Mosaic BRAF Fusions Are a Recurrent Cause of Congenital Melanocytic Nevi Targetable by MAPK Pathway Inhibition

Among children with multiple congenital melanocytic nevi, 25% have no established genetic cause, of whom many develop a hyperproliferative and severely pruritic phenotype resistant to treatment. Gene fusions have been reported in individual cases of congenital melanocytic nevi. We studied 169 patients with congenital melanocytic nevi in this study, 38 of whom were double wild type for pathogenic NRAS/BRAF variants. Nineteen of these 38 patients had sufficient tissue to undergo RNA sequencing, which revealed mosaic BRAF fusions in 11 of 19 patients and mosaic RAF1 fusions in 1 of 19. Recurrently, fusions involved the loss of the 5´ regulatory domain of BRAF or RAF1 but preserved the kinase domain. We validated all cases and detected the fusions in two separate nevi in 5 of 12 patients, confirming clonality. The absence of the fusion in blood in 8 of 12 patients indicated mosaicism. Primary culture of BRAF-fusion nevus cells from 3 of 12 patients demonstrated highly increased MAPK activation, despite only mildly increased BRAF expression, suggesting additional mechanisms of kinase activation. Trametinib quenched MAPK hyperactivation in vitro, and treatment of two patients caused rapid improvement in bulk tissue, improving bodily movement and reducing inflammation and severe pruritus. These findings offer a genetic diagnosis to an additional group of patients and trametinib as a treatment option for the severe associated phenotypes.

Eruptive melanocytic naevi following initiation of elexacaftor/ivacaftor/tezacaftor for cystic fibrosis

A 29 year old woman with cystic fibrosis (CF) presented to CF clinic following the sudden development of over 200 pigmented naevi located predominately on the trunk and limbs 3 months after commencing elexacaftor/tezacaftor/ivacaftor, a novel triple-therapy CFTR modulator therapy for CF. Skin biopsy confirmed benign naevi and the clinical presentation was consistent with eruptive melanocytic naevi. Elexacaftor/tezacaftor/ivacaftor received marketing authorisation in August 2020 and this is the first report of associated naevi. The individual described here remains clinically well, and continues on elexacaftor/tezacaftor/ivacaftor with dermatology follow-up.

A Randomized Double-blind Placebo-controlled Trial of Oral Aspirin for Protection of Melanocytic Nevi Against UV-induced DNA Damage

DNA damage plays a role in ultraviolet (UV)-induced melanoma. We previously showed that aspirin (ASA) can suppress prostaglandin-E2 (PGE2) and protect melanocytes from UV-induced DNA damage in mice, and suggested that taking ASA before acute sun exposure may reduce melanoma risk. We conducted a prospective randomized placebo-controlled trial to determine if orally administered ASA could suppress PGE2 in plasma and nevi and protect nevi from UV-induced DNA damage. After obtaining plasma and determining the minimal erythemal dose (MED) in 95 subjects at increased risk for melanoma, they were randomized to receive a daily dose of placebo, 81 mg ASA, or 325 mg ASA, in double-blind fashion for one month. After this intervention, one nevus was irradiated (dose = 1 or 2 MED) using a solar simulator. One day later, MED was re-determined, a second plasma sample was obtained, and the UV-irradiated nevus and an unirradiated nevus were removed. ASA metabolites were detected in the second plasma sample in subjects in the ASA arms. There were no significant differences in the pre- and post-intervention MED between those patients receiving ASA and placebo. Significantly reduced PGE2 levels were detected in plasma (second vs. first samples) and in nevi (both unirradiated and UV-treated) in subjects receiving ASA compared to placebo. Comparing UV-treated nevi from the ASA and placebo cohorts, however, did not reveal significant reductions in CD3-cell infiltration or 8-oxoguanine and cyclobutane pyrimidine dimers. Thus ASA did not effectively protect nevi from solar-simulated UV-induced inflammation and DNA damage under the conditions examined. PREVENTION RELEVANCE: Despite promising rationale, ASA at conventional dosing was not able to protect nevi against UV-induced DNA damage under the conditions examined.See related Spotlight, p. 71.

