Laugier-Hunziker Syndrome


Article Author:
Shamma Aboobacker


Article Editor:
Gunjan Gupta


Editors In Chief:
Amanda Oakley
Jules Lipoff
Shyam Verma


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
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Saad Nazir
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Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/4/2019 2:24:27 PM

Introduction

Laugier-Hunziker syndrome, also known as Laugier-Gerbig-Hunziker syndrome or Laugier-Hunziker-Baran syndrome or idiopathic lenticular mucocutaneous pigmentation, is a hereditary pigmentary disorder characterized by a unique expression of pigmentation over the mucosal, nail, and acral sites.[1][2]

The condition is known to be benign nevertheless a few associations with esophageal melanocytosis, actinic lichen planus, hypocellular bone marrow, and thrombocytopenia have been reported.[3]

Due to its close semblance to more serious conditions such as Addison disease, Peutz-Jeghers syndrome, Cronkhite-Canada syndrome, and lentiginosis profusa, this is usually classed as a diagnosis of exclusion.

Etiology

The most plausible mechanism for this syndrome is the presence of altered melanocytes in the epidermis.[4] The description is that of L-3,4 dihydroxyphenylalanine reactive melanocytes seen as large dendritic melanocytes. These cells are then capable of increasing melanogenesis.

Epidemiology

Laugier-Hunziker syndrome has more frequently been reported in the Asian population and displays a higher incidence in the Chinese population.[5][6] Cases have also been reported in European regions such as France and Italy. Based on gender predilection, a significant female preponderance has been described. Familial cases usually follow an autosomal dominant as well as recessive traits while sporadic cases are not uncommon.[6][7]

Histopathology

Histopathology of lesions shows increased pigmentation in the basal layer with a few dermal melanophages. Electron microscopy reveals multiple mature melanosomes within keratinocytes and melanophages.[4]

History and Physical

Regarding the presentation, there have been juvenile and adult cases that carry the specific features but show increased severity in adult form.

Juvenile cases have been reported between ages 10 and 22 years, while the majority of adult cases are seen between 43 and 55 years of age. The unique features are better described according to the sites affected.

Mucosal involvement is characterized by well-defined light brown to brown-black macules usually of size 0.1 to 0.5 cm over the oral and genital mucosa. Oral lesions are present over labial mucosa, buccal mucosa, hard palate, tongue, and posterior pharyngeal mucosa while genital lesions are seen on glans and shaft of the penis in males and vulva in females. A few cases of isolated tongue pigmentation have been reported.

Acral or cutaneous involvement manifests as sharply marginated light brown to black lenticular macules and patches approximately 0.5 to 1.5 cm in size specifically seen over distal two-thirds of all digits of the upper limb and bilateral plantar surfaces. Besides this, the lesions extend dorsally by involving the medial and lateral borders of digits.[2][8]

Nail involvement is seen in two-thirds of cases and can be divided into 4 types based on the extent of pigmentation.

  • Single 1 to 2 mm longitudinal streaks
  • Double 2 to 3 mm longitudinal streaks on the lateral parts
  • Homogenous pigmentation involving radial or ulnar half
  • Complete pigmentation

However, one or all types may be seen in the same patient. One striking feature of nail involvement is nail fold pigmentation termed as pseudo-Hutchinson’s sign.[9]

Rare reports of varied pigmentation include isolated tongue pigmentation, conjunctival pigmentation, neck and trunk pigmentation, and diffuse pigmentation are seen while the common finding of oral and acral involvements are more commonly encountered.[10][9][3][11][12]

Evaluation

With Laugier-Hunziker syndrome, owing to the insidious although asymptomatic nature of the condition, there is delayed attendance years after onset is usually seen. A thorough history and clinical examination for signs of fatigue, weight loss, gastrointestinal (GI) involvement, and drug intake are necessary.

In the context of the exclusion of other disorders, investigations for the following are usually carried out after a complete physical examination and routine investigations.[5]

  • Corticotrophin/adrenocorticotrophic hormone
  • Serum cortisol
  • Electrolytes
  • Liver function tests
  • Endoscopy
  • Colonoscopy
  • Ultrasound
  • Thyroid function test
  • HIV testing
  • Radiographic barium studies

Recent reports of associated malignancies have suggested cancer screening, particularly in adult cases.[13]

Treatment / Management

The goal of therapy is purely cosmetic in case of Laugier-Hunziker syndrome.

