Prurigo pigmentosa in a patient with primary biliary cirrhosis and Sjögren syndrome

A 44-year-old Japanese woman suddenly developed severely pruritic erythematous papules on her trunk in a symmetrical distribution. Biopsy specimens showed the typical histopathological findings of prurigo pigmentosa. She had had recurrent episodes of high fever spikes for several years, and lost 10 kg in the last year. She was diagnosed as primary biliary cirrhosis (PBC) associated with subclinical Sjögren syndrome (SjS). Predonisolone (60 mg/day) for two weeks was effective for the PBC and fever, but not for the prurigo pigmentosa. PBC may be involved in the pathogenesis of this rare skin disease.

Linear congenital Becker nevus

Becker nevus is an acquired disorder that usually manifests in late childhood or adolescence as a hyperpigmented hypertrichotic patch usually located on the upper trunk or proximal upper extremities. Only a few cases of congenital and familial Becker nevus have been described. Although the lesions may have various shapes, they consistently have a geographic or blocklike configuration in an irregular fashion; a linear pattern has rarely been reported. We describe a case of linear congenial Becker nevus following Blaschko line that appeared at birth on the right shoulder, with hypertrichosis developing 4 years later.

[Non-melanocytic dischromias]

Non-melanocytic hyperpigmentations (dyschromias), besides common melanotic ones, develop mostly due to the skin reaction to various chemicals and/or drugs of exogenous origin. They can be however also caused by some endogenously formed (evolving) intermediates of several metabolic diseases. The above mentioned factors are of toxic or allergic character and their clinical dermal manifestation often occurs as an allergic reaction after the exposition of the skin to solar radiation, or as a toxic contact reaction both on the skin and the mucosa. As a therapy of individual skin changes is difficult or impossible, the only treatment consists in reliable photoprotective measures.

Pigmented speckling as a sign of basal cell carcinoma

BACKGROUND

Basal cell carcinoma may present as a discrete skin-colored papule, which may mimic other common skin tumors.

OBJECTIVES

We present pigmented speckling as a clinical sign for basal cell carcinoma.

METHODS

Twenty cases of basal cell carcinoma with pigmented speckling were collected and their clinical and histologic features were reviewed.

RESULTS

There were 12 men and 5 women. The patients' average age was 70.5 years (range 33-90 years). Fifteen of the 17 tumors were on the head and neck, and 2 tumors were on the shoulders and back. Clinical examination revealed a "speckled appearance" of brown-black pigmentation within and/or at the border of the tumors. Histopathology showed basal cell carcinoma with melanin pigment (positive for Fontana-Masson stain and negative for Perl's stain) within nests of tumor cells.

CONCLUSION

The speckled pigmentation of a basal cell carcinoma is a distinguishing feature, which may be useful in the differential diagnosis of this tumor from other discrete skin tumors.

Minocycline-induced hyperpigmentation masquerading as alkaptonuria in individuals with joint pain

Alkaptonuria, a rare autosomal-recessive disorder caused by mutations in the HGD gene and a deficiency of homogentisate 1,2-dioxygenase, is characterized by accumulation of homogentisic acid (HGA), ochronosis, and destruction of connective tissue resulting in joint disease. Certain medications have been reported to cause cutaneous hyperpigmentation resembling that of alkaptonuria. We present 5 such cases. Eighty-eight patients with a possible diagnosis of alkaptonuria were examined at the National Institutes of Health Clinical Center between June 2000 and March 2004. The diagnosis of alkaptonuria was confirmed or ruled out by measurement of HGA in the urine. Five patients with findings consistent with ochronosis, including pigmentary changes of the ear and mild degenerative disease of the spine and large joints, were diagnosed clinically as having alkaptonuria, but the diagnosis was withdrawn based on normal urine HGA levels. All 5 patients were women who had taken minocycline for dermatologic or rheumatologic disorders for extended periods. Minocycline-induced hyperpigmentation should be considered in the differential diagnosis of ochronosis. This could be of increased significance now that minocycline and other tetracyclines have been proposed as therapeutic options for rheumatoid arthritis, bringing a new population of patients with ochronosis and arthritis to medical attention with the potential, but incorrect, diagnosis of alkaptonuria.

