Neurocutaneous melanosis: a case of primary intracranial melanoma with metastasis

Neurocutaneous melanosis is a rare disorder characterized by the presence of large or multiple congenital melanocytic naevi and benign or malignant pigment cell tumours of the leptomeninges. Distant metastasis is unusual in primary leptomeningeal/intracranial melanomas. We present the case history of an adult male who had multiple primary intracranial melanomas associated with neurocutaneous melanosis (naevus of Ota) in the ophthalmic division of the left trigeminal nerve. Excision of the intracranial tumours was carried out in two stages, but the patient died 2 days after the second operation. Autopsy showed multiple metastatic deposits in the liver. Symptoms and signs of raised intracranial pressure, the presence of Ota's naevus, and a dural-based mass or masses should alert the treating physician to suspect a primary leptomeningeal/intracranial melanoma.

Safety and efficacy of glycolic acid facial peel in Indian women with melasma

BACKGROUND

Melasma is a common disorder of facial hyperpigmentation. Many modalities of treatment are available, but none is satisfactory.

MATERIALS AND METHODS

Twenty-five nonpregnant female patients with a minimum melasma area and severity index (MASI) of 15 were recruited in the study. After a detailed history and clinical examination under natural light and Wood's light, MASI was calculated and color photographs were taken of all patients. Patients were advised to carry out a prepeel program of daily application of topical sunscreens (sun protection factor-15, SPF-15) and 10% glycolic acid lotion at night for 2 weeks. Patients were then treated with 50% glycolic acid facial peel once per month for three consecutive months. At regular intervals and at the end of the follow-up period (3 months) after the last peel, the degree of improvement in pigmentation was assessed by remeasuring MASI. Side-effects, if any, were also recorded. The data obtained were statistically analyzed using Student's paired t-test and Spearman rank correlation coefficient test.

RESULTS

Improvement in melasma (reduction in MASI) was observed in 91% of patients (P < 0.01). Patients with epidermal-type melasma demonstrated a better response to treatment than those with mixed-type melasma (P < 0.05).

CONCLUSIONS

The prepeel program followed by 50% glycolic acid facial peel once per month for three consecutive months proved to be an effective treatment modality in Indian patients without any significant side-effects.

Dermabrasion: a curative treatment for melasma

Melasma is fairly common in Asian patients with a dark skin tone. It has long been known for its recalcitrance to any form of treatment. The objective of this article is to propose mechanical dermabrasion as a curative treatment for this entity. Five hundred and thirty-three patients with melasma were treated by mechanical dermabrasion using a rotatory diamond fraise. Four hundred and ten patients were available for long-term follow-up (mean follow-up time 5 years, range 1-9 years). Out of 410 patients, 398 (97%) achieved persistent clearance of melasma; in the remaining cases, there was partial recurrence after initial clearance. The common temporary sequelae were postoperative erythema or hyperpigmentation, pruritus, and milia formation. Two patients developed hypertrophic scars, one on the upper lip and one on the jawline, and one patient had permanent hypopigmentation on the forehead. In conclusion, mechanical dermabrasion is a relatively safe and highly effective means for curing melasma.

[Benign melanosis of the lip. Treatment with the Q-switched ruby laser]

BACKGROUND AND OBJECTIVE

Benign melanosis of the lip represents a cosmetic problem for many of those who are afflicted. It responds well to therapy with Q-switched lasers. The value of previous studies has been limited by small numbers of cases or short follow-up times.

PATIENTS/METHODS

In a retrospective study 9 patients were treated by the Q-switched ruby laser (694 nm, pulse duration 25-40 ns, spot size 4 mm, energy density 10 J/cm2) in the period from 5/94 to 10/99. The benignity of the lip melanosis was determined dermatoscopically. In one case, the diagnosis was also confirmed histologically by a punch biopsy. The follow-up time was between 6 months and 5 1/2 years.

RESULTS

In 3 cases a complete clearance of the melanosis was achieved after one session, while in 6 patients a second treatment was required. There were no recurrences. Scars or pigment alterations were likewise not observed.

