Review

A global consensus statement on ashy dermatosis, erythema

dyschromicum perstans, lichen planus pigmentosus,
idiopathic eruptive macular pigmentation, and Riehl’s
melanosis
Sujith Prasad W. Kumarasinghe1, MBBS, MD, FACD, Amit Pandya2, MD, Veena
Chandran3, MD, DNB Dermatology, Michelle Rodrigues4, MBBS, FACD, Ncoza C. Dlova5,
6 7 8
MBChB, FCDerm, PhD, Hee Young Kang , MD, M. Ramam , MBBS, MD, Johannes F. Dayrit ,
9 10
MD, Boon Kee Goh , BSc, MBChB, FRCP, and Davinder Parsad , MBBS, MD

1
Department of Dermatology, Fiona Stanley Abstract
Hospital, Murdoch, WA, Australia, Ashy dermatosis (AD), lichen planus pigmentosus (LPP), erythema dyschromicum perstans
2
Department of Dermatology, University of
(EDP), and idiopathic eruptive macular pigmentation are several acquired macular
Texas Southwestern Medical Center,
hyperpigmentation disorders of uncertain etiology described in literature. Most of the
Dallas, TX, USA, 3Royal Perth Hospital,
Perth, WA, Australia, 4Department of published studies on these disorders are not exactly comparable, as there are no clear
Dermatology, St Vincent’s Hospital, Fitzroy, definitions and different regions in the world describe similar conditions under different
Vic, Australia, 5Department of Dermatology, names. A consensus on the terminology of various morphologies of acquired macular
College of Health Sciences, Durban, South
pigmentation of uncertain etiology was a long-felt need. Several meetings of pigmentary
Africa, 6Department of Dermatology, Ajou
University, Suwon, South Korea,
disorders experts were held to address this problem. A consensus was reached after
7
Department of Dermatology, All India several meetings and collation of e-mailed questionnaire responses and e-mail
Institute of Medical Sciences, New Delhi, communications among the authors of publications on the above conditions. This was
India, 8Department of Dermatology, achieved by a global consensus forum on AD, LPP, and EDP, established after the 22nd
Research Institute for Tropical Medicine,
International Pigment Cell Conference held in Singapore in 2014. Thirty-nine experts
Metro Manila, Philippines, 9Mount Elizabeth
Medical Centre, Singapore, and
representing 18 countries participated in the deliberations. The main focus of the
10
Department of Dermatology, deliberations was terminology of the conditions; as such, we present here the consensus
Postgraduate Institute of Medical Education statement of the forum and briefly review the available literature on the subject. We have
and Research, Chandigarh, India not attempted to discuss treatment modalities in detail.

Correspondence
Sujith Prasad W. Kumarasinghe, MBBS, MD,

FACD

Department of Dermatology
Fiona Stanley Hospital, 11 Robin Warren
Drive, Murdoch, WA 6150
Australia
E-mail: prasadkumarasinghe@yahoo.com

Conflicts of interest: None declared.

doi: 10.1111/ijd.14189

small or large macules of hyperpigmentation which have a gray

Background and Review of Literature
Thousands of patients world over suffer from different clinical
and morphological types of patchy hyperpigmentation. These
disorders are of a greater clinical and psychological concern
among dark-skinned populations (Fitzpatrick’s type III–VI). Ashy
dermatosis (AD), lichen planus pigmentosus (LPP), and ery-
thema dyschromicum perstans (EDP) present with acquired
appearance and are deeper than epidermal pigmentary disor-
ders such as melasma and lentigines.1–3 Some authors con-
sider AD, LPP, and EDP as the same condition, whereas
others consider them to be different.4–9 Furthermore, a similar
condition but with smaller macules of acquired hyperpigmenta-
tion termed idiopathic eruptive macular pigmentation (IEMP)
and an additional condition known as IEMP with papillomatosis 1

ª 2018 The International Society of Dermatology International Journal of Dermatology 2018

