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.