Atypical moles in a patient undergoing chemotherapy with oral 5-fluorouracil prodrug

We present a patient with multiple pigmented lesions on the palms, soles, oral mucosa and nails after chemotherapy with oral 5-fluorouracil (5-FU) prodrug. Dermoscopically, most of the macules showed similar features, with pigmentation present predominantly on the crista superficialis, while a large, dark macule also showed pigmentation along the sulcus superficialis with irregular hyperpigmentation and depigmentation, suggesting malignancy. However, histologically, both types of lesion showed basal hyperpigmentation and the presence of a small number of large atypical melanocytes. We diagnosed these lesions as pigment flecks induced by 5-FU, and the pigmented lesions gradually diminished after the cessation of chemotherapy. Our findings suggested that immunosuppression and 5-FU led to the development of the atypical pigmented lesions.

Failure to diagnose: melanoma

Case histories are based on actual medical negligence claims, however, certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. Medical negligence claims alleging 'failure to diagnose' are a common cause of claims and complaints against general practitioners. This article outlines some risk management strategies designed to minimise the possibility of an adverse event arising from failure to diagnose melanoma.

Topical agents used in the management of hyperpigmentation

Disorders of hyperpigmentation are difficult to treat, particularly in dark-skinned individuals. The goal is to reduce the hyperpigmentation without causing undesirable hypopigmentation or irritation in the surrounding normally pigmented skin. The psychosocial impact caused by these disorders must be considered. Although there are many effective therapeutic modalities available, there are potentially significant side-effects associated with treatment. The most commonly used treatment is topical hydroquinone. There are other phenolic agents, such as N-acetyl-4-cystaminylphenol (NCAP), that are currently being studied and developed. The non-phenolic agents, which include tretinoin, adapalene, topical corticosteroids, azelaic acid, arbutin, kojic acid, and licorice extract, are also used for hyperpigmentation disorders.

Pigmented Bowen's Disease Mimicking Cutaneous Melanoma: Clinical and Dermoscopic Aspects

BACKGROUND

Pigmented Bowen's disease (BD) (squamous cell carcinoma in situ) has been rarely described among white patients.

OBJECTIVE AND METHODS

We report the case of a 48-year-old white male presenting a lesion of pigmented BD on his left thigh, clinically mimicking a superficial spreading melanoma.

RESULTS

Naked-eye physical examination revealed a single 1.8 x 1.5 cm, hyperpigmented plaque with a rough surface, which appeared irregularly shaped and sharply demarcated. The assessment of this uncommon tumor by means of dermoscopy, never reported in literature before, was performed. According to standardized terminology, none among the well-established dermoscopic criteria useful to discriminate between melanocytic and nonmelanocytic origin was detected within the lesion. A reticular pigmentation simulated remnants of atypical pigment network, being of uncertain diagnostic value in the preoperative classification of the lesion. Other recognized patterns were irregular, brown globular structures and wide regression-like areas. None of the features diagnostic for pigmented basal cell carcinoma was found as well.

CONCLUSION

The correct classification of nonmelanocytic origin of the lesion was therefore achieved only at histologic examination, after the complete surgical excision. In spite of its rarity, pigmented BD should be included among those lesions, which may simulate cutaneous melanoma. According to criteria validated by literature, dermoscopy failed to improve a preoperative classification of this peculiar skin tumor.

[Cutaneous hyperpigmentation of the distal falanx in a newborn]

A case of distal falangeal hyperpigmentation in a 2-month female newborn, who did not show any other cutaneous disease at the time of our observation, is presented. The aim of our study is to focus attention on this condition, actually considered a benign, asymptomatic, transitory manifestation, rarely reported in literature. On the basis of the clinical features, it has been proposed to add this pigmentation to the transient benign dermatoses of newborns.

Two cases of lichen planus pigmentosus presenting with a linear pattern

We report two cases of lichen planus pigmentosus (LPP) that developed in a unilateral linear pattern. The patients presented with unilateral linear brown macules on the extremities. Skin biopsy showed orthokeratosis, basal hydropic degeneration with scarce lymphohistiocytic infiltrates, and numerous melanophages in both patients. These patients, to the best of our knowledge, are the first cases of LPP presenting with a linear pattern. LPP should be considered in the differential diagnosis of linear hyperpigmented skin lesions.

Reticulate acropigmentation of dohi: first case reports from Nepal

Acropigmentation of Dohi is a rare acropigmentary disorder. We report two cases of reticulate acropigmentation of Dohi from Nepal. To the best of our knowledge, these two cases represent the first case reports from Nepal.