2 Review Global consensus statement
have also been described, and their relationship with AD, LPP,
and EDP is unclear.10,11
EDP and AD
Ramirez first described AD in 1957 in El Salvador.1 The name
was coined because of the ashy blue-gray color of the lesions.
The term EDP was used by Convit and colleagues in 1961 in a
report of five cases in which the disease was characterized by
numerous small and large macules of a grayish color of varying
intensity, sometimes becoming confluent covering extensive
areas of the body.2 When the lesions were evolving, the mac-
ules had a slightly raised, firm, erythematous border that felt like
a thin piece of string. In 1957, Ramirez had reported 139 similar
cases, some of which had an easily observable nonelevated
erythematous border.12
The above two morphological types were generally thought to
be characterized by acquired small and large macules with
ashy/gray discoloration and on histopathology by a lichenoid
perivascular infiltrate and pigmentary incontinence (me-
lanophages). The major difference between the above two is
the presence of an erythematous border in the early active
phase of EDP.
The etiology mostly remains unknown.1,2,13 There were
attempts to identify the etiology of these conditions. Stevenson
and Miura reported a patient who had similar skin lesions with
associated intestinal parasitism and showed a therapeutic
response to anti-parasite therapy.14 Chua et al., attributed the
pigmentation in their three patients to omeprazole.15 This was
questioned by Chandran and Kumarasinghe who argued that
these cases should be labeled as drug-induced hyperpigmenta-
tion rather than ashy dermatoses.16 EDP has also been associ-
ated with enteroviral, hepatitis C infections and HIV
seroconversion.17–19 There were reports associating EDP/AD
with intake of ethambutol, chlorothalonil, cobalt allergy, ammo-
nium nitrate, Chinese herbal extracts, fluoxetine, etc.20–25 A
study done on Mexican patients suggested genetic susceptibility
conferred by genes located within the major histocompatibility
complex region.26
The age range is from childhood through maturity, and both
sexes are affected equally.13,27–30 Unlike adult patients who are
mostly Hispanic in origin, children are usually Caucasian. Other
important factors in children are absence of consistent trigger
factors and eventual improvement or resolution in 50–69% of
prepubertal patients.27,29 The youngest pediatric patient
reported was 2 years old.30
Different types of therapies have been employed with little or
no benefit.1,2,13
However, several authors have subsequently trialed various
treatment modalities and reported success in some cases. Iso-
tretinoin,31 topical tacrolimus,32,33 dapsone,34 clofazimine,35 and
NBUVB36 have been reported to be successful in some cases.
Some cases of “unilateral AD” have been reported mainly
from Japan.37,38 Some of them were reported to have a
International Journal of Dermatology 2018
Kumarasinghe et al.
Blashkoid distribution whereas others were not. However, in our
opinion, acquired macular hyperpigmentation in unilateral or
Blashkoid distribution should not be labeled as AD just because
of the color of the lesions.
Various authors have elucidated the ultrastructural and
immunopathologic features in patients with EDP/AD.35,39,40
Ashy dermatosis lacks a well-defined histopathological picture
and can be similar to other inflammatory disorders including
lichenoid reactions.4
Vasquez-Ochoa et al.39 in a study of their 43 patients
reported the presence of dermal lymphocytic infiltrate in all of
their cases, which was of perivascular distribution in 86%. Mela-
nophages were demonstrated in all the cases with vacuolization
of basement membrane zone in 58% and exocytosis of lympho-
cytes in 53.5%. There was predominance of CD8+ T lympho-
cytes (cytotoxic) in the dermis and HLA–DR+, ICAM-1+
keratinocytes in the epidermis. Exocytosis of cutaneous lympho-
cyte antigen+ cells were observed in areas of BMZ zone dam-
age suggesting that antigenic stimulation may play a role in the
development of EDP.
Baranda et al.35 found that the expression of ICAM-1 and
HLA–DR positivity in their patients disappeared after treatment
with clofazimine. They found that the dermal cells expressed
CD69 and the cytotoxic cell marker CD94.
Tienthavorn et al.41 patch tested 36 patients with a provi-
sional diagnosis of AD and LPP with histological findings of pig-
mentary alteration with lichenoid infiltration. Patients with a
provisional diagnosis of AD and LPP had positive patch tests in
