Collection of Skin Disorders: Melanomas to Moles
Becker Nevus
Kendall Lane, MD
Concern about the large, hairy “mole” on his left shoulder prompted a 24-year-old African American man to seek medical attention. The lesion first appeared during early adolescence as a group of small, dark blotches. These eventually coalesced into a hyperpigmented patch with hair and acne.
Physical examination findings were otherwise normal. The patient had no significant personal or family history of similar lesions, skin disease, or skin cancer.
This is a classic presentation of a Becker nevus—a hyperpigmented, unilateral patch with hypertrichosis that develops during adolescence. The lesion is fairly uncommon and affects men more than women. Acneform lesions may appear within the nevus, as in this patient. Becker nevi on the lower extremities, head, and hands have been reported.1-3
The clinical history usually rules out other lesions in the differential diagnosis, which includes congenital melanocytic nevus, nevus spilus, café au lait patch, and postinflammatory hyperpigmentation.
Abnormalities, such as smooth muscle hamartoma,4 cystic lymphangioma,5 polythelia,6 unilateral breast hypoplasia,7 ipsilateral pectoralis major hypoplasia,8 asymmetric scalp and beard growth,2 ipsilateral limb asymmetry,9 lichen planus,10 and accessory scrotum,11 have been associated with Becker nevi. This patient had none of these conditions.
The co-occurrence of Becker nevi and melanoma has been rarely reported. In a study of 9 patients with Becker nevi and melanoma, the malignancy developed within a Becker nevus in only 1 patient, on the ipsilateral side of the body in 5 patients, and on the contralateral side in 3 patients.12
Treatment is usually for cosmesis. Surgical excision is generally avoided because it may result in scarring. In contrast, laser therapy (eg, erbium YAG laser and long-pulsed ruby laser) has been used to treat both hyperpigmentation and hypertrichosis with a good cosmetic outcome.
This patient was on active duty in the Navy and planned to pursue laser treatment after his deployment. ■
The views expressed herein are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the US government.
References:
1. Hsu S, Chen JY, Subrt P. Becker’s melanosis in a woman. J Am Acad Dermatol. 2001;45:S195-S196.
2. de Almeida HL Jr, Happle R. Two cases of cephalic Becker nevus with asymmetrical growth of beard or scalp hair. Dermatology. 2003;207:337-338.
3.Al Aboud K, Al Hawsawi K. Becker nevus on the hand. Eur J Dermatol. 2002;12:588.
4. Urbanek R, Johnson WC. Smooth muscle hamartoma associated with Becker’s nevus. Dermatol. 1978;114:104-106.
5. Oyler RM, Davis DA, Woosley JT. Lymphangioma associated with Becker’s nevus: a report of coincident hamartomas in a child. Pediatr Dermatol. 1997;
14:376-379.
6. Urbani CE, Betti R. Polythelia within Becker’s naevus. Dermatology. 1998;196:251-252.
7.Van Gerwen HJ, Koopman RJ, Steijlen PM, Happle R. Becker's naevus with localized lipoatrophy and ipsilateral breast hypoplasia. Br J Dermatol. 1993;129:213.
8. Moore JA, Schosser RH. Becker's melanosis and hypoplasia of the breast and pectoralis major muscle. Pediatr Dermatol. 1985;3:34-37.
9. Lucky AW, Saruk M, Lerner AB. Becker’s nevus associated with limb asymmetry. Arch Dermatol. 1981;117:243.
10. Puri S, Nanda S, Grover C, et al. Congenital Becker nevus with lichen planus. Pediatr Dermatol. 2005;22:328-330.
11. Szylit JA, Grossman ME, Luyando Y, et al. Becker’s nevus and an accessory scrotum. A unique occurrence. J Am Acad Dermatol. 1986;14:905-907.
12. Fehr B, Panizzon RG, Schnyder UW. Becker’s nevus and malignant melanoma. Dermatologica. 1991;182:77-80.
Seborrheic Keratoses
Sunita Puri, MD
A 70-year-old man was concerned about these dark lesions that covered his back and legs.
He was diagnosed seborrheic keratoses. Also called seborrheic wart and verruca seborrheica, these benign growths can present as a single tumor or as crops of lesions. They often appear on the face, trunk, and legs—where sebaceous glands are most common—and generally do not appear on palms, soles, and mucous membranes.
