Topical trametinib for epidermal and sebaceous nevi in a child with Schimmelpenning-Feuerstein-Mims syndrome

We present the case of a 20-month-old girl with Schimmelpenning-Feuerstein-Mims (SFM) syndrome with extensive head, neck, and torso skin involvement successfully managed with topical trametinib. Trametinib interferes downstream of KRAS and HRAS in the MAPK signaling pathway, of which KRAS was implicated in our child's pathogenic variant. Although other dermatologic conditions have shown benefit from oral trametinib, its topical use has not been well reported. Our patient showed benefit from the use of twice-daily topical trametinib, applied to the epidermal and sebaceous nevi over a 16-month period, leading to decreased pruritus and thinning of the plaques.

Improvement of Unilateral Breast Hypoplasia With Oral Spironolactone in a Patient With Becker Nevus Syndrome

Becker nevus (BN) is a benign cutaneous smooth muscle hamartoma that presents with a hyperpigmented patch or plaque with or without hypertrichosis.1 BN may be associated with ipsilateral breast hypoplasia or other musculoskeletal abnormalities, an association which has been termed Becker nevus syndrome (BNS).

Regression of nevi, vitiligo-like depigmentation and halo phenomenon may indicate response to immunotherapy and targeted therapy in melanoma

We present two patients with stage IV melanoma, the first with BRAF wild-type melanoma with multiple visceral metastases treated with immunotherapy (pembrolizumab) and the second with BRAFV600E melanoma with subcutaneous and lymph nodes metastasis treated with BRAF and MEK-inhibitors (dabrafenib/trametinib). Already after the second cycle of immunotherapy, the first patient developed a diffuse regression of nevi, perceptible only with the use of dermoscopy and 3 months later a clinically evident poliosis of the eyebrows. The second patient, treated with dabrafenib/trametinib, developed small areas of leukoderma on his chest and white halos around nevi with a dermoscopic globular or structureless pattern. Both observations are suggestive for an immune reaction against melanocytic cells, which is further supported by the complete response to systemic therapy in both patients. It has been demonstrated that the development of vitiligo-like depigmentation during immunotherapy is associated with a better prognosis; in our patient, the phenomenon of poliosis appeared much later than the dermoscopic presence of regression among his nevi, suggesting that the latter may be an early sign (along with vitiligo-like phenomena) of good response to immunotherapy. On the other hand, the development of halo nevi and leukoderma during treatment with BRAF/MEK-inhibitors, suggests that not only immunotherapy but also targeted therapy may induce an immunologic response against melanoma and nevi, again indicative of a favorable prognosis. More data are needed to confirm these findings; however, they indicate that dermatologists should be involved in the follow-up of patients with melanoma, both in studies and clinical practice.

Infantile hemangioma. Part 2: Management

The majority of infantile hemangiomas (IH) can be managed conservatively, but for those requiring active treatment, management has been revolutionized in the last decade by the discovery of propranolol. Patients that may require active intervention should receive specialist review, ideally before 5 weeks of age to mitigate the risk of sequelae. Propranolol can commence for most infants in the outpatient setting and the most frequently employed dosing regimen is 1 mg/kg twice daily. In the future, β-blockers with a more-selective mechanism of action, such as atenolol, show some promise. In recalcitrant lesions, systemic corticosteroids or sirolimus may be considered. For small, superficial IHs, topical timolol maleate or pulsed dye laser may be considered. Where the IH involutes with cutaneous sequelae, a range of interventions have been reported, including surgery, laser, and embolization. IHs have a well-described clinical trajectory and are readily diagnosed and managed via telemedicine. Algorithms have been constructed to stratify those patients who can be managed remotely from those who warrant in-person review during the COVID-19 pandemic.

Intravitreal bevacizumab associated with photodynamic therapy in a case of polypoidal choroidal vasculopathy associated with choroidal nevus: A case report

RATIONALE

Report the clinical findings and management of a case of polypoidal choroidal vasculopathy associated with choroidal nevus which received combination therapy.