40% and 36% of cases, respectively. The common allergens
implicated were nickel sulphate hexahydrate, fragrance mix,
and cobalt. They highlighted the importance of getting a thor-
ough history about systemic medications and topical contac-
tants and recommended performing patch testing in all cases
that present like AD or LPP. However, as nickel, cobalt, and fra-
grances are common allergens, it is not clear whether these
positive patch tests are really relevant in the pathogenesis of
pigmented macules, as usually there is no history of preceding
pruritus or typical contact dermatitis. Furthermore, proven cases
of clinically relevant typical contact dermatitis due to nickel,
cobalt, or fragrances have not been reported to evolve into AD,
EDP, or LPP.
Some authors have reported cases as EDP with pruritus prior
to the onset of lesions as well as scaling.42,43 In one case
reported as EDP, the patient had a pruritic rash which resem-
bled pityriasis rosea and completely resolved.42 In our view, if
there is a definite history of pruritic pityriasis rosea-like eruption,
it should not be categorized as AD but rather as postinflamma-
tory hyperpigmentation due to pityriasis rosea.
The entity “LPP” and the continuing nosological
controversies
Although similar dermatoses had been reported in Japanese,
French, and Italian literature, it was Bhutani and colleagues
ª 2018 The International Society of Dermatology
Kumarasinghe et al.
who clearly described 40 Indian patients with acquired macular
pigmentation and coined the term LPP.3,6 These patients had
clinical and histological features similar to those of AD/ED. They
categorized LPP as a variant of lichen planus due to the pres-
ence of a lichenoid tissue reaction, the finding of colloid bodies,
and clinical association with different forms of lichen planus in
one-third of their patients. Naidorf and Cohen also proposed
that EDP-like conditions should be labeled as erythema dys-
chromicum variant of lichen planus.5 Tschen et al. also sup-
ported the view that LPP and EDP are the same entity.44
Vega and colleagues4 observed some clinical differences
between AD and LPP though their histopathological study did
not reveal any significant differences between them.
Kanwar, Dawn, and Dhar in 1996 reported 55 patients with
bilaterally symmetrical gray, blue, and brown to black persistent
pigmentation of the face, neck, and upper trunk with tissue evi-
dence of lichenoid reaction and no typical clinical features of
lichen planus. They preferred to categorize this as an entity dis-
tinct from lichen planus as none of the patients showed evi-
dence of lichen planus at any stage of the disease and
45
proposed the term “lichen dyschromicum perstans.”
Later in 2003, Kanwar and coworkers46 reported 124 Indian
patients with slate gray to brownish-black pigmentation of the
face and neck. The pattern of pigmentation was mostly diffuse
(77.4%), followed by reticular (9.7%), blotchy (7.3%), and peri-
follicular (5.6%). Lichen planus was noted in 19 patients with
typical histopathological changes of this disorder. They pro-
posed that LPP is a distinct clinical entity commonly encoun-
tered in the Indian population and should be considered in the
spectrum of lichenoid disorders as a variant of lichen planus.
There have been reports of LPP in linear and segmental pat-
terns.47,48 A variant of LPP with associated annular patches
with central pigmentation has been described in one report.49 In
2013, Dlova published for the first time 24 South African cases
of LPP associated with lichen planopilaris, in the frontal fibros-
ing pattern.50 In this report, it was suggested that LPP could be
a harbinger of frontal fibrosing alopecia. Lichen planus pigmen-
tosus inversus has been described as a variant of lichen planus
with mildly pruritic hyperpigmented macules and/or patches
involving intertriginous and flexural skin folds in light skinned
individuals.51
Subsequently, more cases with the above morphological
types have been reported in the literature, and the controversies
continued.15,51,52
7
Zaynoun et al. in 2008 attempted to alleviate confusion by
their classification of these disorders. They proposed “ashy der-
matoses” as a broad category, which can be divided into:
1 AD: Patients with idiopathic eruptive hyperpigmented mac-
ules, irrespective of the presence or absence of interface der-
matitis histologically at the time of examination.
2 EDP: Patients with lesions similar to those of AD, but who