Treatment options include cryotherapy, Q-switched Nd:YAG laser, Q-switched Alexandrite laser, erbium:YAG laser, CO2 laser, and diode laser.[14][15][16]

Differential Diagnosis

The differential diagnosis and their differentiating features include:

  • Addison’s disease: Described as primary or secondary results from inadequate adrenocorticotrophic hormone. Primary Addison’s disease results in hyperpigmentation that is described to be more generalized with a predilection for sun exposed areas and recent scars. A few reports of coexistent vitiligo have been described. Cutaneous lesions seem to precede systemic features of fatigue, lethargy, myalgia, nausea, personality changes and hypotension.
  • Peutz-Jeghers syndrome: An autosomal dominant condition characterized by intestinal polyposis and increased susceptibility to malignancies. Mucosal pigmentation differs from Laugier-Hunziker syndrome by crossing vermilion border. Nail pigmentation is not seen in Peutz-Jeghers syndrome.
  • McCune-Albright syndrome: Manifests café-au-lait macules and not lentiginous lesions as seen in Laugier-Hunziker syndrome. Other features are polyostotic fibrous dysplasia and precocious puberty
  • Cronkhite-Canada syndrome: This sporadic disorder manifests with gastrointestinal polyposis, anosmia, and dysgeusia. Hyperpigmentation is described with more proximal involvement (arms, legs) than in Laugier-Hunziker syndrome.
  • Lentiginosis profusa and Leopard syndrome: Autosomal dominant syndrome characterized by multiple lentigines, hypertelorism, deafness, and cardiac conduction defects.
  • Carney syndrome: An autosomal dominant syndrome comprising of lentiginous pigmentation, endocrinopathy and malignancies.
  • Bandler syndrome: Hyperpigmentation resembles Laugier-Hunziker syndrome however systemic involvement is seen as intestinal vascular malformations.
  • Acquired immunodeficiency syndrome (AIDS): A diffuse hyperpigmentation may develop in advanced cases.

Other disorders include lichen planus, Smoker’s melanosis, Benign racial pigmentation, melanonychia striata, post-inflammatory hyperpigmentation, Nutritional deficiency (vitamin B12 and folate) and heavy metal poisoning (lead, arsenic, mercury, gold, bismuth, and silver).[17][18][19]

Generalized hypermelanosis can be seen with minocycline, phenothiazine, antimalarials, zidovudine, amiodarone, oral contraceptives, clofazimine, and chemotherapeutic agents.

Disorders that display pseudo-Hutchinson sign include Peutz-Jeghers syndrome, subungual hematoma, Bowen disease, and AIDS while the true Hutchinson sign is specific to melanoma.

Prognosis

The pigmentary lesions of Laugier-Hunziker syndrome usually respond poorly to therapy, and it displays high recurrence. A particular note of is sun avoidance after successful therapy which has shown lower rates of recurrence.[14]

Consultations

Reports of esophageal melanocytosis, actinic lichen planus, hypocellular bone marrow, and thrombocytopenia have been reported; however, these disorders are more likely coincident findings and not directly related to Laugier-Hunziker syndrome.[3] A recent report of pancreatic malignancy warrants evaluation in suspected cases.[13]

Pearls and Other Issues

  • Laugier-Hunziker syndrome is a benign pigmentary condition that can be familial or sporadic.
  • The absence of systemic features has usually led it to be named Laugier-Hunziker pigmentation.
  • Classically presents as lenticular macules involving oral mucosa and palmoplantar skin.
  • Nail pigmentation with pseudo-Hutchinson sign is a common finding.
  • Lesions are usually resistant to treatment and display high rates of recurrence.

Enhancing Healthcare Team Outcomes

Laugier-Hunziker syndrome is a rare disease and diagnosis may be challenging. A coordinated team approach between primary care nurse practitioners, physician assistants, physicians, and dermatologists is necessary to provide the best care of patients with this condition. [Level V]


  • Image 9841 Not availableImage 9841 Not available
    Contributed by Dr Shamma Aboobacker, MD
Attributed To: Contributed by Dr Shamma Aboobacker, MD

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Laugier-Hunziker Syndrome - Questions

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A 49-year-old man who was admitted for generalized myalgia was referred for multiple asymptomatic pigmentary lesions over the extremities. He mentioned the lesions started 6 months back and remained stationary. On examination, multiple well defined dark brown macules sized 0.5 to 1 cm were present over the distal two-thirds of all digits of hands, a few extending to involve nail folds. A few nails exhibited 2 to 3 mm longitudinal streaks. What is the most likely diagnosis?



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Which among the following is a specific finding seen in Laugier-Hunziker syndrome?