PATIENT CONCERNS

Decreased visual acuity in a woman with polypoidal choroidal vasculopathy and choroidal nevus.

DIAGNOSES

Polypoidal choroidal vasculopathy and choroidal nevus.

INTERVENTIONS

The initial visual acuity was 0.5. After the first treatment with photodynamic therapy, exudation and bleeding appeared around the lesion. After this, the patient received 3 doses of intravitreal bevacizumab.

OUTCOMES

After treatment with combination therapy, visual acuity, clinical and imaging findings improved, with no recurrence of exudation and bleeding.

LESSONS

Intravitreal bevacizumab as an adjunctive treatment after photodynamic therapy is a good option for patients with polypoidal choroidal vasculopathy associated with choroidal nevus.

ILVEN - COMPLETE REMISSION AFTER ADMINISTRATION OF TOPICAL CORTICOSTEROID (CASE REVIEW)

Inflammatory linear verrucous epidermal nevus (ILVEN) is a relatively rare disorder with an onset at early age, consisting of pruritic linear papules and/or plaques and histologic features resembling psoriasis or lichenoid dermatitis. The disease is a version of mosaicism caused by somatic mutations. ILVEN belongs to the heterogeneous group of congenital hamartomas of embryonal ectodermal origin, as a variant of verrucous epidermal nevus, representing approximately 5% of all epidermal nevi, with predominance in females and with general therapeutic resistance. We report on an 18-month-old female patient with ILVEN, who failed to respond to topical tacrolimus, but achieved complete resolution with topical application of momethasone furoate 0.1% under occlusion for 2 weeks, with no signs of recurrence to date. Consequent topical therapy can provide excellent results in young children.

Successful Treatment of Inflammatory Linear Verrucous Epidermal Nevus with Tacrolimus and Fluocinonide

Background:

Inflammatory linear verrucous epidermal nevus (ILVEN) is a relatively rare disorder that is characterized by an early age at onset; severely pruritic linear papules and plaques; histologic features resembling spongiotic dermatitis, psoriasis, or lichenified dermatitis; and poor response to treatment.

Objective:

To report the successful treatment of ILVEN with potent topical steroid and tacrolimus ointments.

Methods:

An 11-year-old girl presented with a 1-year history of markedly pruritic, progressive linear eruption that extended from the right foot to the right buttock. She had failed treatment with pimecrolimus, calcipotriol, mometasone furoate, triamcinolone, tazarotene, and alpha-hydroxy acid. Histologic examination revealed the findings of spongiotic dermatitis.

Results:

The lesions resolved with fluocinonide ointment and tacrolimus 0.1% ointment.

Conclusion:

The combination of two therapeutic agents with different mechanisms of action likely resulted in the successful treatment of this usually resistant condition.

From mole to scar: the unintended consequence of treatment with an over-the-counter mole removal cream

A 26-year-old man presented with a scar at the site of a pigmented lesion treated with DermaTend (Solace Interntational, Inc., Reno, NV), an over-the-counter mole removal cream. According to the patient, the pigmented lesion had been present since childhood, was asymptomatic, and had not changed in appearance. It remained cosmetically displeasing to him. In an effort to remove the lesion, he had applied DermaTend on a daily basis for several weeks, at which point he noticed a scar at the site of treatment.

Keratoacanthoma arising in nevus comedonicus

Nevus comedonicus is a benign hamartoma of the pilosebaceous unit and is considered as a rare subtype of epidermal nevus. It was first described in 1895. It manifests as a group of closely dilated follicular openings with dark keratin plugs resembling comedones. Malignant degeneration of a nevus comedonicus is exceptional; we report a case of keratoacanthoma arising in extensive nevus comedonicus.

[Cerebellopontine angle meningeal melanocytoma: a benign tumor?]

We report a case of a rare meningeal melanocytoma in the cerebellopontine angle. One year after tumor gross total removal, the patient suffered a sudden and devastating meningeal melanomatosis. The relevant literature is reviewed looking for the keys to establish preoperative diagnosis and to obtain information about its treatment and postsurgical management.

