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Kandice C. Bailey, MS-2; Louis “Skip” Wise, MD; Persistent facial Tracy Breeden, RN; Robert T. Brodell, MD University of Mississippi hyperpigmentation Medical School (Ms. Bailey), University of Mississippi Medical Center (Ms. Breeden), The patient presented with persistent hyperpigmentation Departments of Dermatology and Pathology, University of that was unaffected by regular face washing. A simple test Mississippi Medical Center (Dr. Brodell), Jackson, Miss; both diagnosed and treated the condition. private practice, Fondren, Miss (Dr. Wise)

[email protected] a 59-year-old woman presented to a derma- discoloration with a slightly rough texture. DEPARTMENT EDITOR Richard P. Usatine, MD tology clinic with an asymptomatic brown facial Upon rubbing the affected area with a 70% iso- University of Texas Health hyperpigmentation that had developed several propyl alcohol pad, normal skin was revealed at San Antonio years earlier, and had persisted, despite regular (FIGURE 1A) and brown flakes were apparent on Dr. Brodell discloses that he is a face washing. Physicians who previously treat- the gauze (FIGURE 1B). principal investigator for multicenter clinical trials for Galderma ed this patient interpreted this as melasma and Laboratories, L.P., Novartis, and advised her to wear sunscreen. The condition GlaxoSmithKline. He also serves on ● WHAT IS YOUR DIAGNOSIS? an advisory board for IntraDerm was not aggravated by sun exposure. The pa- Pharmaceuticals. Ms. Bailey, Ms. tient reported that she was otherwise healthy. ● HOW WOULD YOU TREAT THIS Breeden, and Dr. Wise reported no potential conflict of interest relevant Physical examination revealed a brown PATIENT? to this article.

FIGURE 1 “Alcohol wipe test” clinched the diagnosis A B PHOTOS COURTESY OF: ROBERT T. BRODELL, MD

Rubbing the area with a 70% isopropyl alcohol pad revealed normal skin (A) and left brown flakes (B) on the gauze.

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Dx: Terra firma-forme dermatosis agnosis for this case, including melasma and The physician diagnosed terra firma-forme post-inflammatory hyperpigmentation. How- dermatosis (TFFD) in this patient, noting the ever, these 2 conditions are macular, whereas “dirty brown coloration” and distribution that this hyperpigmented condition had a rough, did not suggest post-inflammatory hyperpig- mildly papular texture. Additionally, melasma mentation or melasma. TFFD is a rare and flares up in the summer with UV exposure, and benign form of acquired hyperpigmentation post-inflammatory hyperpigmentation pres- characterized by “velvety, pigmented patches ents with pruritus and/or a pre-existing rash.4 or plaques.”1 A simple bedside test, known This patient reported that the condition did as an “alcohol wipe test,” both confirms and not itch nor change with increased sunlight, treats TFFD; it involves rubbing the affected thus making melasma and post-inflammatory area with a 70% isopropyl alcohol pad.1 hyperpigmentation unlikely diagnoses. TFFD typically affects the face, neck, Acanthosis nigricans also was considered trunk, or ankles, but the scalp, axilla, back, and because it presents with a velvety brown pig- pubis also can be affected.1 Histopathology will mentation similar to what was seen with this show negligible amounts of dermal inflam- patient. Acanthosis nigricans, however, pri- mation, hyperkeratosis with mild acanthosis, marily affects flexural areas, not the face, mak- and hyperkeratosis and papillomatosis.1 Most ing it improbable. patients diagnosed with TFFD report that the ❚ Our patient. A “wipe test” was per- TFFD is not a hyperpigmentation does not improve despite formed on the patient. This removed the consequence of washing with soap and water.2 brown flaky scaling and revealed the under- poor hygiene, lying normal skin. We instructed the patient but may be a Hygiene is not a factor to wash daily with a soapy wash cloth and result of “sticky” In 2015, Greywal and Cohen followed the case scrub with 70% isopropyl alcohol should the sebum that presentations of 10 Caucasian patients with hyperpigmentation recur. The patient did not produces a TFFD who presented with “brown and/or black return. JFP buildup of plaques or papules or both.”2 Many of the in- keratin debris, dividuals followed in this case series reported CORRESPONDENCE “[practicing] good hygiene and showered a Robert T. Brodell, MD, Department of Dermatology, Univer- sebum, and sity of Mississippi Medical Center, 2500 North State Street, bacteria. minimum of every other day or daily.”2 The Jackson, MS 39216; [email protected] same was reported by the patient in this case. This suggests that TFFD is not a consequence of poor hygiene but perhaps a result of “sticky” sebum that produces a buildup of keratin de- References bris, sebum, and bacteria on the skin.3 This pro- 1. Lunge S, Supraja C. Terra firma-forme dermatosis—a dirty dermatosis: report of two cases. Our Dermatol Online. 2016;7: duces the hyperpigmentation seen clinically. 338-340. 2. Greywal T, Cohen PR. Terra firma-forme dermatosis: A report of ten individuals with Duncan’s dirty dermatosis and literature re- view. Dermatol Pract Concept. 2015;5:29-33. Differential includes post- 3. Alonso-Usero V, Gavrilova M, et al. Dermatosis neglecta or terra firma-forme dermatosis. Actas Dermosifiliogr. 2012;103: inflammatory hyperpigmentation 932-934. Several other hyperpigmentation disorders 4. Lucas J, Brodell RT, Feldman SR. Dermatosis neglecta: a series of case reports and review of other dirty-appearing dermatoses. were considered on the initial differential di- Dermatol Online J. 2006;12:5.

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