A 60-year-old male presented with progressive development of asymptomatic facial discolouration, affecting sun-exposed areas, in the previous 18 months. Physical examination revealed photodistributed, blue-gray hyperpigmentation of the face, sparing the eyelids and nasolabial folds (Figure 1). The patient was being treated with amiodarone, at a dose of 400mg daily, for the last 2 years, with an estimated cumulative dose of 300 g, for cardiac arrhythmia. A diagnosis of amiodarone-induced hyperpigmentation was performed. The patient was advised to avoid direct excessive sunlight exposure and to use sunscreen products with high protection factor against UV-A and UV-B radiation. Switching from amiodarone to another antiarrhythmic drug was also suggested, if considered adequate by the patient’s cardiologist.

Dermatological complications of amiodarone occur in up to 75% of patients with prolonged use of the drug, and the main skin changes encountered are phototoxic and photoallergic reactions, as well as hyperpigmentation.¹ Amiodarone hyperpigmentation occurs after an average of 20 months of continuous treatment and a cumulative dose of 160 g, typically with blue-grey discoloration of the face, ears and palms.^1,2 Young age, total dose and duration of treatment, rate of amiodarone metabolism, frequency and intensity of exposure to sun and photosensitivity influence the likelihood of skin discolouration.³ The mechanism by which these changes occur is not precisely understood: deposition of lipofuscin aggregates or insoluble compounds of amiodarone and phospholipids, as well as inflammation around microvessels, have been proposed.¹ Skin changes are usually reversible with drug withdrawal, although it may take a few months to several years as a consequence of slow elimination of amiodarone and its metabolites.^1,2 There have been reports of significant efficacy of cosmetic laser application, which could possibly be very beneficial in patients with too many cardiovascular complications to allow amiodarone withdrawal.^1,3

Figura I

Figure 1 - Blue-gray hyperpigmentation of the face.

  BIBLIOGRAFIA  

1. Jaworski K, Walecka I, Rudnicka L, Gnatowski M, Kosior D. Cutaneous adverse reactions of amiodarone.Med Sci Monit.2014;20:2369–2.

2. Ammoury A, Michaud S, Paul C, Prost-Squarcioni C, Alvarez F, Lamant L, et al. Photodistribution of blue-gray hyperpigmentation after amiodarone treatment: molecular characterization of amiodarone in the skin.Arch Dermatol.2008;144(1):92–6.

3. Wiper A, Roberts DH, Schmitt M. Amiodarone-induced skin pigmentation: Q-switched laser therapy, an effective treatment option.Heart.2007;93(1):15.