Amiodarone-induced ceruloderma

Case summary

These images depict classic skin findings associated with a rare but important side effect of amiodarone. It is imperative that physicians be aware of this unique side effect of amiodarone, be able to differentiate it from photosensitivity, and know which treatments are available.

Case description

An 86-year-old man with a history of ischaemic heart disease was noted to have asymptomatic blue–grey facial hyperpigmentation (Figures 1and2) during an admission to the coronary care unit for ventricular tachycardia. The patient was on oral amiodarone for a history of sustained ventricular tachycardia despite prior substrate ablation. He received an estimated cumulative dose of 730 g of oral amiodarone prior to the onset of skin changes. Amiodarone is an iodinated benzofuran derivative with antiarrhythmic properties that has primarily Class III activity but also has Class I, II, and IV effects. It is metabolized by the hepatic cytochrome p450 system, is highly lipophilic, and has a large volume of distribution.¹

Figure 1.

Typical blue–grey skin discoloration seen in amiodarone-induced ceruloderma.

Figure 2.

Close-up of nasal bridge blue–grey skin discoloration.

Blue–grey hyperpigmentation (ceruloderma) is a rare side effect of chronic amiodarone use that occurs in less than 10% of patients.² It is related to drug deposition in photoexposed skin and should not be confused with photosensitivity, a more common side effect that occurs in 29–57% of patients.¹ Treatment involves discontinuation of the medication, sun avoidance, and laser therapy in some cases.^1–3 If amiodarone discontinuation is not possible, less toxic alternative medications should be considered. Ultimately, the decision to continue amiodarone or use alternative medications should involve shared decision making with a cardiologist.

Despite prior substrate ablation our patient continued to experience symptomatic ventricular tachycardia. His skin findings did not resolve as amiodarone was continued given his advanced age and reduced systolic function, both of which limited his antiarrhythmic options. Furthermore, he had previously failed or did not tolerate alternative antiarrhythmic agents.

Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.

Conflict of interest: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, or the Department of Defense or the U.S. Government.