have or have had lesions with erythematous borders
ª 2018 The International Society of Dermatology
Global consensus statement Review 3
3 Simulators: (i) LPP and actinic LP (ii) postinflammatory hyper-
pigmentation (iii) drug-induced melanodermas (iv) mastocytosis.
According to this classification, LPP also falls under ashy der-
matoses.
Idiopathic Eruptive Macular Pigmentation
IEMP was initially described by Dego et al.53 and Sanz de
Galdeano proposed the diagnostic criteria.10 IEMP is charac-
terized by asymptomatic, nonconfluent brown macules involv-
ing the neck, proximal extremities, and trunk with no preceding
inflammation or history of drug exposure.10 Histology is char-
acterized by hyperpigmentation of the basal layer of the epi-
dermis and prominent dermal melanophages without visible
basal layer damage or lichenoid inflammatory infiltrate and nor-
mal mast cell counts. Stinco and colleagues reviewed 26
cases and in the majority of them, the condition typically
regressed in several months or in a few years with no treat-
ment required.54 The pigmented macules in most reports were
smaller in size (ranging from 5 to 25 mm) compared to the
typical larger macules of AD. Joshi et al. reported 10 cases of
IEMP from India with features of acanthosis nigricans of some
of the lesions and histology showing pigmented papillomatosis.
They proposed to classify IEMP to an eruptive form of acan-
thosis nigricans.11,55
Riehl’s Melanosis
This condition, first described by Riehl in 1917, is characterized
by facial hyperpigmentation, most pronounced on the forehead
and in the zygomatic and/or temporal region. Riehl suggested
that certain foods used during World War I could be responsi-
ble. Some authors consider Riehl’s melanosis almost synony-
mous with pigmented contact dermatitis of the face. The
commonest cause has been sensitizing chemicals in cosmet-
ics.56 In our view, if a definite relevant contact allergy is demon-
strated in patients with finely reticulated pigmented lesions on
the face and neck region, the disorder may be labeled as pig-
mented contact dermatitis. In a study of 14 Korean women with
acquired bilateral melanosis of the neck consistent with Riehl’s
melanosis, Park et al. have noted that although some cases
showed positive photopatch tests, they were of doubtful rele-
vance.57 Various treatments, individually as well as in combina-
tions, have been attempted with variable success in Riehl’s
melanosis.58
The Global Consensus Forum and the
Consensus Statement
A consensus on the terminology of various morphologies of
acquired macular pigmentation of uncertain etiology (MPUE)
was a long-felt need.
International Journal of Dermatology 2018
4 Review Global consensus statement
Objectives
To arrive at a consensus on the terminology of various mor-
phologies of acquired MPUE.
Methods
Establishment of the consensus forum and the forum
meetings
The consensus was planned and proposed by a forum headed
by coconveners Professor Prasad Kumarasinghe (SPK) and
Professor Davinder Parsad with the support of the Asian Soci-
ety for Pigment Cell Research.
The consensus forum was established after a panel discus-
sion on the same subject which was held during the Interna-
tional Pigment Cell conference (IPCC) held in Singapore in
2014.59 After this first meeting, authors of publications on AD,
EDP, and LPP were contacted by the conveners if an e-mail
address could be obtained. Several rounds of questionnaires
were circulated to understand the views of clinicians, authors of
papers, and researchers from different regions of the world. Dr.
Veena Chandran collated the questionnaire responses. E-mail
communications were very useful, as all the members of the
group could not attend all the meetings.
The second meeting was held during the World Congress of
Dermatology (WCD), Vancouver, Canada, in June 2015, and
the third meeting was held during the American Academy of
Dermatology (AAD) Meeting in Washington, DC, in March 2016.
After each meeting, detailed minutes were circulated to all
participants.
Both the conveners were involved in another panel discus-
sion on the topic at the Indian National Dermatology Congress
(Dermacon) in Kolkata in January 2017. The Final Consensus
Statement was presented by one of the conveners (SPK) at the
23rd IPCC held in Denver Colorado, USA in August 2017.
The methods used in arriving at the consensus are summa-
rized in Table 1. Thirty-nine experts on pigmentary disorders
representing 18 countries took part in the meetings and/or e-
mail discussions (Table 2).
