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Progressive discoloration over the right shoulder
A 15-year-old Caucasian boy presented for evaluation of an asymptomatic brown patch on his right shoulder. While the patient’s mother first noticed the patch when he was 5 years old, the discolored area had recently been expanding in size and had developed hypertrichosis. The patient was otherwise healthy; he took no medications and denied any symptoms or history of trauma to the area. None of his siblings were similarly affected.
A physical examination revealed a well-demarcated hyperpigmented patch with an irregularly shaped border and an increased number of terminal hairs (FIGURE 1). The affected area was not indurated, and there were no muscular or skeletal abnormalities on inspection. Examination of the patch under a dermatoscope revealed islands of reticular (lattice-like) hyperpigmentation, focal hypopigmentation, and prominent follicles (FIGURE 2).
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
DIAGNOSIS: Becker melanosis
Becker melanosis (also called Becker’s nevus or Becker’s pigmentary hamartoma) is an organoid hamartoma that is most common among males.1 This benign area of hyperpigmentation typically manifests as a circumscribed patch with an irregular border on the upper trunk, shoulders, or upper arms of young men. Becker melanosis is usually acquired and typically comes to medical attention around the time of puberty, although there may be a history of discoloration (as was true in this case).
A diagnosis that’s usually made clinically
Androgenic origin. Because of the male predominance and association with hypertrichosis (and for that matter, acne), androgens have been thought to play a role in the development of Becker melanosis.2 The condition affects about 1 in 200 young men.1 To date, no specific gene defect has been identified.
Underlying hypoplasia of the breast or musculoskeletal abnormalities are uncommonly associated with Becker melanosis. When these abnormalities are present, the condition is known as Becker’s nevus syndrome.3
Look for the pattern. Becker melanosis is associated with homogenous brown patches with perifollicular hypopigmentation, sometimes with a faint reticular pattern.4,5 The diagnosis can usually be made clinically, but a skin biopsy can be helpful to confirm questionable cases. Dermoscopy can also assist in diagnosis. In this case, our patient’s presentation was typical, and additional studies were not needed.
Other causes of hyperpigmentation
The differential diagnosis includes other localized disorders associated with hyperpigmentation (TABLE1,3,4).
Continue to: Morphea
Morphea represents a thickening of collagen bundles in the skin. Although morphea can affect the shoulder and trunk, as Becker melanosis does, lesions of morphea feel firm to the touch and are not associated with hypertrichosis.
Localized post-inflammatory hyperpigmentation occurs following a traumatic event, such as a burn, or a prior dermatosis, such as zoster. Careful history-taking can uncover an antecedent inflammatory condition. Post-inflammatory pigment changes do not typically result in hypertrichosis.
Café-au-lait macules can manifest as isolated areas of discoloration. These macules can be an important indicator of neurofibromatosis, a genetic disorder in which tumors grow in the nervous system. Melanocytic hamartomas of the iris (Lisch nodules), axillary freckling (Crowe’s sign), or multiple cutaneous neurofibromas serve as additional clues to neurofibromatosis. In ambiguous cases, a skin biopsy can help differentiate a café au lait macule from Becker melanosis.
To treat or not to treat?
No treatment other than reassurance is needed in most cases of Becker melanosis, as it is a benign condition. Protecting the area from sunlight can minimize darkening and contrast with the surrounding skin. Electrolysis and laser therapy can be used to treat the associated hypertrichosis; laser therapy can also reduce the hyperpigmentation. Nonablative fractional resurfacing accompanied by laser hair removal is also reported to be of value.6
Our patient was satisfied with reassurance of the benign nature of the condition and did not elect treatment.
CORRESPONDENCE
Matthew F. Helm, MD, 500 University Drive, Suite 4300, Department of Dermatology, HU14, UPC II, Hershey, PA 17033-2360; Mhelm2@pennstatehealth.psu.edu
1. Rabinovitz HS, Barnhill RL. Benign melanocytic neoplasms. In: Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology. 3rd ed. New York, NY: Elsevier Saunders; 2012;112:1853-1854.
2. Person JR, Longcope C. Becker’s nevus: an androgen-mediated hyperplasia with increased androgen receptors. J Am Acad Dermatol. 1984;10:235-238.
3. Cosendey FE, Martinez NS, Bernhard GA, et al. Becker nevus syndrome. An Bras Dermatol. 2010;85:379-384.
4. Ingordo V, Iannazzone SS, Cusano F, et al. Dermoscopic features of congenital melanocytic nevus and Becker nevus in an adult male population: an analysis with 10-fold magnification. Dermatology. 2006;212:354-360.
5. Luk DC, Lam SY, Cheung PC, et al. Dermoscopy for common skin problems in Chinese children using a novel Hong Kong-made dermoscope. Hong Kong Med J. 2014;20:495-503.
6. Balaraman B, Friedman PM. Hypertrichotic Becker’s nevi treated with combination 1,550nm non-ablative fractional photothermolysis and laser hair removal. Lasers Surg Med. 2016;48:350-353.
