A 20-year-old woman with Greek heritage is referred to a dermatologist regarding localised bilateral areas of facial hyperpigmentation that have been present for the past five months.

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A 20-year-old woman with Greek heritage is referred to a dermatologist regarding localised bilateral areas of facial hyperpigmentation that have been present for the past five months.

The lesions started three months after commencing an oral contraceptive pill containing levonorgestrel and ethinylestradiol. They worsen during the sugar pill interval by becoming erythematous and papular, without any systemic symptoms. She has associated pain in the roof of her mouth.

Prior to starting the pill, her period was regular, every 28 days, with associated dysmenorrhoea requiring naproxen sodium 275mg tds for day 1-3, which she still requires during her pill withdrawal bleed.

There is no relevant past medical history and no known drug allergies. She is a non-smoker/vaper, occasionally drinks alcohol and uses no other substances. Her mother has vitiligo and alopecia.

On examination, there are well-demarcated round dusky-red to brown macules over the left and right cheeks (pictured). There is no mucosal involvement.