Naevus comedonicus: a spectrum of body involvement

Naevus comedonicus (NC) is a rare developmental anomaly, with < 200 cases reported in the literature. It usually occurs on the face, neck or chest, appearing as groups of closely arranged dilated follicular openings with keratin plugs. Several associations have been made in the literature. We review the current literature, emphasizing the clinical features, associated conditions and therapeutic options.

Treatment of atypical nevi with imiquimod 5% cream

BACKGROUND

5% Imiquimod cream is a topical immune response modifier that has been used off-label to treat malignant melanocytic proliferations such as lentigo maligna. To our knowledge, imiquimod has not been previously used to treat atypical nevi (AN).

OBSERVATIONS

Three patients each with 1 selected clinically AN were treated with imiquimod 5 nights per week for 12 weeks. The lesions were subsequently excised and sent for routine histologic and immunohistochemical analysis. None of the lesions cleared. Two were consistent with atypical compound nevus on excisional biopsy and demonstrated inflammation, while the third showed congenital features and demonstrated minimal inflammation. The AN were initially interpreted as displaying more severe histologic atypia on excisional biopsy than was present at baseline. Immunohistochemical studies revealed that the AN but not the congenital-like nevus exhibited increased staining for CD4(+) and CD8(+) cells and for a surrogate marker of interferon alpha expression.

CONCLUSIONS

Twelve weeks of imiquimod treatment failed to cause lesional resolution. A differential inflammatory response was observed between the AN and the congenital-like nevus. The character of the inflammatory infiltrate was similar to that observed with halo nevi. Uncertainties remain concerning imiquimod use for chemoprevention of AN, and the posttreatment histologic features may be misinterpreted as severe melanocytic atypia or melanoma.

Management of symptomatic choroidal naevi with photodynamic therapy

BACKGROUND/AIMS

To describe the use of photodynamic therapy (PDT) in the management of symptomatic serous retinal detachment associated with choroidal naevi.

METHODS

Interventional case series. The records of seven patients with choroidal naevus and associated serous retinal detachment, treated with PDT were reviewed retrospectively. Main outcome measures were Snellen visual acuity, clinical appearance, and ocular tomographic findings.

RESULTS

All seven patients showed a reduction in the degree of serous detachment and symptomatic improvement. Five patients showed a corresponding improvement in visual acuity that persisted over a mean period of 9 months.

CONCLUSION

PDT appears to be effective in the management of serous retinal detachment associated with choroidal naevus.

Unilateral nevoid hyperkeratosis of the nipple: a report of two cases

Nevoid hyperkeratosis of the nipple and areola is an unusual condition. Two female patients aged 31 and 18 years presented with chronic unilateral warty lesions of the nipple. One patient had difficulty in breastfeeding from the affected side. A skin biopsy showed acanthosis, hyperkeratosis, papillomatosis and lymphocytic infiltrate in the dermis. There was no significant improvement with topical tretinoin cream in both the patients.

Nevus anelasticus, papular elastorrhexis, and eruptive collagenoma: clinically similar entities with focal absence of elastic fibers in childhood

Focal absence of elastic fibers is a defining characteristic of three rare, clinically similar conditions: nevus anelasticus, papular elastorrhexis, and eruptive collagenoma. We present a 16-year-old with nevus anelasticus treated with intralesional steroid injections, resulting in erythematous atrophic depressions. We also review the English language literature on nevus anelasticus, papular elastorrhexis, and eruptive collagenoma. There may be sufficient clinical and histopathologic similarity to indicate that these three entities represent a single disease or disease spectrum. We believe that this entity should be referred to as papular elastorrhexis.

Linear naevoid psoriasis along lines of Blaschko

Congenital linear naevoid psoriasis along Blaschko's lines on the thigh of a 3-year-old girl is reported. The history of asymptomatic, erythematous scaly lesions since birth, the peculiar distribution and the histopathology confirmed the diagnosis.

