Hydroxychloroquine-Associated Hyperpigmentation Mimicking Elder Abuse

BACKGROUND Hydroxychloroquine may result in cutaneous dyschromia. Older individuals who are the victims of elder abuse can present with bruising and resolving ecchymoses. PURPOSE The features of hydroxychloroquine-associated hyperpigmentation are described, the mucosal and skin manifestations of elder abuse are reviewed, and the mucocutaneous mimickers of elder abuse are summarized. CASE REPORT An elderly woman being treated with hydroxychloroquine for systemic lupus erythematosus developed drug-associated black and blue pigmentation of her skin. The dyschromia was misinterpreted by her clinician as elder abuse and Adult Protective Services was notified. The family was eventually cleared of suspected elder abuse. A skin biopsy of the patient's dyschromia confirmed the diagnosis of hydroxychloroquine-associated hyperpigmentation. CONCLUSION Hyperpigmentation of skin, mucosa, and nails can be observed in patients treated with antimalarials, including hydroxychloroquine. Elder abuse is a significant and underreported problem in seniors. Cutaneous findings can aid in the discovery of physical abuse, sexual abuse, and self-neglect in elderly individuals. However, medication-associated effects, systemic conditions, and accidental external injuries can mimic elder abuse. Therefore, a complete medical history and appropriate laboratory evaluation, including skin biopsy, should be conducted when the diagnosis of elder abuse is suspected.