A 15-year-old Caucasian boy presented for evaluation of an asymptomatic brown patch on his right shoulder. While the patient’s mother first noticed the patch when he was 5 years old, the discolored area had recently been expanding in size and had developed hypertrichosis. The patient was otherwise healthy; he took no medications and denied any symptoms or history of trauma to the area. None of his siblings were similarly affected.
A physical examination revealed a well-demarcated hyperpigmented patch with an irregularly shaped border and an increased number of terminal hairs (FIGURE 1). The affected area was not indurated, and there were no muscular or skeletal abnormalities on inspection. Examination of the patch under a dermatoscope revealed islands of reticular (lattice-like) hyperpigmentation, focal hypopigmentation, and prominent follicles (FIGURE 2).
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
DIAGNOSIS: Becker melanosis
Becker melanosis (also called Becker’s nevus or Becker’s pigmentary hamartoma) is an organoid hamartoma that is most common among males.1 This benign area of hyperpigmentation typically manifests as a circumscribed patch with an irregular border on the upper trunk, shoulders, or upper arms of young men. Becker melanosis is usually acquired and typically comes to medical attention around the time of puberty, although there may be a history of discoloration (as was true in this case).
A diagnosis that’s usually made clinically
Androgenic origin. Because of the male predominance and association with hypertrichosis (and for that matter, acne), androgens have been thought to play a role in the development of Becker melanosis.2 The condition affects about 1 in 200 young men.1 To date, no specific gene defect has been identified.
Underlying hypoplasia of the breast or musculoskeletal abnormalities are uncommonly associated with Becker melanosis. When these abnormalities are present, the condition is known as Becker’s nevus syndrome.3
Look for the pattern. Becker melanosis is associated with homogenous brown patches with perifollicular hypopigmentation, sometimes with a faint reticular pattern.4,5 The diagnosis can usually be made clinically, but a skin biopsy can be helpful to confirm questionable cases. Dermoscopy can also assist in diagnosis. In this case, our patient’s presentation was typical, and additional studies were not needed.
Other causes of hyperpigmentation
The differential diagnosis includes other localized disorders associated with hyperpigmentation (TABLE1,3,4).
Continue to: Morphea
Morphea represents a thickening of collagen bundles in the skin. Although morphea can affect the shoulder and trunk, as Becker melanosis does, lesions of morphea feel firm to the touch and are not associated with hypertrichosis.
Localized post-inflammatory hyperpigmentation occurs following a traumatic event, such as a burn, or a prior dermatosis, such as zoster. Careful history-taking can uncover an antecedent inflammatory condition. Post-inflammatory pigment changes do not typically result in hypertrichosis.
Café-au-lait macules can manifest as isolated areas of discoloration. These macules can be an important indicator of neurofibromatosis, a genetic disorder in which tumors grow in the nervous system. Melanocytic hamartomas of the iris (Lisch nodules), axillary freckling (Crowe’s sign), or multiple cutaneous neurofibromas serve as additional clues to neurofibromatosis. In ambiguous cases, a skin biopsy can help differentiate a café au lait macule from Becker melanosis.
To treat or not to treat?
No treatment other than reassurance is needed in most cases of Becker melanosis, as it is a benign condition. Protecting the area from sunlight can minimize darkening and contrast with the surrounding skin. Electrolysis and laser therapy can be used to treat the associated hypertrichosis; laser therapy can also reduce the hyperpigmentation. Nonablative fractional resurfacing accompanied by laser hair removal is also reported to be of value.6
Our patient was satisfied with reassurance of the benign nature of the condition and did not elect treatment.
CORRESPONDENCE
Matthew F. Helm, MD, 500 University Drive, Suite 4300, Department of Dermatology, HU14, UPC II, Hershey, PA 17033-2360; Mhelm2@pennstatehealth.psu.edu
A 15-year-old Caucasian boy presented for evaluation of an asymptomatic brown patch on his right shoulder. While the patient’s mother first noticed the patch when he was 5 years old, the discolored area had recently been expanding in size and had developed hypertrichosis. The patient was otherwise healthy; he took no medications and denied any symptoms or history of trauma to the area. None of his siblings were similarly affected.
A physical examination revealed a well-demarcated hyperpigmented patch with an irregularly shaped border and an increased number of terminal hairs (FIGURE 1). The affected area was not indurated, and there were no muscular or skeletal abnormalities on inspection. Examination of the patch under a dermatoscope revealed islands of reticular (lattice-like) hyperpigmentation, focal hypopigmentation, and prominent follicles (FIGURE 2).
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
DIAGNOSIS: Becker melanosis
Becker melanosis (also called Becker’s nevus or Becker’s pigmentary hamartoma) is an organoid hamartoma that is most common among males.1 This benign area of hyperpigmentation typically manifests as a circumscribed patch with an irregular border on the upper trunk, shoulders, or upper arms of young men. Becker melanosis is usually acquired and typically comes to medical attention around the time of puberty, although there may be a history of discoloration (as was true in this case).
