Also concerning to him and his wife was the whip like nature of the rash which was somewhat linear and run vertically right down his back in a manner unlikely to be produced by simple excoriation. In addition, he denied reaching for or scratching his back in any manner. Review of systems was negative, and he denied any recent history of travel, similarly sick contacts or recent outdoor contactants or change in body soaps or laundry detergents.\nHe denied any prior history of similar rashes and his past medical history was non-contributory. A detailed exposure history revealed the patient had eaten mushrooms 48 hours ago during dinner at a Chinese cuisine buffet. He admitted to ingesting great quantities of a medley of cooked and raw mushroom including the Shiitake mushroom variety.\nPhysical examination was striking with a truncal dominant but generalized rash in a centripetal distribution (). The lesions consisted of raised, relatively uniform erythematous papulovesicles arranged in linear arrangement. Close-up views [] confirmed the papulo-vesicular nature of the rash with multiple small papules grouped both along the breadth and length of each linear streak within an erythematous background.\nGiven the clinical history and presentation the diagnosis was consistent with a shiitake dermatitis. Flagellate patterns of eruption have also been noted in drug reactions particularly to bleomycin, peplomycin (a bleomycin derivative), docetaxel, adult-onset Still’s disease, and dermatomyositis [].\nThe patient was put on a mid-potency topical steroid (Triamcinolone 0.1% ointment applied to affected areas twice daily). The rash resolved within 1 week. It has been reported that shiitake dermatitis can also resolve spontaneously.