Histone deacetylase inhibitor Vorinostat (SAHA) suppresses micropthalmia transcription factor expression and induces cell death in nevocytes from large/giant congenital melanocytic nevi

Large/giant congenital nevi (L/GCMN) are benign neoplasms of the melanocytic neural crest lineage covering extensive areas of skin presenting risk for melanoma. Surgical resection often leads to scarring and trauma. Histone deacetylase inhibitors (iHDACs) as topical therapeutic agents may prove beneficial as an alternative/adjunct to surgery in this disease. Here we describe the effect of in vitro treatment of iHDACs drugs on primary nevocytes isolated from L/GCMN patients. Micropthalmia transcription factor (MITF) expression in L/GCMN patients' lesions was detected by immunohistochemistry, in cultured nevocytes by immunofluorescence, immunoblot and quantitative polymerase chain reaction. Cellular senescence was detected by SA-ß galactosidase activity. Markers for melanocytic differentiation were evaluated by immunoblot analysis and extracted melanin content was estimated spectrophotometrically. Cell death was measured by lactate dehydrogenase (LDH) assay and necrosis confirmed by polymerase (PARP) cleavage and acridine orange staining of the nuclei. MITF was expressed ubiquitously in nevocytes and melanocytes in patients' lesions. In culture, iHDAC treatment suppressed MITF protein and mRNA expression resulting in a senescent-like phenotype with positive ß-galactosidase staining, progressing to necrotic cell death as evidenced by increased LDH activity, appearance of cleaved PARP and necrotic nuclei. This is the first report showing evidence of iHDACs-induced MITF suppression in congenital nevocytes in vitro leading to a morphologic change with positive ß-galactosidase staining, followed by necrotic cell death in nevocytes, indicating that iHDAC drugs could be valuable therapeutic agents for treatment of L/GCMN lesions.

DOCUMENTATION OF A NEW CHOROIDAL NEVUS

PURPOSE

To describe the occurrence of an acquired choroidal nevus in a 73-year-old white man.

METHODS

Case report.

RESULTS

A 73-year-old white man was referred for an evaluation and treatment of macular changes in his left eye consistent with pachychoroid neovasculopathy. Baseline funduscopic examination and color fundus photographs showed two small peripheral choroidal nevi in the right eye and a single small choroidal nevus in the far temporal macula of the left eye. Treatment with intravitreal aflibercept was initiated in the left eye on a treat-and-extend dosing regimen. Approximately 1 year later, a new pigmented choroidal lesion was detected in the left macula in an area where previous high-resolution color fundus photographs had shown no abnormal pigmentation. Swept-source optical coherence tomography of the new pigmented lesion showed flat hyperreflectivity within the inner choroid consistent with a small choroidal nevus. The patient was referred to his internist who found no evidence of an occult malignancy. Over the course of more than 4 additional years of continuous follow-up, the new choroidal nevus remained stable, no new fundus abnormalities were detected in either eye, and the patient remained medically stable.

CONCLUSION

To the best of our knowledge, this is the first documented case of a new choroidal nevus. Multimodal imaging performed before lesion detection and over the ensuing 4 years showed its stability, thus allowing for the conclusion that it was a benign choroidal nevus rather than a neoplastic or paraneoplastic process.

Cutaneous skeletal hypophosphatemia syndrome (CSHS) is a multilineage somatic mosaic RASopathy

BACKGROUND

We recently demonstrated multilineage somatic mosaicism in cutaneous skeletal hypophosphatemia syndrome (CSHS), which features epidermal or melanocytic nevi, elevated fibroblast growth factor (FGF)-23, and hypophosphatemia, finding identical RAS mutations in affected skin and bone.

OBJECTIVE

We sought to: (1) provide an updated overview of CSHS; (2) review its pathobiology; (3) present a new patient with CSHS; and (4) discuss treatment modalities.