A diagnosis that’s usually made clinically
Androgenic origin. Because of the male predominance and association with hypertrichosis (and for that matter, acne), androgens have been thought to play a role in the development of Becker melanosis.2 The condition affects about 1 in 200 young men.1 To date, no specific gene defect has been identified.
Underlying hypoplasia of the breast or musculoskeletal abnormalities are uncommonly associated with Becker melanosis. When these abnormalities are present, the condition is known as Becker’s nevus syndrome.3
Look for the pattern. Becker melanosis is associated with homogenous brown patches with perifollicular hypopigmentation, sometimes with a faint reticular pattern.4,5 The diagnosis can usually be made clinically, but a skin biopsy can be helpful to confirm questionable cases. Dermoscopy can also assist in diagnosis. In this case, our patient’s presentation was typical, and additional studies were not needed.
Other causes of hyperpigmentation
The differential diagnosis includes other localized disorders associated with hyperpigmentation (TABLE1,3,4).
Continue to: Morphea
Morphea represents a thickening of collagen bundles in the skin. Although morphea can affect the shoulder and trunk, as Becker melanosis does, lesions of morphea feel firm to the touch and are not associated with hypertrichosis.
Localized post-inflammatory hyperpigmentation occurs following a traumatic event, such as a burn, or a prior dermatosis, such as zoster. Careful history-taking can uncover an antecedent inflammatory condition. Post-inflammatory pigment changes do not typically result in hypertrichosis.
Café-au-lait macules can manifest as isolated areas of discoloration. These macules can be an important indicator of neurofibromatosis, a genetic disorder in which tumors grow in the nervous system. Melanocytic hamartomas of the iris (Lisch nodules), axillary freckling (Crowe’s sign), or multiple cutaneous neurofibromas serve as additional clues to neurofibromatosis. In ambiguous cases, a skin biopsy can help differentiate a café au lait macule from Becker melanosis.
To treat or not to treat?
No treatment other than reassurance is needed in most cases of Becker melanosis, as it is a benign condition. Protecting the area from sunlight can minimize darkening and contrast with the surrounding skin. Electrolysis and laser therapy can be used to treat the associated hypertrichosis; laser therapy can also reduce the hyperpigmentation. Nonablative fractional resurfacing accompanied by laser hair removal is also reported to be of value.6
Our patient was satisfied with reassurance of the benign nature of the condition and did not elect treatment.
CORRESPONDENCE
Matthew F. Helm, MD, 500 University Drive, Suite 4300, Department of Dermatology, HU14, UPC II, Hershey, PA 17033-2360; Mhelm2@pennstatehealth.psu.edu
1. Rabinovitz HS, Barnhill RL. Benign melanocytic neoplasms. In: Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology. 3rd ed. New York, NY: Elsevier Saunders; 2012;112:1853-1854.
2. Person JR, Longcope C. Becker’s nevus: an androgen-mediated hyperplasia with increased androgen receptors. J Am Acad Dermatol. 1984;10:235-238.
3. Cosendey FE, Martinez NS, Bernhard GA, et al. Becker nevus syndrome. An Bras Dermatol. 2010;85:379-384.
4. Ingordo V, Iannazzone SS, Cusano F, et al. Dermoscopic features of congenital melanocytic nevus and Becker nevus in an adult male population: an analysis with 10-fold magnification. Dermatology. 2006;212:354-360.
5. Luk DC, Lam SY, Cheung PC, et al. Dermoscopy for common skin problems in Chinese children using a novel Hong Kong-made dermoscope. Hong Kong Med J. 2014;20:495-503.
6. Balaraman B, Friedman PM. Hypertrichotic Becker’s nevi treated with combination 1,550nm non-ablative fractional photothermolysis and laser hair removal. Lasers Surg Med. 2016;48:350-353.
1. Rabinovitz HS, Barnhill RL. Benign melanocytic neoplasms. In: Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology. 3rd ed. New York, NY: Elsevier Saunders; 2012;112:1853-1854.
2. Person JR, Longcope C. Becker’s nevus: an androgen-mediated hyperplasia with increased androgen receptors. J Am Acad Dermatol. 1984;10:235-238.
3. Cosendey FE, Martinez NS, Bernhard GA, et al. Becker nevus syndrome. An Bras Dermatol. 2010;85:379-384.
4. Ingordo V, Iannazzone SS, Cusano F, et al. Dermoscopic features of congenital melanocytic nevus and Becker nevus in an adult male population: an analysis with 10-fold magnification. Dermatology. 2006;212:354-360.
5. Luk DC, Lam SY, Cheung PC, et al. Dermoscopy for common skin problems in Chinese children using a novel Hong Kong-made dermoscope. Hong Kong Med J. 2014;20:495-503.
6. Balaraman B, Friedman PM. Hypertrichotic Becker’s nevi treated with combination 1,550nm non-ablative fractional photothermolysis and laser hair removal. Lasers Surg Med. 2016;48:350-353.
