Melanosis of the areola and nipple

Abstract

To the Editor: Melanosis is a benign lesion characterized by hyperpigmented basal keratinocytes and a normal to slightly increased number of melanocytes. We present a patient with melanosis of the areola that manifested clinical features suggestive of evolving melanoma during pregnancy. A 28-year-old woman presented with a pigmented lesion on her right breast that had undergone rapid growth and color variation during the previous 3 to 4 months, coinciding with her becoming pregnant (Fig 1). The patient recalled that the lesion appeared 10 years ago as “a freckle and a white spot” on the nipple. Until her pregnancy, it had been expanding very slowly. A biopsy performed soon after the lesion appeared reportedly demonstrated a simple lentigo. The patient had no significant medical history but reported that her mother had a history of melanoma. A total of 7 3-mm punch biopsies were performed. Histopathologic findings were similar in all biopsy specimens (Fig 2). No findings of melanoma, including atypia, pagetoid spread, or confluence of melanocytes, were noted on any biopsy specimen. A mammogram and ultrasound of the breast revealed unremarkable findings. The patient subsequently underwent elective termination of her pregnancy (for reasons unrelated to the melanosis), after which the pigmentation lightened somewhat but the morphology remained unchanged.Fig 2All biopsy specimens demonstrated similar changes: mild acanthosis, no hyperkeratosis, basilar hyperpigmentation, and scattered melanophages in papillary dermis. There was very slightly increased number of melanocytes having somewhat prominent dendritic processes. (Hematoxylin-eosin stain; original magnification: ×10.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Melanosis of the areola is rare, with only 5 cases reported, all in women age 25 to 40 years.1Pittis J.D. Barber F.A. Melanosis of the areola.Arch Dermatol. 1990; 126: 542-543Crossref PubMed Scopus (9) Google Scholar, 2Mannone F. De Giorgi V. Cattaneo A. Massi D. De Magnis A. Carli P. Dermoscopic features of mucosal melanosis.Dermatol Surg. 2004; 30: 1118-1123Crossref PubMed Scopus (74) Google Scholar, 3Blum A. Metzler G. Caroli U. Melanosis of the areola in dermoscopy.J Am Acad Dermatol. 2004; 51: 664-665Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Melanosis is more commonly seen on the vulva, penis, oral mucosa, and volar areas. Melanosis of the areola was first described by Pittis and Barber.1Pittis J.D. Barber F.A. Melanosis of the areola.Arch Dermatol. 1990; 126: 542-543Crossref PubMed Scopus (9) Google Scholar They presented a 25-year-old woman with a 13-month history of an enlarging pigmented area on the left areola. A pregnancy during that period had no effect on the growth or intensity of pigmentation of the lesion, unlike our patient. Histopathologic findings in that patient were similar to ours, namely, basilar hyperpigmentation, scattered dermal melanophages, and a normal number of melanocytes. One interesting aspect of our case was its rapid evolution during pregnancy after a 10-year history of slow growth. Hyperpigmentation is a well-known pregnancy-induced change, and is accentuated in normally hyperpigmented areas, including the areolae. Melanocytes in these areas may have a higher sensitivity to hormonal stimulation.4Wong R.C. Ellis C.N. Physiologic skin changes in pregnancy.J Am Acad Dermatol. 1984; 10: 929-940Abstract Full Text PDF PubMed Scopus (115) Google Scholar In addition, nevi and ephelides have been reported by some authors to darken or enlarge.4Wong R.C. Ellis C.N. Physiologic skin changes in pregnancy.J Am Acad Dermatol. 1984; 10: 929-940Abstract Full Text PDF PubMed Scopus (115) Google Scholar Given the pigmentary alterations that may occur during pregnancy, melanosis may also be expected to undergo change. In addition, any pigmented lesion that undergoes rapid change can arouse concern for melanoma. It has been debated whether pregnant patients are at a higher risk of melanoma or whether melanomas evolving during pregnancy have a worse prognosis.5O'Meara A.T. Cress R. Xing G. Danielsen B. Smith L.H. Malignant melanoma in pregnancy: a population-based evaluation.Cancer. 2005; 103: 1217-1226Crossref PubMed Scopus (145) Google Scholar A population-based study of 412 women given the diagnosis of melanoma during or within 1 year of pregnancy found no data, however, to support a more advanced stage, thicker tumors, increased metastases to lymph nodes, or worsened survival in patients with pregnancy-associated melanoma.5O'Meara A.T. Cress R. Xing G. Danielsen B. Smith L.H. Malignant melanoma in pregnancy: a population-based evaluation.Cancer. 2005; 103: 1217-1226Crossref PubMed Scopus (145) Google Scholar Melanosis can replicate the clinical features of melanoma, including asymmetry, border irregularity, variation in color, and large size and, therefore, can be worrisome for patients and physicians.1Pittis J.D. Barber F.A. Melanosis of the areola.Arch Dermatol. 1990; 126: 542-543Crossref PubMed Scopus (9) Google Scholar We present this case to alert clinicians to this rare entity.