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Minocycline-induced Tongue Hyperpigmentation in Treatment of Severe Keratitis

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Title: Minocycline-induced Tongue Hyperpigmentation in Treatment of Severe Keratitis


1
Minocycline-induced Tongue Hyperpigmentation in
Treatment of Severe Keratitis Recurrent Chalazia
  • Amit Todani, MD
  • Samir Melki, MD PhD
  • Massachusetts Eye Ear Infirmary
  • Harvard Medical School, Boston

The authors do not have any financial interest
in any of the products or companies mentioned in
this poster
2
Introduction
  • Minocycline is occasionally used systemically in
    the management of meibomian gland dysfunction
    and/or severe keratitis.
  • It recently appeared in the market in a specific
    package combined with a lid scrub foam solution
    (Cleeravue-MTM, Stonebridge Pharma), which may
    lead to its increased use as compared to other
    tetracyclines.
  • Pigmentation at various body sites is a well
    recognized though innocuous side-effect, which
    warrants discontinuation of minocycline therapy.1
    Hence, patients on chronic minocycline therapy
    merit screening for development of pigmentation.

3
Case Report
  • A 27-year old Asian woman was given 100 mg of
    minocycline hydrochloride once daily by mouth for
    bilateral severe keratitis with dry eyes and
    bilateral recurrent chalazia (figure below).

4
Case Report (Contd.)
  • Other medications artificial tears, topical
    cyclosporine 0.05.
  • Also daily warm compress with lid massage.
  • No systemic conditions.
  • Past medical history- unremarkable.

5
Case Report (Contd.)
  • 2 months after starting minocycline, she noted
    multiple dark spots on her tongue.
  • Our examination revealed isolated patches of
    dark-grey pigmentation scattered over the tip and
    dorsolateral aspects of her tongue (Figure ?)
  • These lesions were painless. No other changes
    were found in the oral cavity, skin or the
    ocular surface. Her fundus examination was
    unremarkable.

6
Case Report (Contd.)
  • Oral minocycline was discontinued because of the
    appearance of lingual hyperpigmentaion.
  • 3 months following discontinuation of her
    minocycline therapy, she reported partial
    resolution of the hyperpigmentation.
  • She was subsequently started on oral doxycycline
    (50 mg twice daily) which lead to symptomatic
    relief of ocular pain and redness.
  • Her last follow-up was 12 months after
    discontinuing minocycline. The lingual
    pigmentation was found to be persistent but much
    lighter in intensity.

7
Discussion
  • Minocycline offers some distinct advantages over
    other tetracyclines. It is generally well
    tolerated, absorbed well in the gastrointestinal
    tract, is highly lipophilic and has a large
    volume of distribution along with a long serum
    half life. This contributes to excellent tissue
    penetration with convenient once or twice daily
    dosing regimen.
  • Unlike other tetracyclines, it does not bind
    calcium from dairy products and is less likely to
    contribute to phototoxic reactions.

8
Discussion
  • On the other hand, minocycline has been reported
    to cause pigmentation in various body sites, esp.
    the skin, nails, bones, thyroid, mouth, sclera,
    conjunctiva and macula.1-4
  • Lingual hyperpigmentation is rarely reported and
    may be easily overlooked.5-8 To the best of our
    knowledge, no cases have been reported in
    ophthalmic literature.
  • Many cases of pigmentary change tend to resolve
    spontaneously on discontinuation of the therapy.
    Successful treatment of a rare case of persistent
    pigmentation has been reported with Q-switched
    laser.8
  • We encourage ophthalmologists to inform patients
    of possible muco-cutaneous and ocular
    discoloration with the use of minocycline therapy
    and to look out for this adverse effect. It is
    recommended to stop minocycline therapy if it is
    the suspected cause of the discoloration.

9
References
  1. Eisen D, Hakim MD. Minocycline-induced
    pigmentation. Incidence, prevention and
    management. Drug Saf. 1998 Jun18(6)431-40.
  2. Fraunfelder FT, Randall JA. Minocycline-induced
    scleral pigmentation. Ophthalmology. 1997
    Jun104(6)936-8.
  3. Bradfield YS, Robertson DM, Salomao DR, Link TP,
    Rostvold JA. Minocycline-induced ocular
    pigmentation. Arch Ophthalmol. 2003
    Jan121(1)144-5.
  4. Morrison VL, Kikkawa DO, Herndier BG.
    Tetracycline induced green conjunctival pigment
    deposits. Br J Ophthalmol. 2005
    Oct89(10)1372-3.
  5. Tanzi EL, Hecker MS. Minocycline-induced
    hyperpigmentation of the tongue. Arch Dermatol.
    2000 Mar136(3)427-8.
  6. Meyerson MA, Cohen PR, Hymes SR. Lingual
    hyperpigmentation associated with minocycline
    therapy. Oral Surg Oral Med Oral Pathol Oral
    Radiol Endod. 1995 Feb79(2)180-4.
  7. Alkhatib AA, Sessoms S. The tarnished tongue. Am
    J Med. 2006 Oct119(10)832-4.
  8. Friedman IS, Shelton RM, Phelps RG.
    Minocycline-induced hyperpigmentation of the
    tongue successful treatment with the Q-switched
    ruby laser. Dermatol Surg. 2002 Mar28(3)205-9.
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