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Which of the following diagnostic procedures is not considered for evaluation of Laugier-Hunziker syndrome?



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A 55-year-old male presents with a 2-year history of multiple lentiginous macules over his palms and soles and pigmentary streaks over his nails. Which of the following is not an appropriate part of the evaluation?



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A 14-year-old female presents with pigmentation over her lips, palms, soles, and nails occurring over the past 4 years. The patient denies any cosmetic concerns regarding the lesions. After a detailed evaluation, she is diagnosed with Laugier-Hunziker syndrome. What is the most appropriate management?



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Laugier-Hunziker Syndrome - References

References

Wei Z,Li GY,Ruan HH,Zhang L,Wang WM,Wang X, Laugier-Hunziker syndrome: A case report. Journal of stomatology, oral and maxillofacial surgery. 2018 Apr     [PubMed]
Dupré A,Viraben R, Laugier's disease. Dermatologica. 1990     [PubMed]
Montebugnoli L,Grelli I,Cervellati F,Misciali C,Raone B, Laugier-hunziker syndrome: an uncommon cause of oral pigmentation and a review of the literature. International journal of dentistry. 2010     [PubMed]
Moore RT,Chae KA,Rhodes AR, Laugier and Hunziker pigmentation: a lentiginous proliferation of melanocytes. Journal of the American Academy of Dermatology. 2004 May     [PubMed]
Nayak RS,Kotrashetti VS,Hosmani JV, Laugier-Hunziker syndrome. Journal of oral and maxillofacial pathology : JOMFP. 2012 May     [PubMed]
Sachdeva S,Sachdeva S,Kapoor P, Laugier-hunziker syndrome: a rare cause of oral and acral pigmentation. Journal of cutaneous and aesthetic surgery. 2011 Jan     [PubMed]
Duan N,Zhang YH,Wang WM,Wang X, Mystery behind labial and oral melanotic macules: Clinical, dermoscopic and pathological aspects of Laugier-Hunziker syndrome. World journal of clinical cases. 2018 Sep 26     [PubMed]
Lampe AK,Hampton PJ,Woodford-Richens K,Tomlinson I,Lawrence CM,Douglas FS, Laugier-Hunziker syndrome: an important differential diagnosis for Peutz-Jeghers syndrome. Journal of medical genetics. 2003 Jun     [PubMed]
Wang WM,Wang X,Duan N,Jiang HL,Huang XF, Laugier-Hunziker syndrome: a report of three cases and literature review. International journal of oral science. 2012 Dec     [PubMed]
Asati DP,Tiwari S, Laugier-Hunziker syndrome. Indian journal of dermatology, venereology and leprology. 2011 Jul-Aug     [PubMed]
Jabbari A,Gonzalez ME,Franks AG Jr,Sanchez M, Laugier Hunziker syndrome. Dermatology online journal. 2010 Nov 15     [PubMed]
Makhoul EN,Ayoub NM,Helou JF,Abadjian GA, Familial Laugier-Hunziker syndrome. Journal of the American Academy of Dermatology. 2003 Aug     [PubMed]
Wondratsch H,Feldmann R,Steiner A,Breier F, Laugier-hunziker syndrome in a patient with pancreatic cancer. Case reports in dermatology. 2012 May     [PubMed]
Ergun S,Saruhanoğlu A,Migliari DA,Maden I,Tanyeri H, Refractory Pigmentation Associated with Laugier-Hunziker Syndrome following Er:YAG Laser Treatment. Case reports in dentistry. 2013     [PubMed]
Abduljabbar T,Vohra F,Akram Z,Ghani SMA,Al-Hamoudi N,Javed F, Efficacy of surgical laser therapy in the management of oral pigmented lesions: A systematic review. Journal of photochemistry and photobiology. B, Biology. 2017 Aug     [PubMed]
Pereira PM,Rodrigues CA,Lima LL,Reyes SA,Mariano AV, Do you know this syndrome? Anais brasileiros de dermatologia. 2010 Sep-Oct     [PubMed]
Miličević T,Žaja I,Tešanović D,Radman M, Laugier-Hunziker syndrome in endocrine clinical practice. Endocrinology, diabetes     [PubMed]
Niiyama S,Katsuoka K, Laugier-Hunziker syndrome. European journal of dermatology : EJD. 2013 Apr 1     [PubMed]
Barman PD,Das A,Mondal AK,Kumar P, Laugier-Hunziker Syndrome Revisited. Indian journal of dermatology. 2016 May-Jun     [PubMed]

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