METHODS

We searched PubMed for "nevus AND rickets," and "nevus AND hypophosphatemia," identifying cases of nevi with hypophosphatemic rickets or elevated serum FGF-23. For our additional patient with CSHS, we performed histopathologic and radiographic surveys of skin and skeletal lesions, respectively. Sequencing was performed for HRAS, KRAS, and NRAS to determine causative mutations.

RESULTS

Our new case harbored somatic activating HRAS p.G13 R mutation in affected tissue, consistent with previous findings. Although the mechanism of FGF-23 dysregulation is unknown in CSHS, interaction between FGF and MAPK pathways may provide insight into pathobiology. Anti-FGF-23 antibody KRN-23 may be useful in managing CSHS.

LIMITATIONS

Multilineage RAS mutation in CSHS was recently identified; further studies on mechanism are unavailable.

CONCLUSION

Patients with nevi in association with skeletal disease should be evaluated for serum phosphate and FGF-23. Further studies investigating the role of RAS in FGF-23 regulation are needed.

Spectral-Domain Optical Coherence Tomography of Polypoidal Choroidal Vasculopathy Associated With Benign Choroidal Nevus

Two cases of polypoidal choroidal vasculopathy (PCV) complicating benign choroidal nevus and their tomographic features at spectral-domain optical coherence tomography (SD-OCT) are reported. Two eyes with choroidal nevus and associated subretinal fluid underwent complete ophthalmological examination, SD-OCT, fundus fluorescein angiography, and indocyanine green angiography (ICGA). SD-OCT and ICGA confirmed the diagnosis of PCV in both cases. Ophthalmologists should be aware of this rare combination between choroidal nevus and PCV. If a choroidal nevus presents with subretinal fluid, this does not always herald malignant transformation, and PCV should be ruled out so that the correct treatment can be planned.

Evolution of melanocytic nevi under vemurafenib, followed by combination therapy with dabrafenib and trametinib for metastatic melanoma

Treatment of advanced melanoma with selective BRAF and MEK inhibitors is associated with a series of mucocutaneous side effects, among which morphological changes in preexisting nevi and the development of new melanocytic lesions, both benign and malignant. Objective was to describe the changes observed in melanocytic nevi under vemurafenib therapy, followed by combination therapy with dabrafenib and trametinib for metastatic melanoma. The melanocytic lesions of a 51-year-old Caucasian male patient diagnosed with stage IV melanoma were monitored both clinically and dermoscopically throughout vemurafenib, followed by combined treatment with dabrafenib and trametinib. The 65 monitored nevi presented different behaviors under vemurafenib treatment: 18 reticular nevi, 9 reticular-homogenous nevi, 3 reticular-globular nevi, and 2 globular nevi showed a diffuse decrease in pigmentation. Ten reticular nevi remained unchanged, while the rest of the nevi, independent of the dermoscopic pattern, presented a gradual increase in pigmentation. On the other hand, under dabrafenib and trametinib treatment 57 of these nevi showed gradual decrease in pigmentation and central involution, while 7 reticular nevi and 1 globular nevus remained unchanged; none of the monitored nevi increased in pigmentation nor presented new globules following this combination therapy. Systematic total body skin examination is mandatory in patients receiving BRAF inhibitors. The divergent course of melanocytic nevi during vemurafenib vs. dabrafenib and trametinib therapy remains to be elucidated by further research.

[Optic nerve melanocytoma--associated with age related macular degeneration]

We report the case of a 73 year old patient who presented for decreased vision in his right eye, ocular examination revealed a pigmented tumour in the left optic disc (optic nerve melanocytoma). We briefly mention another case of optic nerve melanocytoma in a 6 year old, Caucasian patient.

Changes in the dermoscopic appearance of melanocytic naevi after photochemotherapy or narrow-band ultraviolet B phototherapy

BACKGROUND

Although phototherapeutic modalities are commonly used for the treatment of skin diseases, the effects of therapeutic ultraviolet (UV) irradiation on the dermoscopic appearance of melanocytic naevi are unknown.

OBJECTIVES

We aimed to analyse the effects of photochemotherapy (psoralen plus ultraviolet A, PUVA) and narrow-band ultraviolet B phototherapy (NB-UVB) on the dermoscopic appearance of naevi.