a consensus on the following:
Table 1 Methods used in arriving at a consensus
Analysis of responses to two rounds of questionnaires sent by e-mail
Panel discussions on the subject with audience participation at
international dermatology meetings/pigment cell research meetings in
Singapore, Canada, USA
Face-to-face Discussions of the core group of experts at international
meetings in Singapore, Canada, USA
Small group meetings, telephone discussions by the conveners
Broad agreement of the final consensus report circulated by e-mail to
the full group
a
The Final Consensus Statement was presented by one of the con-
veners (SPK) at the International Pigment Cell Conference held in
Denver, Colorado, USA in August 2017.
International Journal of Dermatology 2018
Kumarasinghe et al.
Table 2 List participants and the countries of the ashy
dermatosis, erythema dyschromicum perstans, and lichen
planus pigmentosus global forum
1. Australia: S. Prasad W. Kumarasinghe, Michelle Rodrigues, Adrian
Mar, Veena Chandran
2. Brazil: Marcia Ramos-e-Silva
3. China: Flora Xiang
4. France: Michelle Verschore
5. India: Davinder Parsad, Rashmi Sarkar, M. Ramam, Binod Khaitan,
Deepti Ghia, Saumya Panda, Siddharth Sonthalia, Mala Bhalla
6. Italy: Torrello Lotti
7. Japan: Chika Ohata
8. Kuwait: Nawaf Al-Mutairi
9. Mexico: Judith Dominguez-Cherit, Jorge Ocampo, Maira Herz
Ruelas, Zulema Olazaran Medrano
10. Saudi Arabia: Sanjeev Mulekar
11. Singapore: CheeLeok Goh, Boon Kee Goh, Steven Thng
12. South Africa: Ncoza Dlova
13. South Korea: Hee Young Kang, Kyoung Chan Park
14. Thailand: Pailin Puangpet
15. Taiwan: Eric Lan
16. The Philippines: Johannes Dayrit, Evangeline Handog
17. The Netherlands: Marcel Bekkenk
18. United States of America: Amit Pandya, Robert Schwartz, Seemal
Desai, Iltefat Hamzavi, Marsha Henderson
Results
Having the consensus deliberations during three different but
relevant conferences (IPCC, WCD, and AAD) gave a wide
exposure to the consensus effort. Experts from many countries
across the world participated in the deliberations and the e-mail
discussions. Interesting and fruitful discussions ensued at the
meetings. Experts from all over the world agreed on several
important aspects of the vexing problems of acquired MPUE.
This forum has also led to planning of a global prospective mul-
ticenter study on these conditions and is spearheaded by Prof
Amit Pandya.
Conclusions
Ashy dermatosis/EDP/LPP Global Consensus Forum reached
1 Morphologies typical of AD, EDP, and LPP are in the spec-
trum of acquired MPUE.
2 Many etiologies can cause acquired macular hyperpigmen-
tation as a sequel. Examples of these include, but are not
limited to, lichen planus and drug eruptions.
3 Only a minority of cases of LPP have past or current evi-
dence of typical lichen planus.
4 There should be an erythematous border, past or current; to
definitively label acquired MPUE, as EDP.
5 If there is a history of pruritus, and clinical features of
papules and plaques associated with the pigmented lesions,
the condition is unlikely to be AD.
ª 2018 The International Society of Dermatology
Kumarasinghe et al.
6 Due to usage of previous publications by numerous authors,
acquired large (e.g., >5 cm) and small (e.g., 0.5–5 cm) mac-
ules of pigmentation of uncertain etiology involving predomi-
nantly the head and neck region, with or without present or
past evidence of lichen planus elsewhere, predominantly
occurring in the people of South Asian extraction (e.g., India,
Pakistan, Sri Lanka) and the African Continent, may be
termed LPP. However, the working group understands that
most such cases do not ever develop typical lichen planus
and that LPP may not be etiopathologically related to lichen
planus. If the hyperpigmentation is limited to known areas of
previous lichen planus lesions, or current visible and palpa-
ble lesions of lichen planus, it is best to avoid labelling such
cases as LPP. It is preferable to categorize such cases as
simply lichen planus with postinflammatory hyperpigmenta-
tion (the analogy for this is when a patient’s pigmented
macules are secondary to a known fixed drug eruption or
eczema, we label the condition by the original diagnosis).
7 LPP involves the head and neck region in most cases.
8 In LPP, temple, forehead, preauricular region, ears, mental
and submental region, and neck are the more common
areas of involvement in the head and neck region.
9 In LPP, after the head and neck region, the next most com-
mon area of involvement is the flexures, particularly axillae.