CONCLUSIONS

The treatment of benign melanosis of the lip with the Q-switched ruby laser is an elegant and safe method with excellent cosmetic results.

Vaporization of melanin in oral tissues and skin with a carbon dioxide laser: a canine study

PURPOSE

This study tested the efficacy of carbon dioxide (CO2) laser vaporization in ablating gingival, oral mucosal, and cutaneous melanin in dogs.

MATERIALS AND METHODS

Three mongrel dogs with pigmentation of the oral mucosa, gingivae, and skin were used. Biopsy specimens from the melanin sites were obtained from all 3 dogs before laser application. Removal of the melanin sites was performed by using a 3 W continuous-wave CO2 laser. Biopsies of the treated areas were performed 1, 2, 4, and 6 weeks after laser treatment in all 3 dogs and also, at 11 weeks in 1 dog. The histologic sections were stained with hematoxylin and eosin and Masson-Fontana dye. A computerized morphometric program calculated the average percentage of the melanin layer in the Masson-Fontana-stained sections.

RESULTS

Clinical and histologic examination showed the CO2 laser to be effective in eliminating the pigmented areas in all tissues treated. No recurrence of melanin was detected in either the oral mucosa or gingiva at any of the follow-up times. In the skin, however, a small amount of melanin repigmentation was noticeable.

CONCLUSIONS

CO2 laser surgery proved an effective tool for obliterating superficial melanin discoloration. To prevent recurrence of the pigmentation, the area must be cleared completely of melanin, directing the laser beam carefully along the visible margins of the area.

Q-switched Nd:YAG laser treatment for acquired bilateral nevus of ota-like maculae: a long-term follow-up

BACKGROUND AND OBJECTIVE

Acquired bilateral nevus of Ota-like maculae (ABNLM) is not an uncommon dermal melanosis in Asian people. It is known for its recalcitrance to conventional treatment. We proposed Q-switched Nd:YAG laser for the treatment of this entity.

STUDY DESIGN/PATIENTS AND METHODS

Seventy female patients with ABNLM, who were 25-40 years old (mean, 37 years), were included in a prospective clinical study. Q-switched Nd:YAG laser at fluence of 8-10 J/cm(2), spot size 2 or 4 mm, and a repetition rate of 10 Hz was used to treat the lesions.

RESULTS

Two patients were lost to follow-up. In the remaining 68 cases, all lesions attained a 100% clearance after two to five treatment sessions (mean, 2.8 sessions). The results had persisted at 3-4 years follow-up (mean, 42 months). Temporary hyperpigmentation was found in 50% of patients; there was no scarring or changing of skin texture.

CONCLUSION

Q-switched Nd:YAG laser is a safe and effective noninvasive alternative treatment for ABNLM.

Treatment of gingival hyperpigmentation for esthetic purposes by Nd:YAG laser: report of 4 cases

Gingival hyperpigmentation may cause esthetic problems and embarrassment, especially in patients with a gummy smile. This report presents the use of the Nd:YAG laser for gingival depigmentation. Four cases, 3 females and 1 male, ages between 24 to 28 years old, presented with the same chief complaint of unesthetic gingiva caused by melanin hyperpigmentation. The Nd:YAG laser was set at 6 watts, 60 millijoules per pulse, and 100 pulses per second. The procedures were performed with contact mode in all pigmented areas by using a handpiece with a 320 microm diameter fiber optic. Ablation of the gingival hyperpigmented areas were accomplished without any bleeding complications or significant postoperative pain. Three to 4 weeks after the procedures, the hyperpigmented gingiva appeared healthy, pink, and firm. No recurrence of hyperpigmentation had been found in 11 to 13 months of follow-up. However, in delicate areas such as the marginal gingiva, the Nd:YAG laser should be used cautiously.

Erbium:YAG laser resurfacing for refractory melasma

BACKGROUND

Melasma is a facial dyspigmentation which is a common complaint in patients with darker skin tones. Many current therapies used for this condition are ineffective and can cause significant adverse effects.

OBJECTIVE

The purpose of this study was to evaluate the role of erbium:YAG laser resurfacing in the management of refractory melasma.

