Dermatology: Practical and Conceptual


Image Letter | Dermatol Pract Concept. 2022;12(1):e2022041 1

A Gray Patient
Gabriela Fortes Escobar1, Kelli Wagner Gomes2, Mariana Quirino Tubone3,  

Gabriela Maldonado4

1 Department of Dermatology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brasil

2 Private Practice - Rua Felipe Camarão 690/Sala 402, Porto Alegre, Brasil

3 Private Practice - Av. Marcolino Martins Cabral, 2099/ Sala 902, Tubarão, Brasil 

4 Private Practice - Rua 24 de Outubro, 1440 /Sala 1103, Porto Alegre, Brasil

Citation: Escobar GF, Gomes KW, Tubone MQ, Maldonado G. A gray patient. Dermatol Pract Concept. 2022;12(1):e2022041.  
DOI: https://doi.org/10.5826/dpc.1201a41

Accepted: July 1, 2021; Published: January 2022

Copyright: ©2022 Escobar et al. This is an open-access article distributed under the terms of the Creative Commons  
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted 
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.

Funding: None.

Competing interests: None.

Authorship: All authors have contributed significantly to this publication.

Corresponding author: Gabriela Fortes Escobar, MD MSc Department of Dermatology, Hospital de Clínicas de Porto Alegre, Porto Alegre, 
Brasil. E-mail: gescobar@hcpa.edu.br

Case Presentation 

A 46-year-old Caucasian woman presented with a 10-year 

history of an asymptomatic progressive darkening of the 

skin. There was no previous history of inflammation, and 

she denied the use of medications. Examination revealed 

symmetric blue-gray patches involving the face, trunk 

(Figure 1, A and B) and extremities. Dermoscopy showed 

a diffuse reticulated- homogenous brown-gray pigmentation 

(Figure 1C). Skin biopsy revealed multiple spindle-shaped 

dendritic melanocytes in the dermis (Figure 1D) and immu-

nohistochemical staining was positive for Melan-A and 

HMB-45. 

Teaching Point 

Acquired dermal melanocytosis is a rare pigmentary disor-

der and its etiology remains unknown. Three theories may 

explain this disorder: migration of epidermal melanocytes to 

the dermis; migration of hair bulb melanocytes; or reactiva-

tion of pre-existing latent dermal melanocytes triggered by 

local inflammation or an unknown stimulus [1,2]. Melanin- 

containing dendritic melanocytes can be seen in the upper- 

middle portions of the dermis and, with the Tyndall effect, 

they result in a brown to bluish-gray skin pigmentation [2].

Informed consent: Written informed consent for publi-

cation of clinical details and clinical  images was obtained 

from the patient.



2 Image Letter | Dermatol Pract Concept. 2022;12(1):e2022041

References

1. Harrison-Balestra C, Gugic D, Vincek V. Clinically distinct form 

of acquired dermal melanocytosis with review of published 

work. J Dermatol. 2007;34(3):178–182. DOI: 10.1111/j.1346-

8138.2007.00245.x. PMID: 17291298.

2. Baykal C, Yılmaz Z, Sun GP, Büyükbabani N. The spectrum of 

benign dermal dendritic melanocytic proliferations. J Eur Acad 

Dermatol Venereol. 2019;33(6):1029–1041. DOI: 10.1111/

jdv.15492. PMID: 30767282.

Figure 1. (A) and (B) Remarkable blue-gray pigmentation on the trunk. (C) Dermoscopy (10x) revealing a diffuse reticulated-homogenous 

brown-gray pigmentation. (D) Histopathology showing multiple spindle-shaped dendritic melanocytes in the dermis (arrows).