Poikiloderma of Civatte

Poikiloderma of Civatte is a chronic, sun related change of the neck and upper chest with reticulate red brown pigmentation, telangiectasia and slight atrophy. It spares the skin shaded by the chin.

It affects mainly women between 40 and 60 years of age, particularly those with fair skin of Fitzpatrick type 2 or 3, and may be more visible after the menopause. Cumulative sun exposure is the major cause.

Contributing factors may include perfumes (photosensitisation), cosmetics, hormonal change and genetic susceptibility. The condition is benign but often distressing.

Pathophysiology.

Chronic ultraviolet damage causes dermal elastosis, telangiectasia and increased, patchy basal pigmentation, with thinning of the epidermis. Photosensitising chemicals in some cosmetics may add to the pigment change.

• Red brown, reticulate pigmentation with fine telangiectasia and mild atrophy and hypopigmented spots on the sides of the neck, the V of the chest and sometimes the lateral cheeks.
• The submental area under the chin is spared.
• Usually no itch or burning, though some patients report mild burning.

• Clinical diagnosis from distribution, age and appearance.
• Skin biopsy is rarely needed: epidermal atrophy, basal pigment, telangiectasia and solar elastosis.
• Photopatch testing if a photoallergic reaction to cosmetics is suspected.

Differential diagnosis.

• Dermatomyositis and lupus erythematosus (poikilodermatous changes with systemic features).
• Rothmund-Thomson syndrome and other genetic poikilodermas, mycosis fungoides (poikilodermatous type) and chronic radiation damage.
• Riehl melanosis, photoallergic contact dermatitis and erythromelanosis follicularis.

• Stop further sun damage: broad spectrum sunscreen of SPF 30 or more daily, with a scarf or collar. Stop perfumes and cosmetics on the neck that cause photosensitivity.
• Pulsed dye laser (595 nm) or intense pulsed light for telangiectasia and redness, usually 2 to 4 treatments at intervals of 4 to 6 weeks. Q-switched or fractional lasers for pigment. Test areas first, since the neck skin scars more easily than the face.
• Topical tretinoin 0.025 to 0.05% nightly may improve texture and pigment. Hydroquinone is used for short periods only because of the risk of ochronosis.
• Reassure the patient that the condition is benign and treatment is for appearance, with an unpredictable result.

Monitoring. Review at the end of laser courses, then yearly.

Referral and escalation. Dermatology for laser; investigate for connective tissue disease if the rash itches, includes a heliotrope rash or comes with proximal weakness.