METHODS

Ten female patients with melasma unresponsive to previous therapy of bleaching creams and chemical peels were included in this study. Full face skin resurfacing using an erbium: YAG laser (2.94 microm) was performed using 5.1-7.6 J/cm2 energy. Clinical evaluations using the Melasma Area and Severity Index (MASI) and melanin reflectance spectrometry measurements were taken preoperatively and at 0.5, 1, 1.5, 3, and 6 weeks and 3, 5, and 6 months postoperatively. Adverse effects after laser resurfacing such as prolonged erythema, infection, and hyperpigmentation were recorded.

RESULTS

There was marked improvement of the melasma immediately after laser surgery using the parameters outlined; however, between 3 and 6 weeks postoperatively, all patients exhibited post-inflammatory hyperpigmentation. Decreased MASI and melanin reflectance spectrometry measurement scores were noted after biweekly glycolic acid peels and at the end of 6 months, significant clinical improvement in the melasma was seen compared to the preoperative evaluation.

CONCLUSION

Erbium:YAG laser resurfacing effectively improves melasma; however, the almost universal appearance of transient post-inflammatory hyperpigmentation necessitates prompt and persistent intervention. The use of this laser therapy is recommended only for refractory melasma.

Cryosurgical treatment of melanin-pigmented gingiva

OBJECTIVE

Abnormal deposition of melanin in gingiva can often occur. Complaints of "black gums" are common, and demand for depigmentation is usually made for esthetic reasons. A simple and effective cryosurgical technique to eliminate the pigmentation is the subject of this article.

STUDY DESIGN

Twenty patients with dark gingiva were treated by direct application of liquid nitrogen with a cotton swab for 20 to 30 seconds.

RESULTS

The treated gingiva appeared normal within 1 to 2 weeks after 1 or 2 cryosurgical treatments. The acceptance of the treatment was excellent.

CONCLUSIONS

This was a simple, bloodless cryosurgery for the depigmentation of gingiva, requiring no local anesthesia or sophisticated equipment.

Chemical peels

A chemical peel is a procedure in which a topically applied wounding agent creates smooth, rejuvenated skin by way of an organized repair process. This article describes the indications, classifications, operative procedure, and complications of chemical resurfacing. In addition, alternatives to chemoexfoliation are discussed.

Acquired malalignment: a complication of lateral longitudinal nail biopsy

We report the development of malalignment of the nail following lateral longitudinal biopsy of the nail unit in seven subjects. The lateral biopsies were in excess of the routine 3 mm diagnostic biopsy performed for investigation of a nail dystrophy, being indicated for excision of focal pathology. Deviation of the distal nail towards the side of excision might be accounted for by one or both of two mechanisms. First, the matrix might become skewed by the unilateral loss of a ligamentous structure extending from the lateral ligament of the distal interphalangeal joint. Second, there may be a reduction of embedding of nail in the lateral nail fold on the operative side in spite of a thorough lateral nail fold reconstruction. This reduction may result in an unopposed inward force from the remaining nail fold.

Choroidal melanoma in a 14-year-old patient with ocular melanocytosis

A 14-year-old male adolescent with ocular melanocytosis and secondary glaucoma in the left eye had a 2-year history of a progressively enlarging fundus lesion. Ocular examination revealed diffuse hyperpigmentation of the episclera and a smooth velvety thickening and hyperpigmentation of the left iris. Ophthalmoscopy disclosed diffuse choroidal pigmentation and a pigmented mass that occupied the macular area and surrounded the optic nerve. Ultrasonography showed an acoustically hollow lesion with scleral bowing and choroidal excavation. Based on clinical and ultrasonographic findings, the diagnosis was choroidal melanoma in a young patient with ocular melanocytosis. The eye was enucleated. Histopathologic examination revealed ocular melanocytosis with diffuse uveal melanocytosis and amelanotic malignant melanoma of the choroid. The choroidal melanoma apparently arose from a preexisting choroidal nevus. Even young patients with ocular melanocytosis should have regular follow-up examinations for early detection of uveal melanoma.