PATIENTS AND METHODS

We monitored 187 melanocytic naevi of 38 patients receiving NB-UVB or PUVA treatment for miscellaneous skin diseases. Dermoscopic images of naevi were taken before, shortly after, and after a median of 31 weeks after the UV therapy. A random selection of naevi was covered during UV treatment, the others remained uncovered. Baseline and follow-up images of naevi were viewed side by side on a computer screen to compare size, pigmentation, and dermoscopic structure of naevi.

RESULTS

Twenty-one patients received NB-UVB treatment, and 17 patients received PUVA treatment. Of 187 naevi, 70 (37%) were covered and 117 (63%) were uncovered during UV treatment. When NB-UVB- and PUVA-treated patients were analysed together, an increase in size of uncovered lesions was seen in both treatment groups. Pigmentation appeared darker at the end of UV treatment in 67.5% (n=79) of uncovered naevi compared with 41.4% (n=29) of covered naevi (P<0.001). In patients receiving NB-UVB therapy, a significant increase in the number of dots or globules in 20.3% (n=14) of uncovered naevi compared with only 5.0% (n=2) of covered naevi (P=0.03) was found. This effect was not observed after PUVA therapy. With the exception of four naevi with continuous enlargement and seven naevi with a persisting increase in dots and globules, the observed changes were reversible. All naevi with persistent changes belonged to the NB-UVB group.

CONCLUSION

In general, PUVA and NB-UVB therapy cause reversible dermoscopic changes in melanocytic naevi. Increase in dots and globules is more frequent with NB-UVB.

Effect of Neonatal Phototherapy on Melanocytic Nevus Count in Children

BACKGROUND

Melanocytic nevus is the strongest risk factor for the development of cutaneous melanoma. Fair skin and exposure to UV light, especially in childhood, are correlated with the development of childhood nevi.

OBJECTIVE

To assess the role of blue light neonatal phototherapy used to treat hyperbilirubinemia in nevus acquisition in childhood.

DESIGN

Case-control prospective study.

SETTING

University hospital.

PARTICIPANTS

Fifty-eight children were included in this study. Selection criteria included the following: age, 8 to 9 years; and skin type, less than IV by Fitzpatrick classification (ie, brown, always tans, rarely burns). The case group consisted of 18 children exposed to neonatal phototherapy (mostly intensive phototherapy) retrospectively found by review of consecutive neonatal medical records at Saint-Antoine Hospital, Paris, France. The control group was composed of 40 nonexposed children consecutively recruited from a public school in the same geographic area.

MAIN OUTCOME MEASURES

Total body nevus count in children, phenotypic characteristics, solar exposure, and demographic data were assessed by the same dermatologist.

RESULTS

A comparison of both groups showed that the number of nevi larger than 2 mm was significantly higher in the exposed group. The mean (SD) nevus count was 3.5 (3.05; median, 3.0) per child in the exposed group, compared with 1.45 (1.99; median, 1.0) per child in the nonexposed group (P(mean) = .02 and P(median) = .01). Multivariate analysis confirmed these results, with a statistically significant correlation with nevus count, especially with nevi 2 to 5 mm in greatest diameter. The association between neonatal phototherapy and nevus count was not significant for nevi smaller than 2 mm or larger than 5 mm. Solar exposure, especially during vacations, was strongly associated with total nevus count and all nevus sizes (2-5 mm, <2 mm, and >5 mm). At univariate analysis, hair color was significantly associated with nevus size smaller than 2 mm (P(mean) = .03).

CONCLUSIONS

Intensive neonatal phototherapy is a strong risk factor for nevus development in childhood. While childhood development of nevi is correlated with fair skin and solar light exposure, and having many nevi is a recognized risk factor in persons with melanoma, we must be careful not to equate childhood nevi development in response to neonatal phototherapy with an individual's risk of developing melanoma. The treatment of hyperbilirubinemia remains neonatal phototherapy. Exposed children should undergo dermatologic preventive measures and surveillance for the development of melanoma.