A case of porokeratotic eccrine ostial and dermal duct naevus of late onset

We describe the case of a 21-year-old man with an 8-year history of porokeratotic eccrine ostial and dermal duct naevus (PEODDN) of late onset. The patient had pruritic, keratotic papules on the dorsal surface of his left hand, bilaterally on his palms and multiple yellowish lesions on the plantar surface of his feet. On histopathological examination cornoid lamella-like parakeratotic columns above eccrine sweat ducts were observed. The acrosyringium was also dilated. The lesions were refractory to treatment with salicylic acid in petrolatum and acitretin for 2 months. This entity should be taken into consideration in the differential diagnosis of linear keratotic cutaneous eruptions.

Aggressive management of orbital meningeal melanocytoma

OBJECTIVE

Meningeal melanocytoma generally occurs in the posterior fossa. Orbital manifestation is rarely encountered.

METHODS

A thirty-five year-old man presented with progressive proptosis of his right eye. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) of the brain showed an expansive intraconal mass lesion occupying the superior orbital compartment, the entire orbital apex, and the optic foramen. Histological analysis and Immunohistochemical staining for S-100 and HMB-45 monoclonal antibodies confirmed melanocytoma.

FINDINGS

Microsurgical removal was accomplished through a fronto-orbital craniotomy. Chemotherapy and irradiation followed the initial intervention. The patient returned for follow up two years after surgery, complaining of headache and right visual loss. A subfrontal tumor with massive edema was found on follow up CT scan.

INTERPRETATION

Meningeal melanocytomas are rare benign pigmented tumors of the central nervous system. They are predominant in the posterior fossa and spinal cord and frequently mistaken for melanomas, especially on frozen sections. Orbital presentation is rare. The natural history is poorly defined.

Adult onset of inflammatory linear verrucous epidermal nevus

Adult onset of inflammatory linear verrucous epidermal nevus (ILVEN) is reported in a 44-year-old Japanese man. A mild pruritic eruption appeared one year earlier and extended from the left dorsal foot to the gluteal region. Histologically, acanthosis and papillomatous thickening of epidermis as well as spongiotic edema and exocytosis with lymphocytes and neutrophils were observed. Topical tacalcitol was not effective, but the pruritus as well as the eruption slightly improved with topical corticosteroid and vaseline containing salicylic acid. This adult onset of ILVEN is considered to be a rare case.

Unusual giant comedo naevus

Comedo naevi are usually well circumscribed, and although extensive cases have been reported individual lesions crossing the midline are rare. Associated neurological, skeletal and ophthalmological abnormalities are also recognized. thus, the patient now reported is unusual in that she had an extensive systematized comedo naevus with crossing of the midline but no associated abnormalities. Topical tretinoin was helpful in improving the texture and appearance of the comedones, and various larger lesions responded to curettage.

Effect of topical tretinoin under occlusion on atypical naevi

Atypical naevi are potential precursors of melanoma and markers of increased melanoma risk. To examine the possibility of chemoprevention of melanoma by retinoids, we studied the effect of topical tretinoin 0.1% (all-transretinoic acid; vitamin A acid) and tretinoin 0.1% with hydrocortisone on atypical naevi. Thirty patients with atypical naevi were enrolled in a prospective randomized double blind study. For each patient three comparable naevi were selected and randomized to receive tretinoin 0.1% (T), tretinoin 0.1% with hydrocortisone 1% (C) or a placebo cream (P) once a week under Actiderm occlusion for 4 months. Baseline views of the naevi, taken with a videomicroscope (magnification 20 x), were assessed for morphological changes compared with views taken 2 months after the beginning of treatment, 1 week after completion of treatment and 6 months later. After completion of the study all naevi in the T and C groups and six naevi in the P group were removed and evaluated histologically for the presence of atypia. The number of naevi that had changed in colour or size was significantly higher in the T and C groups compared with the placebo group. A size reduction took place in 42.9% (T) and 40.0% (C) of the naevi and the colour changed in 75.0% (T) and 66.7% (C). The effect of treatment, in general subtle, did not differ significantly between groups T and C, but naevi treated with C became significantly less irritated. Histologically, 75.0% of the naevi treated with T and 69.6% of the naevi treated with C were atypical. Therefore, no major change was seen in the clinical aspect of atypical naevi after treatment with tretinoin 0.1% or tretinoin with hydrocortisone 1%, and most of the treated naevi still met the histological criteria for atypia after the treatment period. The current management of follow-up of atypical naevi and excision when change to melanoma is suspected is therefore still recommended. Nevertheless, some response was seen, which may justify a further exploration of tretinoin and hydrocortisone 1% therapy for a longer treatment period in combination with research to clarify its mechanism.

