Hyperpigmentation of the Tongue and Buccal Mucosa
Am Fam Physician. 2020 Aug 1;102(3):181-182.
A 45-year-old woman with a 10-year history of primary adrenal insufficiency was admitted to the hospital for treatment of pyelonephritis caused by Escherichia coli infection, for which she was given intravenous antibiotics and fluids.
On physical examination, her heart rate was 120 beats per minute, and her blood pressure was 90/58 mm Hg. Oral examination revealed hyperpigmentation of her tongue, the vermilion border of her lips, and the buccal mucosa (Figure 1).
Based on the patient's clinical findings and appropriate treatment of the related underlying diagnosis, which one of the following steps is correct?
A. Check adherence to glucocorticoid therapy.
B. Increase the dose of glucocorticoid therapy.
C. Increase the dose of fludrocortisone.
The correct answer is A: check adherence to glucocorticoid therapy. Hyperpigmentation is a characteristic clinical finding of primary adrenal insufficiency. Successful treatment of adrenal insufficiency depends on taking the correct dosage of the glucocorticoid for the prescribed period.
Hyperpigmentation is caused by an increase in adrenocorticotropic hormone, which acts as an agonist of the melanocortin-1 receptor. This receptor is highly expressed on the surface of melanocytes.1 The hyperpigmentation is most prominent at flexures, sites of pressure and friction, palmar and plantar creases, and sun-exposed areas. However, it can also affect scars and buccal, vaginal, and anal mucous membranes.
Primary adrenal insufficiency hyperpigmentation usually resolves when the excess secretion of adrenocorticotropic hormone is blocked by replacement doses of glucocorticoid. Persistence of hyperpigmentation in a patient
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This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.
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