A 52 year old female, presented with asymptomatic pigmented lesions all over the body which developed over a period of 5 months. She was referred from her family physician to the endocrinology clinic with the probable diagnosis of Addisonian pigmentation, which was ruled out by endocrine workup. Later on she was sent to our dermatology clinic. There was no history of skin fragility, blisters and erythematous lesions preceeding these lesions. There was no history of treatment with antimalarials or other drugs implicated in causing pigmented skin lesions. Initially lesions started over the face and then progressed to involve the upper limbs, trunk and lower limbs. There were no similar pigmented lesions in the mucosa.
The diagnosis of systemic lupus erythematosus was made based on the presence of photosensitivity, painless oral ulcers, unexplained fatigue, anaemia, arthralgia, leukopenia, low platelets and the presence of antinuclear and deoxyribonucleic antibodies. Histopathology showed epidermal interface activity including degeneration of the basal layer, apoptotic keratinocytes and a irregular thickening of the basement membrane and pigmentary incontinence. On examination she had generalized thin hyperpigmented plaques with darker thread like irregular border coalescing to form large plaques with islands of normal skin between them giving a tattooed appearance all over the body. The patient was treated with hydroxyl chloroquine, sunscreen, emollients and topical calcineurin inhibitors with good response. In view of here progressively increasing fatigue she was referred to rheumatology center for the initiation of oral corticosteroids and for further systemic evaluation.