Inflammatory nevus comedonicus in children

More than 100 years has passed since the first report of a nevus comedonicus. The earliest reports emphasized the inflammatory aspect of the nevus comedonicus as being the most significant problem. In the past 30 years, publications have ignored the inflammatory aspect of nevus comedonicus while emphasizing a variety of associated malformations. In this review, we describe five prepubertal children with prominent and persistent inflammatory changes limited to areas within a nevus comedonicus. In our experience, inflammation can be severe and resistant to treatment. Ultimately, surgical removal of the involved skin was required in two children.

Diffuse whitening of the oral mucosa in a child

We report a healthy 16-year-old Caucasian boy, who consulted us for white, asymptomatic lesions in the mouth. The lesions were stable and had been present for 6 years. On physical examination, there were diffuse white, soft, corrugated plaques involving the buccal and labial mucosa, oral commissures, and floor of the mouth. No other mucosae were affected and there were no skin or nail abnormalities. The histologic findings revealed epidermal hyperplasia with parakeratosis and intracellular edema in the squamous cell layer. No nuclear atypia was observed. A differential diagnosis of three entities is proposed: white sponge nevus, leukoedema, and focal epithelial hyperplasia.

Membrane transport proteins associated with drug resistance expressed in human melanoma

Melanoma cells often display a multidrug-resistant phenotype, but the mechanisms involved are largely unknown. We have studied here the recently identified transport-associated proteins, MRP and LRP, and the well-known drug resistance marker P-glycoprotein using a panel of 16 human melanoma cell lines and 71 benign and malignant melanocytic tissue samples. By flow cytometry and immunohistochemistry, expression of P-glycoprotein was not detectable on the protein level in the 10 cell lines analyzed, although by reverse transcriptase polymerase chain reaction, MDR-1 gene expression was demonstrated in 2 of 10 cell lines. In addition, immunohistology revealed P-glycoprotein expression in only 1 of 71 melanocytic lesions. In contrast, MRP was detected in a subset of melanoma cell lines by reverse transcriptase polymerase chain reaction and immunohistology (4 of 10). LRP expression was observed in 8 of 10 melanoma cell lines by immunochemistry and in 10 of 10 by reverse transcriptase polymerase chain reaction. Furthermore, MRP was detected immunohistologically in almost 50% of primary and metastatic melanoma specimens, although no significant differences were found between metastases taken before or after chemotherapy. Expression of LRP was detected in a subset of nevi with nevus cells exhibiting up to 25% positive LRP reactivity. In 13 of 21 primary melanomas and 23 of 37 metastases, more than 25% of tumor cells were stained by the LRP-56 monoclonal antibody. Particularly in the group of metastases with more than 50% of LRP-positive cells, 7 of 11 of the metastases had been previously exposed to chemotherapeutic drugs. Although the expression of membrane transport proteins may explain only the chemoresistance toward lipophilic, natural compounds and not resistance against alkylating agents, the lack of P-glycoprotein expression after chemotherapeutic treatment and the significant expression of MRP and LRP in melanoma cells provide first insights into the drug-resistant phenotype in melanoma. Additional studies analyzing the role of MRP and LRP in chemoresistance of melanoma are warranted.