Initially, seborrheic keratoses are flat, sharply demarcated, brown maculae. Over time, the lesions become polypoid with an uneven surface and may be warty, dark brown or black, and greasy (Figure 1). They are identified by their “stuck-on” appearance. On the trunk, they may develop in the pattern of a “Christmas tree” (Figure 2), as in this case. Because clothes and jewelry can catch on the lesions, they are considered cosmetically undesirable and annoying.
The age of onset is typically after the 5th decade. Men and women with a familial tendency are equally affected. Rarely, a sudden appearance of multiple lesions may be associated with underlying malignancy.1 When there is diagnostic doubt, or when a skin cancer is suspected, a biopsy is indicated. These lesions can be removed with cryosurgery, curettage, or laser therapy. This patient was reassured about the benign nature of the lesions. ■
References:
1. Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick's Dermatology in General Medicine. Vol 1. 5th ed. New York, NY: McGraw-Hill Co; 1999:814.
Nodular Melanoma
Thomas N. Helm, MD, Nna Li, and Richard Narins
A 74-year-old man presented for evaluation of a pigmented nodule on the left arm that had grown over 2 months’ time. A biopsy was performed, which revealed nodular melanoma.
Nodular melanoma describes a clinical presentation of melanoma devoid of a significant macular (radial) component.1 Although older studies suggested histologic criteria such as limitation of the radial growth phase to less than 3 rete ridges,2 there has been no accepted standardized histologic approach to diagnosis. Clinical presentation remains the most important defining feature.
Nodular melanoma comprises approximately one-tenth of all melanomas and is more commonly found in men.1 Recent reports have addressed differences in nodular melanoma from metastases and primary dermal melanoma.3 Nodular melanoma is increasing in incidence, along with all other types of melanoma.4 Most nodular melanomas do not exhibit the asymmetry, irregular border, variegated color, and diameter larger than 6.0 mm that have been successfully publicized as warning signs for superficial spreading malignant melanoma.5 Because nodular melanoma may be symmetrical and well-circumscribed and exhibit none of the ABCD features, an “E” has recently been added to alert patients to the dangers of a growing or erythematous, elevated, or evolving tumor.6 Any lesion suspected of being a melanoma should be biopsied.
Even with early detection, nodular melanomas can grow several millimeters over a few weeks’ time and may be associated with high mortality and poor outcome.7 Some studies have shown the surprising results that delay in detection may not be associated with a worse prognosis due to the rapid rate of growth and proclivity to metastasis of some melanomas.8
Therapy for metastatic melanoma is difficult. Although commonly performed, sentinel lymph node studies followed by lymphadenectomy when indicated are helpful in determining prognosis but have questionable benefits for overall survival.9,10 Interferon alpha therapy is of some utility.11 Early diagnosis followed by complete removal is still the best treatment. ■
References:
1. Cohen PJ, Lambert WC, Hill GJ, Schwartz RA. Melanoma. In: Skin Cancer: Recognition and Management. Schwartz RA, ed. New York: Springer-Verlag; 1988:104-105.
2. McGovern VJ, Mihm MC, Bailly C, et al. The classification of malignant melanoma and its histologic reporting. Cancer. 1973;32(6):1446-1457.
3. Cassarino DS, Cabral ES, Karthar V, Swetter SM. Primary dermal melanoma: Distinct immunohistochemical findings and clinical outcome compared with nodular and metastatic melanoma. Arch Dermatol. 2008;144:49-56.
4. Sober AJ, Lew QA, Koh HK, Barnhill RL. Epidemiology of cutaneous melanoma: an update. Dermatology Clinics. 1991;9(4):617-631.
5. Friedman RJ, Rigel DS, Kopf AW. Early detection of malignant melanoma: the role of physician examination and self examination of the skin. CA Cancer J Clin. 1985;35(3):130-151.
6. Brodell RT, Helms SE. The changing mole. Additional warning signs of malignant melanoma. Postgrad Med. 1998;104(4):145-148.
7.Liu W, Dowling JP, Murray WK, et al. Rate of growth in melanomas: characteristics and associations of rapidly growing melanomas. Arch Dermatol. 2006;142:1551-1558.