VARIABLE OUTCOME OF PHOTODYNAMIC THERAPY FOR CHOROIDAL NEOVASCULARIZATION ASSOCIATED WITH CHOROIDAL NEVUS

PURPOSE

To report five cases of classic choroidal neovascularization (CNV) associated with choroidal nevus treated with photodynamic therapy (PDT) with verteporfin.

METHODS

The patients underwent an ophthalmologic evaluation, including fluorescein angiography and indocyanine green angiography. Clinical and angiographic data were retrospectively analyzed to evaluate visual acuity outcomes and both clinical evolution and angiographic evolution.

RESULTS

Two patients presented with subfoveal CNV, and three had juxtafoveal CNV. The mean follow-up was 25.8 months. Visual outcomes were extremely variable. Indeed, best-corrected visual acuity decreased in three eyes, stabilized in one case, and improved in the other case. The number of PDT sessions necessary to obtain CNV stabilization with cessation of fluorescein leakage varied from one to six.

CONCLUSION

Bearing in mind that both the natural history and the post-PDT outcome may be extremely variable, further studies are needed to assess the real benefit of PDT for classic CNV secondary to choroidal nevus.

Elevated fibroblast growth factor-23 in hypophosphatemic linear nevus sebaceous syndrome

We report on an adolescent who experienced the onset of linear nevus sebaceous syndrome (LNSS) prior to 1 year of age. At 7 years of age he was diagnosed to have hypophosphatemic rickets. He was suboptimally controlled with phosphate and calcitriol treatment and sustained numerous insufficiency fractures ipsilateral to the linear sebaceous nevus. Fibroblast growth factor-23 (FGF-23), the phosphaturic peptide, was elevated in the plasma. Treamtent with the somatostatin agonist, octreotide, and excision of the nevus were followed by normalization of FGF-23 and clinical improvement. The patient also had hyperimmunoglobulinemia E, which responded to octreotide and surgery. We speculate that in some patients with LNSS there may be more than one mediator of hypophosphatemia and that FGF-23 is the mediator of hyperphosphaturia in this and other hypophosphatemic syndromes.

Treatment of Nevus comedonicus with topical tazarotene and calcipotriene

Nevus comedonicus is a rare developmental defect of the pilosebaceous unit. It is also thought to be a variant of epidermal nevus. Previously reported treatments include surgical excision, CO2 laser, dermabrasion, extraction, topical retinoic acid, and numerous topical keratolytics. We present a case of a 7-year-old boy with bilateral nevus comedonicus who experienced cosmetic improvement with topical tazarotene and calcipotriene cream. This combination represents a novel therapeutic approach to the treatment of this cutaneous abnormality.

Influence of PUVA therapy on dermoscopic features of acquired melanocytic nevi

The aim of the present study was to investigate whether PUVA therapy can induce changes in the dermoscopic image of acquired melanocytic nevi. In this study, 28 acquired melanocytic nevi of 14 patients undergoing PUVA therapy were examined. Two nevi of morphologically similar features were selected in each patient. During UVA radiation, 14 nevi were protected from UVA exposure and 14 nevi were left unprotected. Before and after 3 months of PUVA therapy, all nevi were documented under standardized conditions by means of a Dermaphot apparatus. Color dermoscopic images of all nevi were examined by two investigators for size, color and structural features (pigment network-streaks, brown globules, black dots). After PUVA therapy, an increase in size (p < 0.05 in protected nevi and p < 0.01 in unprotected nevi) and a general color darkening (p < 0.01 for both groups) were documented in both groups. While significant structural changes (broadness of pigment network, formation of focal branched streaks, increasing in number and size of brown globules) were detected in unprotected nevi (p < 0.05), no significant changes were in protected nevi (p > 0.05).

Melanin bleaching in argyrophilic staining of AgNORs in pigmented lesions: a morphometric evaluation

OBJECTIVE

To establish a procedure that can effectively bleach melanin from pigmented lesions without affecting quantification of argyrophilic staining of nucleolar organizer regions (AgNORs).