Melanoses of the gastrointestinal tract

This article reviews various forms of abnormal pigmentation of gastrointestinal tract with special regard to melanosis coli. Aetiology, pathogenesis of these states are discussed including practical consequence.

[Benign focal melanotic lesions of the oral mucosa: a clinicopathologic study of 41 cases]

41 patients with benign focal melanotic lesions on the oral mucosa were studied. The results showed that among the patients, 27 were female and 14 male, the mean age was 33 years old, and the most common site was the lip and gingiva. Clinically, the lesions were focal and well-defined, the size was about 0.6 cm in diameter. Histologically, 21 cases were pigmented nuvus on the oral mucosa (18 cases with nevocellular nevus and 3 cases with the common blue nevus), 2 cases were junctional change, 5 cases were the lentigo simplex, and 13 cases were oral melanotic macule. The characteristics of the oral melanotic macule and the junctional change were discussed.

Pigmented squamous cell carcinoma with dendritic melanocytes

A 79-year-old man presented with a pigmented nodule on the right ear which, on epiluminescence microscopy, demonstrated a diffuse grey-blue colour. Skin biopsy revealed an irregularly acanthotic epidermis with lobular clusters of atypical keratinocytes that projected into the dermis in the pattern of an invasive squamous cell carcinoma. Numerous dendritic melanocytes were present throughout the lesion. Although the close relationship between the highly dendritic intra-epidermal melanocytes and the atypical keratinocytes raised the issue of whether this tumour represented a malignant melanoacanthoma, the authors considered the lesion to be better classified as an unusual variant of pigmented squamous cell carcinoma.

Surgical management of conjunctival tumors. The 1994 Lynn B. McMahan Lecture

To our knowledge, there are no articles that describe the specific step-by-step details of the surgical removal of premalignant and malignant conjunctival tumors. We describe our current approach to the surgical management of squamous cell carcinoma (intraepithelial or invasive), localized melanoma, and primary acquired melanosis of the conjunctiva. The surgical method differs with limbal tumors, extralimbal tumors, and primary acquired melanosis. Limbal lesions are managed by localized alcohol corneal epitheliectomy, removal of the main mass by a partial lamellar scleroconjunctivectomy, and supplemental cryotherapy. Tumors located in the extralimbal conjunctiva are managed by alcohol application, wide circumferential surgical resection, and cryotherapy. Primary acquired melanosis is managed by alcohol epitheliectomy, removal of suspicious foci, quadrantic staging biopsies, and cryotherapy from the underside of the conjunctiva. In all cases, a "no touch" method is used and direct manipulation of the tumor is avoided to prevent tumor cell seeding into a new area. We have employed this technique on 109 patients with conjunctival squamous neoplasms and 137 patients with conjunctival melanoma, about 80 of which neoplasms were associated with primary acquired melanosis. Our observations suggest that well-planned initial surgical management using this technique decreases the chance of tumor recurrence for conjunctival melanoma and squamous cell carcinoma. We describe a detailed stepwise approach to the surgical management of conjunctival neoplasms. It requires meticulous clinical evaluation and complete removal of the tumor in one operation using a specific technique.

Treatment of severe physiologic gingival pigmentation with free gingival autograft

Melanin is normally found in the skin of all people, and normal pigmentation of the intraoral tissues is a relatively frequent finding. The highest rate of gingival pigmentation has been observed at the incisors. Until recently, however, very little attention has been paid to the esthetic treatment of severe gingival pigmentation. To answer the cosmetic demand for a pleasing smile, pigmented gingiva was replaced with an unpigmented free gingival autograft in 10 patients. At least two areas in each patient were grafted. In all 10 areas in which the recipient site received full-thickness bed preparation, no evidence of repigmentation was found after 4.5 years. Of the 10 areas that received partial-thickness bed preparation, only one exhibited repigmentation (after 1 year).