8. Richard MA, Grob JJ, Avril MF, et al. Melanoma and tumor thickness: challenges of early diagnosis. Arch Dermatol. 1999;135(3):269-274.
9. Kettlewell S, Moyes C, Bray C, et al. The value of sentinel node status as a prognostic factor in melanoma: perspective observational study. BMJ. 2006;332(7555):1423.
10. Wick MR, Patterson JW. Sentinel lymph node biopsies for cutaneous melanoma. [Review]. Am J Surg Pathol. 2005;29 (3):412-414.
11. Moschos S, Kirkwood JM. Present role and future potential of type I interferon in adjuvant therapy high-risk operable melanoma. Cytokine Growth Factor Rev. 2007;18 (5-6):451-458.
Favre-Racouchot Nodular Elastosis
Eric J. Lewis and Charles E. Crutchfield III
A 69-year-old woman, who was being seen regularly for treatment of psoriasis, was noted to have numerous open comedones on the sides of her face in association with photodamaged skin.
This is Favre-Racouchot nodular elastosis (or nodular elastoidosis with cysts and comedones), a condition classified in the group known as the solar elastotic syndromes; they are characterized microscopically by the accumulation of degenerative material that stains with elastic tissue stains.
Favre-Racouchot syndrome, which is more prevalent in men, typically affects the periorbital and malar skin but may also occur at other sites of photodamage, such as the nose, neck, and retroauricular area. Initially, enlarged pilosebaceous orifices filled with keratinous debris appear on a background of photodamaged skin. In some advanced cases, cystic nodules develop that may coalesce into thickened, yellowish plaques containing large comedones. The condition is thought to result from weakening of the supporting stroma surrounding pilosebaceous units secondary to photodamage. ■
References:
1.Calderone DC, Fenske NA. The clinical spectrum of actinic elastosis. J Am Acad Dermatol. 1995;32:1016-1024.
2.Fenske NA, Lober CW. Aging and its effects on the skin. In: Moschella SL, Hurley HJ, eds. Dermatology. 3rd ed. Philadelphia, PA: WB Saunders Company; 1992:107-122.
3.Lyon NB, Fitzpatrick TB. Geriatric dermatology. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al, eds. Dermatology in General Medicine. New York, NY: McGraw-Hill; 1993:2961-2979.
Nummular Eczema
Joe Monroe, PA-C
The multiple, uniformly scaly, coin-shaped, papulosquamous lesions shown here on the lower leg of a 61-year-old man had persisted for 3 months despite application of topical clotrimazole and 1% hydrocortisone. The rash involved only the legs and was variably pruritic. The patient had a long history of dry skin. Recently, he had begun to swim daily for exercise. Every day, he took long, hot showers and used highly perfumed bar soap. A potassium hydroxide preparation of scrapings from the lesions was negative for fungal elements.
These lesions are highly characteristic of nummular eczema—a reaction associated with dry skin that may be aggravated by soaps, frequent bathing, allergies, and certain medications. Exposure to winter weather and regular use of a hot tub are also well-known triggers. This rash is common, but it is frequently misdiagnosed as a “fungal infection.” Affected patients are often given multiple courses of antifungal therapy without success and are then referred to a dermatologist. Nummular eczema primarily occurs in middle-aged and elderly persons; the cause is unknown. The dorsum of the hand is the most commonly involved site; other frequently involved areas include the extensor aspects of the forearms, lower legs, flanks, and hips. The course is variable, but it is usually chronic.1
Besides tinea, the differential diagnosis includes psoriasis, Bowen disease, and discoid lupus erythematosus (DLE). Psoriasis usually involves additional areas, such as the elbows and knees; patients often have a history of psoriatic eruptions. Bowen disease typically appears as a fixed, solitary lesion on sun-damaged skin. DLE is almost always triggered by sun exposure; the annular lesions have central clearing. Treatment of nummular eczema involves adequate skin moisturizing; use of nonirritating soaps; and reduced temperature, length, and frequency of showers and baths.
The application of mid- to high-potency topical corticosteroid ointments may hasten resolution. Failure of this treatment indicates the need for a biopsy. This patient was successfully treated with clobetasol ointment. ■
References:
1. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. Philadelphia: Mosby;2004:61.