10 LPP lesions are found on sun-exposed areas as well as
non-sun-exposed areas.
11 LPP-like pigmentation has been associated with lichen
planopilaris of the scalp in some cases.
12 Diffuse (not patchy or discrete macules) acquired hyperpig-
mentation as in Addison’s disease should not be labeled as
LPP, EDP, or AD.
13 Histopathology of LPP/AD/EDP can appear similar, at least
during some periods of the disease.
14 Acquired large (>5 cm) hyperpigmented macules are char-
acteristic in AD and EDP. In typical cases of AD and EDP,
the trunk is a common area of involvement.
15 Cases described as EDP without a history or current evi-
dence of erythematous border can be considered synony-
mous with AD.
16 Other causes of pigmentation such as medicinal drugs, food
additives, and food coloring should be carefully excluded as
the pigmentation can be insidious. Pigmentation identical to
the morphology of AD/EDP has been reported due to some
drugs.
17 LPP/EDP/AD morphological patterns occur in different
regions in communities with different eating habits and differ-
ent sociocultural practices. These conditions are unlikely to
be due to a particular oil applied on the skin or a particular
dietary ingredient (i.e., cultural practices and dietary habits
are diverse in countries such as Brazil, Mexico, India, Saudi
Arabia, USA, South Africa, and the Philippines).
18 There is no uniformly effective therapy for LPP/AD/EDP.
ª 2018 The International Society of Dermatology
Global consensus statement Review 5
19 Considering that “ashy dermatosis” has negative social con-
notations among the dark-skinned ethnic groups in the North
American Continent, the term EDP was favored over AD.
20 Melanophages in the dermis cause the ashy pigmentation in
AD, LPP, and EDP. It is not clear why the melanophages in
LPP/AD/EDP do not clear as rapidly as in cases of simple
postinflammatory hyperpigmentation.
21 Interface dermatitis is not necessarily a feature required to
diagnose LPP/AD/EDP/RM or IEMP.
22 Adding new, contradictory subgroups to describe entities such
as “AD with plaque lesions,” “EDP with hyper and hypopig-
mented lesions,” “EDP with pruritic and scaly lesions,” “LPP
with a Zosteriform pattern” etc., should be discouraged as pig-
mentation can be due to varied causes in these cases.
23 Small macules (0.5–2 cm) of acquired pigmentation, occur-
ring predominantly in adolescents and young adults with or
without raised velvety pigmented lesions, which resolve
within a few months or a few years could be termed IEMP,
provided that the pigmented macules did not appear follow-
ing a known disease episode such as a viral exanthem, a
lichenoid drug eruption, or pityriasis rosea, etc.
24 The condition described as IEMP with papillomatosis
appears to be a different entity to typical IEMP as the mor-
phology involves patchy, velvety thickening of skin as
opposed to macular lesions, with the histopathological char-
acteristic of papillomatosis.
25 The term Riehl’s Melanosis should only be used to describe
numerous fine (i.e., few millimeters in size) or reticulate,
acquired macules of pigmentation of uncertain etiology
occurring on the face, neck, and upper chest.
26 If a diagnosis of a relevant contact dermatitis can be estab-
lished; numerous fine (e.g., few millimeters in size) acquired
macules of pigmentation of uncertain etiology occurring on
the face, neck, and upper chest, should be termed pig-
mented contact dermatitis
27 If a definite etiology (e.g., drug eruption, postinflammatory)
or a definite morphological pattern (LPP, EDP/AD, IEMP,
Riehl’s melanosis, etc.) cannot be established at the time of
presentation, any other form of acquired macular hyperpig-
mentation may be termed as “MPUE” or “dyschromia of
uncertain etiology.” The clinician should then try to work out
the diagnosis by carefully monitoring the evolution of the dis-
ease while carefully analyzing contributory factors in a given
patient. Of the two terms, “MPUE” implies hyperpigmenta-
tion (as in the case of IEMP), whereas “dyschromia” may
imply hypo- or hyperpigmentation.
28 Simple postinflammatory hyperpigmentation due to known
conditions (e.g., dermatitis, graft vs. host disease, lichenoid
drug eruption) should not be labeled as LPP, EDP, or AD.
29 More research should be conducted on these conditions to
characterize the conditions, identify etiology, discover effec-
tive treatments, and prevent progression.
International Journal of Dermatology 2018
6 Review Global consensus statement Kumarasinghe et al.