Q-switched ruby laser treatment of mucocutaneous melanosis associated with Peutz-Jeghers syndrome

Peutz-Jeghers syndrome is an eponym for circumscribed mucocutaneous melanosis in association with gastrointestinal polyposis. Irregular pigmented macules of varying size and color can be found on the perioral skin, lip vermillion border, buccal mucosa, palate, and tongue. Previous treatments, such as surgical excision, cryosurgery, electrodesiccation, dermabrasion, and carbon dioxide or argon laser ablation commonly result in incomplete removal, scarring, or changes in normal pigmentation. The Q-switched ruby laser used at 694 nm, a wavelength well absorbed by melanin relative to other optically absorbing structures in skin, causes highly selective destruction of pigment-laden cells. In addition, the 20-nanosecond pulse duration produced by this laser approximates the thermal relaxation time for melanosomes, thereby confining the energy to the target. The Q-switched ruby laser produces clinically significant fading of mucocutaneous melanosis in association with Peutz-Jeghers syndrome without complications often seen with other therapeutic modalities.

Melanomas in children

Although rare, melanomas do occur in children and adolescents. Pediatricians should be aware of the clinical features of melanoma and the risk factors for developing this malignancy. Children at high risk for melanoma should have at least annual cutaneous examinations in search of suspicious lesions. If a lesion is suspected of being a melanoma, it should be removed surgically and submitted for pathologic examination. Education of parents and children about the deleterious effects of ultraviolet light affords a means of counteracting the increasing incidence of melanoma at the grassroots level. The use of sunscreens, hats, and other protective clothing and the judicious timing of daily solar exposure should serve to prevent sunburning, limit tanning, and decrease the incidence of melanoma and other more common cutaneous malignancies, such as basal cell carcinoma and squamous cell carcinoma.

Melanosis of the prostate in an elderly patient--a case report

A case of melanosis of the prostate in an 85 year old Libyan patient is reported. This rare lesion is the first incidence from our area. The occurrence of melanin pigment in the prostate is extremely rare. After the initial report by Nigogosyan and co-workers in 1963, Ro et al in their review have analysed 23 documented lesions in which melanin pigment was confined to melanocytes in the stroma of the prostate only (blue nevus of the prostate), melanin pigment was present in both the stromal melanocytes and glandular epithelium (melanosis of the prostate) and lessions in which the pigment was observed in both normal and neoplastic epithelium. Later Lew et al reported another case of blue nevus of the prostate. However, reports of melanosis of the prostate are less frequent than blue nevus of the prostate. Melanosis of the prostate has not been reported from the African continent and from the Arab population according to the accessible English literature. Here we present the first case of melanosis of the prostate in an 85 year old Libyan Arab bringing the total number of melanosis of the prostate to nine.

The removal of cutaneous pigmented lesions with the Q-switched ruby laser and the Q-switched neodymium: yttrium-aluminum-garnet laser. A comparative study

BACKGROUND

The Q-switched ruby laser (QSRL) (694 nm) has been used successfully in the removal of tattoos and a variety of cutaneous pigmented lesions. The frequency-doubled Q-switched neodymium:yttrium-aluminum-garnet laser (QSNd:YAG) (1064 and 532 nm) has also been shown to be effective in the treatment of tattoos, however, little has been published regarding the QSNd:YAG laser in the removal of cutaneous pigmented lesions.

OBJECTIVE

The purpose of this study is to compare the efficacy and side effect profile of the QSRL and the frequency-doubled QSNd:YAG lasers in the removal of cutaneous pigmented lesions, including lentigines, café-au-lait macules, nevus of Ota, nevus spilus, Becker's nevus, postinflammatory hyperpigmentation, and melasma.

METHODS

Twenty patients with pigmented lesions were treated with the QSRL and the frequency-doubled QSNd:YAG lasers. Clinical lightening of the lesion was assessed 1 month after a single treatment. Side effects and patient satisfaction were also evaluated.

RESULTS

A minimum of 30% lightening was achieved in all patients after only one treatment with either the QSRL or the frequency-doubled QSNd:YAG laser. The QSRL seems to provide a slightly better treatment response than the QSNd:YAG laser. Neither laser caused scarring or textural change of the skin. Most patients found the QSRL to be more painful during treatment, but the QSNd:YAG laser caused more postoperative discomfort.

CONCLUSION

Both the QSRL and the frequency-doubled QSND:YAG laser are safe and effective methods of treatment of epidermal and dermal pigmented lesions.