STUDY DESIGN

Twenty banal compound nevi, five from each of nonpigmented, slightly pigmented, moderately pigmented and heavily pigmented groups, were bleached by 10% H202 for periods of 0 (nonbleached controls) and 24 hours. AgNOR size and count parameters of nevomelanocytic nuclei were measured by video image analysis. Melanin bleaching using KMnO4 was also investigated.

RESULTS

In all lesions treated with 10% H202 for 24 hours, the melanin was bleached effectively, with no qualitative change in AgNOR appearance. There were no significant differences in mean AgNOR number per nucleus (AgNOR number), mean individual AgNOR size (AgNOR size) or mean percentage of AgNOR area per nucleus (% nuclear area) between nonbleached and bleached sets in both the nonpigmented and slightly pigmented groups. However, disintegration of AgNOR dots was observed in those treated with 1% KMnO4 for 5, 10 and 15 minutes. There were significant decreases in AgNOR size (P = .002) and % nuclear area (P = .003) and increase in AgNOR number (P = .05) in the slightly pigmented group evaluated when treated with 1% KMnO4 for five minutes.

CONCLUSION

Melanin in pigmented lesions can be bleached effectively with an H202 procedure without significantly affecting AgNOR staining properties in contrast to bleaching with KMnO4.

Nevoid hyperkeratosis of the nipple and areola: treatment of two patients with topical calcipotriol

Nevoid hyperkeratosis of the nipple and areola, which is characterized by verrucous thickening and pigmentation of the nipple or areola, is a rare condition. Different therapeutic options have been used with varying results, but there is no uniformly effective treatment. We describe two patients with hyperkeratosis of the nipple and areola who responded well to topical calcipotriol ointment.

[A case of Cogan-Reese syndrome (iris nevus syndrome)]

A case of 37 years old woman with a classic form of Cogan-Reese iris naevus syndrome is presented. Closure angle glaucoma, being a part of syndrome, with glaucomatous disc damage was initially treated with drugs (betaxolol, trusopt) without effective IOP decrease. A surgery was performed (goniotrepanatio by Fronimopoulos modified by Palmberg, but without iridectomy), 5 fluorouracil subconjunctival injections were given to the patient postoperatively for 5 days. We received a good IOP control on the level of 12 mm Hg. The visual acuity was 1.0 after surgical procedure. We wanted to present this case because of its rarity and a typical surgical procedure (without applying iridectomy).

Disseminated eruptive nevocellular nevi

A 13-year-old boy suddenly developed about 2,000 dark brown to black colored papules on his face and neck and about 500 lesions on his trunk and upper extremities during a six month period. Histopathologic features were compatible with junctional nevus. The results of alpha melanocyte stimulating hormone (MSH), proliferating cell nuclear antigen (PCNA), and epidermal growth factor receptor (EGF/R) studies are presented. To the best of our knowledge, this report represents an outbreak of the highest number of nevocellular nevi in a short period without any malignant nature or evident triggering factor.

Risk of melanoma after treatment of pigmented lesions with Solcoderm

A 40-year-old patient developed a 5-mm-deep melanoma from a lesion on her chest which had been treated with Solcoderm 10 years previously. We recently described 3 other cases of melanoma that evolved in a lesion treated by Solcoderm. Much debate surrounds the recommendation as to the appropriate method for treatment of pigmented lesions when the removal is indicated for cosmetic reasons only. Most of the authors agree that any pigmented lesion which merits excision merits submission for histological examination. The aim of the present report was to express a warning regarding what we think is an inappropriate and hazardous method of treating pigmented lesions, namely their chemical destruction with Solcoderm. In view of the reported cases of melanoma evolving in lesions treated previously with Solcoderm, we believe that this treatment is absolutely contraindicated for pigmented lesions.

Apparent progression of lentigo maligna to invasive melanoma during treatment with topical azelaic acid

Nine patients with lentigo maligna were treated with topical azelaic acid. Clinical improvement was observed in four, with complete clearing in one. Two patients developed invasive lentigo maligna melanoma while on treatment. Caution should be exercised in the use of topical azelaic acid in the treatment of lentigo maligna.