It is hoped that more emphasis will be now be given for Some examples of the above conditions are depicted in
identifying various causes of acquired macular pigmentation Figs. 1–7.
including AD, EDP, and LP and researching into the ways and Tables 3–6 summarize the salient features of the above con-
means of expediting elimination of dermal pigment in these ditions.
conditions.

(a) (b)

Figure 1 (a) Forty-year-old man of Indian descent with hyperpigmented macules with erythematous borders on the abdomen. Inset:
Histopathology of a biopsy from an erythematous area depicting a florid lichenoid reaction pattern. (Hematoxylin and eosin, 91,000).
(b) Same patient 12 months later without any visible erythema but with only hyperpigmented macules. Inset: Histopathology of an older
hyperpigmented lesion without any erythema showing dermal melanophages and some dermal cellular infiltrate. (Hematoxylin and eosin,
91,000)

Figure 2 A patient with lesions of ashy dermatosis on the

abdomen (Photo courtesy: Dr. Jose  Eleuterio Gonzalez,
Dermatology Service, Hospital Universitario, Monterrey, Mexico.).
After the erythema disappears, lesions of erythema dyschromicum
perstans can also look identical to this appearance

Figure 3 Hyperpigmented, ill-defined blotchy, pigmentation on the

neck and upper back consistent with lichen planus pigmentosus

International Journal of Dermatology 2018 ª 2018 The International Society of Dermatology

Kumarasinghe et al. Global consensus statement Review 7

Figure 4 Macular pigmentation on the

forehead in a 30-year-old Indian man
consistent with lichen planus pigmentosus.
Inset: Skin biopsy showing prominent
dermal melanophages (Hematoxylin and
eosin, 91,000)

Figure 5 Riehl’s melanosis. An 83-year-old

Eurasian woman with reticulate pigmentation
of the neck and the face

Figure 6 Idiopathic eruptive macular

pigmentation in a 7-year-old Filipino boy.
Inset: Biopsy shows hyperpigmentation of
the basal cell layer and few pigment-laden
macrophages (Hematoxylin and eosin,
91,000) (Photograph courtesy of Dr
Johannes F. Dayrit of De La Salle University
Health Sciences Institute, Philippines)

ª 2018 The International Society of Dermatology International Journal of Dermatology 2018