Adult onset of inflammatory linear verrucous epidermal nevus in a mother and her daughter

Inflammatory linear verrucous epidermal nevus (ILVEN) is a rather uncommon dermatosis that typically has an early age of onset, is unilateral, localized, pruritic and relatively refractory to treatment. Atypical presentations of ILVEN have also been described and include late onset in life, widespread involvement and response to treatment. We report the adult onset of an extremely pruritic systemized eruption in both mother and her daughter that clinically and histologically was most compatible with ILVEN. The eruptions were also partially responsive to therapy.

Treatment of inflammatory linear verrucous epidermal nevus

Inflammatory linear verrucous epidermal nevus (ILVEN) is a rare and chronic skin disorder, which may trouble the patient considerably. The condition is generally believed to be resistant to therapy, although some authors have reported success with several treatments. including dithranol and etretinate. The present case, a classical presentation of ILVEN, again illustrates the refractoriness to various treatments, including an experimental treatment with topical 13-cis-retinoic acid. A review of the literature on therapeutic possibilities of ILVEN is presented. Based on our own observations and literature data, it is attractive to hypothesize that a positive result with treatments such as dithranol and retinoids should be interpreted as an antipsoriatic effect in ILVEN with superimposed psoriasis.

Treatment of nevus comedonicus with ammonium lactate lotion

A patient with an extensive nevus comedonicus, which is associated frequently with the development of large inflammatory cysts and abscesses within the nevus, responded dramatically within 1 month to a once-daily application of 12% ammonium lactate lotion. A marked beneficial effect on the comedonal component of the nevus was noted. One inflammatory cyst has developed in an area left untreated by the patient, but none have occurred in treated areas since therapy with ammonium lactate lotion was begun. Previous treatments, which were either ineffective or of minimal effectiveness, included oral isotretinoin, topical tretinoin, salicylic acid, lactic acid, and d-tartaric acid creams.

Premature epiphyseal closure--a complication of etretinate therapy in children

Two children are described who developed premature epiphyseal closure while receiving etretinate for treatment of congenital hyperkeratotic disorders. The first patient was an 8 1/2-year-old boy with nonbullous ichthyosiform erythroderma who had been on treatment for 6 years, 4 months when premature fusion of the right distal tibial epiphysis was detected. Shortness of stature, thinning of long bones, and traumatic fractures were also observed in this patient. The second child was an 11-year-old girl with systematized verrucous nevi in whom symmetric fusion of both elbow epiphyses and narrowing of the femoral epiphyses bilaterally were noted following treatment with etretinate for 5 years, 5 months.

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.

Clinical observations, virologic studies, and treatment trials in patients with epidermodysplasia verruciformis, a disease induced by specific human papillomaviruses

We have studied 11 patients with the papillomavirus-induced disease epidermodysplasia verruciformis (EV). Clinical diagnostic features are widespread, long-lasting, pityriasis versicolor-like macules and flat, wart-like papules, both usually occurring in early childhood, with the subsequent development in the third decade of multiple skin cancers of the Bowenoid in situ and squamous cell types, primarily in sun-exposed skin. Virologic studies using the methods of immunofluorescence microscopy, restriction endonuclease analysis, and DNA blot hybridization have shown benign lesions to be associated with one or several types of the human papillomaviruses (HPVs) specifically associated with EV (at least 15 types recognized on the basis of sequence homology studies of molecularly cloned genomes). Skin cancers in these patients were associated with the genomes of either HPV-5, HPV-8 or HPV-14, suggesting that these three viruses are potentially oncogenic. A genetic factor appears to play a role in the pathogenesis of EV, since 5 of our patients were children of consanguineous parents and 2 had siblings also suffering with EV, suggesting a recessive inheritance pattern. Treatment of 4 EV patients with an oral retinoid resulted in partial temporary improvement of benign lesions, and the treatment of 2 patients with intralesional interferon injections into multiple Bowenoid cancers in situ has resulted in the disappearance of these lesions. Finally, EV serves as a model for studying the interplay of oncogenic viruses, genetic and immunologic factors, and sunlight in the production of skin cancer in humans.