Unwell for 6 months with increasing pigmentation
Last reviewed: April 2025
Author(s): Dr Ian Coulson, Dermatologist, United Kingdom (2025).
Edited by the DermNet content team.
Background
This 38-year-old lady has been feeling unwell for the last six months. She is constantly tired, has lost weight and feels dizzy when she stands up.
She has noticed that her skin generally has become slightly darker.
Describe what you see on her tongue and lips.
The photograph shows increased pigmentation on both the mucosa of the lateral side of the tongue and her lips.
What do you think is the most likely diagnosis?
This coupled with her symptoms of tiredness and dizziness should suggest Addison disease, due to dysfunction of the adrenal cortex.
The pigmentation is due to excess levels of ACTH, that is being produced by the pituitary gland in response to low levels of glucocorticoids.
What bedside test should you do?
It is likely that she will have significant postural hypotension. Her lying and standing blood pressure should be measured.
How would you confirm the diagnosis by special investigations?
The diagnosis can be confirmed by doing a short Synacthen test. Administration of ACTH produces a blunted response in the production of cortisol.
Addison disease is usually the result of autoimmune destruction of the adrenal cortex. However, it can be destroyed by infection (tuberculosis and systemic fungal infection), tumours and acutely due to sepsis and haemorrhage into the adrenal glands.
It is important to consider other associated autoimmune diseases such as thyroid disease, type I diabetes, vitiligo, and pernicious anaemia.
