Pigmentation of Wrinkles, Body Flexures, and Oral Mucosa

CLINICAL DIAGNOSTIC MANUAL

Abnormal pigmentation of wrinkles, body flexures, and the oral mucosa can indicate underlying hormonal imbalances, particularly those related to the hypothalamic-pituitary-adrenal axis.

This pigmentation is often a result of increased adrenocorticotropic hormone (ACTH) levels due to various endocrine pathologies. Identifying and assessing abnormal pigmentation is crucial for the proper diagnosis and treatment of these conditions.

Pathology	Symptoms and Clinical Signs	Suspected Diagnosis	Confirmed Diagnosis
Addison’s Disease	Fatigue, muscle weakness, weight loss, hypotension, nausea, vomiting. Hyperpigmentation of skin and mucosa.	Clinical history and physical examination. Elevated ACTH and low cortisol levels.	Confirmation with ACTH stimulation test. CT/MRI of adrenal glands.
Cushing’s Disease	Weight gain, moon face, fatigue, muscle weakness, hypertension, hyperglycaemia. Purplish stretch marks, thin skin.	Clinical history and physical examination. Elevated cortisol levels.	Confirmation with dexamethasone suppression test. CT/MRI of adrenal glands or pituitary gland.
Ectopic ACTH Secretion	Symptoms similar to Cushing’s syndrome. Generalised hyperpigmentation.	Clinical history and physical examination. Very high ACTH and cortisol levels.	Confirmation with CT/MRI to locate the ectopic ACTH-producing tumour.