Sudden onset of Multiple nevi after administration of 6-mercaptopurine in an adult with Crohn's disease: a case report

Eruptive Melanocytic Nevi: A Review

Eruptive melanocytic nevi (EMN) is a phenomenon characterized by the sudden onset of nevi. Our objective was to compile all published reports of EMN to identify possible precipitating factors and to evaluate the clinical appearance and course. We conducted a systematic bibliographic search and selected 93 articles, representing 179 patients with EMN. The suspected causes were skin and other diseases (50%); immunosuppressive agents, chemotherapy or melanotan (41%); and miscellaneous, including idiopathic (9%). The clinical manifestations could largely be divided into two categories: EMN associated with skin diseases were frequently few in number (fewer than ten nevi), large, and localized to the site of previous skin disease, whereas those due to other causes presented most often with multiple small widespread nevi. In general, EMN seem to persist unchanged after their appearance, but development over several years or fading has also been reported. Overall, 16% of the cases had at least one histologically confirmed dysplastic nevus. Five cases of associated melanoma were reported. We conclude that the clinical appearance of EMN may differ according to the suggested triggering factor. Based on the clinical distinction, we propose a new subclassification of EMN: (1) widespread eruptive nevi (WEN), with numerous small nevi, triggered by, for example, drugs and internal diseases, and (2) Köbner-like eruptive nevi, often with big and few nevi, associated with skin diseases and most often localized at the site of previous skin disease/trauma. The nature of the data precluded assessment of risk of malignant transformation.

Drug-induced eruptive melanocytic nevi

INTRODUCTION

The sudden eruption of melanocytic nevi has been associated with a number of conditions, such as bullous skin diseases, immunodeficiency and immunosuppression. The exact mechanisms leading to the development of eruptive melanocytic nevi are unknown. Areas covered: The aim of this article is to review the literature concerning eruptive melanocytic nevi following the administration of immunosuppressive drugs and other medications. Expert opinion: The literature regarding the development of eruptive nevi in association with pharmacological therapies includes a relatively low number of reports. Prevalence of this phenomenon is likely to be underestimated, thus reporting should be encouraged in order to better define the actual significance and related clinical implications. The development of multiple melanocytic nevi during immunosuppressive treatments highlights the importance of immune system integrity in the regulation of nevi growth. The observation of eruptive nevi as an unexpected effect of targeted therapies for specific types of cancer, including melanoma, provided intriguing hints to understand the mechanisms underlying this paradoxical event. The synergistic role of additional triggers in the occurrence of drug-induced eruptive nevi has not been explored and may be an interesting area of research.

[Eruptive melanocytic nevi during azathioprine therapy in myasthenia gravis]

While being treated with azathioprine and dexamethasone, a 21-year old man with myasthenia gravis suddenly developed rapidly progressing brown macules, predominantly on the trunk, palms and soles. We made a diagnosis of eruptive melanocytic nevi (EMN). This rare entity can appear after blistering skin diseases, in immunocompromised patients, and, in particular, during immunosuppressive therapy for autoimmune diseases. Since therapeutic regimens including azathioprine have been frequently reported in association with EMN, we recommended to our patient a treatment switch to mycophenolic acid to prevent the development of more nevi.

Regression of advanced melanoma upon withdrawal of immunosuppression: case series and literature review

We report two cases of stage IV malignant melanoma arising in patients treated with azathioprine for myasthenia gravis. In both cases, the melanoma metastases regressed upon withdrawal of immunosuppression. One patient remains melanoma free at 10 years, and the second patient experienced an 18-month disease free period. There is one prior case report in the medical literature to support full immune reconstitution for treatment in advanced immunosuppression-related melanoma, and one case series suggesting that transplant patients developing melanoma may benefit from a switch to sirolimus. Virtually, no data exist for the medical management of early stage melanoma in the immunosuppressed patients. We review the limited preclinical data in support of immune reconstitution and the data on immunosuppression as a risk factor for melanoma. We conclude that reduction or withdrawal of immunosuppression may be beneficial in patients with advanced stage melanoma and warrants further consideration in patients with early stage melanoma.

Nevos plantares múltiples posquimioterapia

The induction of multiple melanocytic nevi in children after chemotherapy has been documented in the literature. This situation apparently has more to do with the state of immunosuppression that is produced than with any specific agent used. We present the case of a 12-year-old girl who presented with multiple plantar melanocytic nevi after multidrug chemotherapy for acute lymphocytic leukemia. None of the lesions showed any alarming clinical signs. Although the degeneration of post-chemotherapy melanocytic nevi to melanoma has not been documented in any of the cases described, the presence of a high number of melanocytic nevi is an accepted risk factor for melanoma; thus, close clinical follow-up of these patients seems advisable.

Induction of eruptive benign melanocytic naevi by immune suppressive agents, including biologicals

BACKGROUND

Eruptive naevi have been described to potentially arise in immune compromised patients.

OBJECTIVES

We describe three patients with eruptive benign melanocytic naevi during a phase of immunosuppressive therapy. METHODS/DIAGNOSIS: Two patients with Crohn disease were treated with either azathioprine monotherapy or a combination of azathioprine and infliximab, when eruptive naevi arose particularly at the palms and soles. Our third patient with plaque psoriasis developed eruptive naevi during two episodes of treatment: during a course with the biological agent alefacept and during etanercept therapy.

CONCLUSIONS

We conclude that treatment with the recently available biological agents might be associated with the formation of eruptive naevi. Although positive evidence for the occurrence of malignant pigmented lesions is lacking, alertness to the development of eruptive melanocytic naevi during treatment with biological agents is indicated.