8 Review Global consensus statement
Figure 7 An 11-year-old Indian patient with idiopathic eruptive
macular pigmentation (Photograph courtesy of Dr Vinay
Keshavmurthy of Post Graduate Institute of Medical Education and
Research, Chandigarh, India). Inset: Closer view of periumbilical
lesions showing velvety thickening of the pigmented lesions
Table 3 Ashy dermatosis (AD)/erythema dyschromicum
perstans (EDP)
Characterized by acquired large hyperpigmented macules > 5 cm
Etiology unknown
Commonly involves trunk
AD and EDP can be considered to be synonymous except for the
presence of erythematous border in the active stage of EDP
Melanophages in dermis cause the ashy gray pigmentation
Interface dermatitis may be present but is not a feature necessary to
diagnose these conditions
Table 4 Lichen planus pigmentosus (LPP)
Acquired large (e.g., >5 cm) and small macules (e.g., 0.5–5 cm) of
pigmentation of uncertain etiology, with or without present or past
evidence of lichen planus elsewhere
Most such cases do not ever develop typical lichen planus and that
LPP may not be etiopathologically related to lichen planus
The commonest area of involvement is head and neck region followed
by flexures
If the hyperpigmentation is limited to known areas of previous lichen
planus lesions, or current visible and palpable lesions of lichen
planus, such cases should be labeled as lichen planus with
postinflammatory hyperpigmentation and not LPP
Histology may be similar to EDP/AD with presence of dermal
melanophages with or without interface dermatitis at some stage
International Journal of Dermatology 2018
Kumarasinghe et al.
Table 5 Idiopathic eruptive macular pigmentation
Characterized by asymptomatic, nonconfluent small brown macules
(0.5–2 cm) involving the neck, proximal extremities, and trunk
No preceding inflammation or history of drug exposure
Histology is characterized by hyperpigmentation of the basal layer of
the epidermis and prominent dermal melanophages without visible
basal layer damage or lichenoid inflammatory infiltrate
Resolves in few months to years
Predominantly involves adolescents and young adults
Table 6 Reihl’s melanosis and pigmented contact dermatitis
Characterized by numerous fine (e.g., few millimeters in size) or
reticulate, acquired macules of pigmentation of uncertain etiology
Occurs on the face, neck, and upper chest
If a definite relevant contact allergy is demonstrated in patients with
finely reticulated pigmented lesions on the face and neck region, the
disorder may be labeled as pigmented contact dermatitis
Questions (answers provided after
references)
For questions 1–4, choose the correct response; there may be
more than one correct response
1. The major difference/s between EDP and AD is/are:
(a) The presence of an erythematous border in EDP
(b) The presence of a surrounding area of depigmentation
on AD
(c) Presence of elevated plaque lesions in AD
(d) None of the above
2. The characteristic/s of idiopathic eruptive macular pigmen-
tation is/are:
(a) Asymptomatic lesions
(b) Typically regresses over several months or a few years
(c) The lesions are mostly large macules >5 cm in size
(d) Most cases have an associated history of drug exposure
3. Which of the following is/are false about LPP:
(a) Trunk is the commonest site of involvement
(b) Appearance of lesions is not related to sun exposure
(c) Histopathology LPP can be similar to AD
4. Which of the following statement/s is/are false:
(a) Lesions of Reihl’s melanosis are very fine macules,
usually 1–2 mm in size, predominantly involving the
head and neck region
(b) If a diagnosis of relevant contact dermatitis can be
established, numerous fine macular pigmented lesions
of uncertain etiology occurring on the face, neck, and
upper chest should be termed pigmented cosmetic
dermatitis
ª 2018 The International Society of Dermatology
Kumarasinghe et al.
(c) Melanophages in the dermis in patients with AD and
EDP clear very rapidly but there is persistence of pig-
mented cells in the basal layer of the epidermis
(d) Simple postinflammatory hyperpigmentation due to
known conditions should not be labeled as AD
5. MPUE includes postinflammatory hyperpigmentation fol-
lowing lichen planus.
(a) True
(b) False
6. In the majority of cases of EDP, there is a history of asso-
ciated intestinal parasitosis.
(a) True
(b) False
7. The cases of EDP/AD reported in children rarely showed
eventual improvement/resolution.
(a) True
(b) False
8. The incidence of EDP and AD is affected by eating habits
and sociocultural practices in different regions of the world.
(a) True
(b) False
9. Small pigmented macules which appear following a dis-
ease episode such as viral exanthem, lichenoid drug eruption,
or pityriasis rosea should not be labeled as IEMP.
(a) True
(b) False
10. Only a minority of cases of LPP have past or current evi-
dence of typical lichen planus.
(a) True
(b) False
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Answers to Questions
1. (a); 2. (a,b); 3. (a); 4. (c); 5. (b); 6. (b); 7. (b); 8. (b);
9. (a); 10. (a)
ª 2018 The International Society of Dermatology