Can levofloxacin cause skin pigmentation changes?

Levofloxacin and Skin Pigmentation

Yes, levofloxacin can cause skin pigmentation changes, though this is a rare cutaneous adverse effect. While the common cutaneous reactions associated with levofloxacin include rash, pruritus, and photosensitivity (occurring in 0.2-0.4% of patients), skin hyperpigmentation has been documented in case reports 1, 2.

Evidence of Levofloxacin-Induced Skin Pigmentation

• Levofloxacin has been implicated in causing dark hyperpigmentation, particularly in sun-exposed areas, suggesting a photosensitive distribution pattern 2
• A case report documented brown-gray hyperpigmentation in a photosensitive distribution after levofloxacin exposure in an immunocompromised patient 2
• Another case report showed dark hyperpigmentation appearing on the lower limbs, predominantly on the anterior aspects of the legs, after treatment with a regimen that included levofloxacin 1

Mechanism and Histological Findings

• Histological examination in reported cases revealed dark, perivascular and interstitial deposits throughout the dermis 1
• These deposits stained positive with both Fontana-Masson (for melanin) and Perls (for iron) stains, suggesting the presence of both melanin and iron in the affected skin 1
• In one case, infrared microspectroscopy was able to identify the medication in the dermis of involved skin 1
• The exact mechanism appears similar to minocycline-induced hyperpigmentation, with deposits of iron and/or melanin within the dermis 1

Risk Factors and Clinical Presentation

• Photosensitivity appears to be a contributing factor, with pigmentation often developing in sun-exposed areas 2
• Immunocompromised status may increase risk, as seen in a case involving an orthotopic liver transplant patient 2
• Longer duration of therapy may increase the risk, similar to other drug-induced pigmentation disorders 1
• The pigmentation typically develops several weeks after initiation of antibiotic therapy 1

Management

• Discontinuation of levofloxacin typically leads to gradual resolution of the hyperpigmentation over several weeks 2
• No specific treatment is required beyond drug discontinuation 1, 2
• Patients should be advised to use sun protection measures when taking levofloxacin to minimize photosensitivity reactions 3

Other Known Cutaneous Adverse Effects of Levofloxacin

• Rash, pruritus, and photosensitivity occur in 0.2-0.4% of patients taking levofloxacin 3
• Photosensitivity is a class effect of fluoroquinolones, with levofloxacin having a lower photosensitizing potential compared to some other quinolones 4
• Serious cutaneous reactions like Stevens-Johnson syndrome are rare but have been reported with fluoroquinolones 4

Clinical Implications

• When prescribing levofloxacin, clinicians should be aware of this rare but documented adverse effect 1, 2
• In patients developing unusual skin pigmentation while on levofloxacin, consider drug-induced hyperpigmentation in the differential diagnosis 2
• Patients taking multiple medications pose a diagnostic challenge when hyperpigmentation develops, requiring careful assessment of temporal relationships and resolution patterns after drug discontinuation 2
• Patients should be counseled about photosensitivity and advised to use sun protection while taking levofloxacin 3