Inflammatory linear verrucous epidermal nevus: report of seven new cases and review of the literature

In seven patients with inflammatory linear verrucous epithelial nevus (ILVEN) examined, the condition demonstrated the typical clinical and histologic picture. Based on this experience, we suggest revised criteria for the disease. Dermatologists and pediatricians aware of ILVEN can easily differentiate it from similar lesions and thus be able to suggest effective therapy.

Oral retinoid (Tigason R etretinate) therapy in congenital disorders of keratinisation

We report our experience in Singapore with the use of the new oral Retinoid-etretinate (Tigason RO 10-9359) in 23 patients suffering from various congenital disorders of keratinisation. In this study the drug was administered to 8 patients with Darier's disease, 7 patients with congenital ichthyosis, 4 patients with palmar plantar keratoderma, 2 patients with systematised epidermal naevus and 2 patients with progressive symmetrical erythrokeratoderma. The best results were obtained in patients with ichthyosis where complete clearance was possible. All patients with Darier's except one showed significant improvement. Palmar plantar keratoderma except for one patient gave only fair to minimal improvement. Etretinate was useful in systematised epidermal naevus and progressive symmetrical erythrokeratoderma. Pruritus and cheilitis were the commonest side effect. In two patients (both with Darier's disease) treatment was stopped because of side effects. The side effects were dose related. The histology showed a reduction of the keratin layer but remnants of the original features of the pathology were still present.

Proprietary depigmenting cream used wrongly for lentigo maligna

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Topical chemotherapy of dysplastic melanocytic nevi with 5% fluorouracil

A therapeutic response to topical fluorouracil in a patient with the large atypical nevus syndrome is presented. Six of the patients' dysplastic melanocytic nevi were treated with topical fluorouracil. Four common acquired melanocytic nevi from normal individuals were also treated. All six dysplastic nevi responded with inflammation, ulceration, and subsequent disappearance of the lesion, while the four control melanocytic nevi remained unchanged. Although we do not presently advocate the therapeutic use of fluorouracil for large atypical nevi until its safety and efficacy have been established, the response reported herein may herald an important advance in the therapy of these troublesome lesions that are known to be histogenetic precursors of malignant melanoma.

Effect of dicarboxylic acids on lentigo maligna

Dicarboxylic acids from C8 to C14 are competitive inhibitors of tyrosinase in vitro, and here, the effect of a cream containing 15% azelaic acid (C9) on 3 cases of lentigo maligna is described. The lesions were treated for 90 days, with remarkable clinical and histological effect, maintained for up to 2 yr after cessation of treatment. Progress during treatment of one case was additionally monitored by electron microscopy, which revealed progressive elimination of abnormal melanocytes both basally and suprabasally, and their replacement by essentially normal cells engaged in normal melanogenesis. There was also progressive diminution in the general disorganization of the epidermis, and disappearance of lymphocyte response. It is concluded that dicarboxylic acids have a direct inhibitory and cytotoxic effect on abnormally active or structurally disordered melanocytes in lentigo maligna, but further investigations are required to establish their precise mode of action. Similar application of dicarboxylic acids to normal skin affects only a small proportion of melanocytes, suggesting that some phasic factor, or individual states of activity, may be concerned in their susceptibility.

Chemosurgery for familial malignant melanomas

Three patients with numerous melanomatous lesions of the B-K mole syndrome are reported who were the first to be treated chemosurgically. The fixed-tissue chemosurgical technique provided a microscopically controlled, safe, effective, and conservative means of removing the melanomas. Atypical moles suspected of malignant change were removed by biopsy-excision.

Inflammatory linear verrucose epidermal nevus

A typical case of inflammatory linear verrucose epidermal nevus (ILVEN), with quite a psoriasiform histologic pattern, is reported. Intralesionally administered paramethasone acetate caused a temporary suppression of the clinical and histopathologic inflammatory features. The concept of ILVEN is briefly discussed.