Asymptomatic Macules Research Articles

Idiopathic Eruptive Macular Pigmentation: An Uncommon Hyperpigmentation Disorder in Children

Abstract The diagnosis and management of pediatric hyperpigmented lesions can be challenging, given the vast list of differentials to consider. We report a case of a 13-year-old Chinese girl who presented with a 1-year duration of generalized hyperpigmented macules and was eventually diagnosed with idiopathic eruptive macular pigmentation, a rare and benign melanosis, characterized by an eruption of brown, nonconfluent asymptomatic macules in children and adolescents. The clinical and histopathological features, differential diagnoses, and management are discussed in this article to raise awareness of this condition among pediatricians and general practitioners.

Palmar Tinea nigra Non-Invasive Diagnosis with Dermoscopy, Reflectance Confocal Microscopy and Microbiology

Tinea nigra is an uncommon superficial mycosis caused by the darkly pigmented fungus Hortaea werneckii. which occurs mainly in tropical and subtropical regions. Clinically, it is characterized by a brown-to-black asymptomatic macule, with well- defined edges, most commonly affecting the palms and soles. We report a case of palmar Tinea nigra and the features found on dermoscopy, reflectance confocal microscopy and microbiology. It is important to recognize this disease early for proper treatment and to distinguish it from other melanocytic lesions with worse prognoses, such as melanoma.

LIVING WITH VITILIGO: IMPACT OF THE DISEASE ON THE INDIVIDUALS’ QUALITY OF LIFE

Introduction: Vitiligo is a disease characterized by asymptomatic hypochromic and/or achromic macules, localized or generalized in the integumentary system. The visible depigmentation in the skin of the individual and usually exposed in daily life changes the body image, impacting their quality of life. Objective: To evaluate the quality of life of people living with vitiligo. Method: This is a cross-sectional study carried out with 86 individuals with vitiligo. For data collection, the Vitiligo-Specific Quality-of-Life Instrument questionnaire was used for quality of life. Results: Adult women (81.4%) (mean age 39 years old) with vitiligo had a medium impact on quality of life, and the factors that interfered with quality of life are related to intensified skin care, progression, and appearance of the disease. Conclusion: The vitiligo pathology interfered in the quality of life of adults. The factors that impacted quality of life were intensified skin care in leisure activities, the progression of the disease and the appearance of hypochromic spots.

Annular Lichenoid Dermatitis (of Youth).

About 20 years after its first description, Annular Lichenoid Dermatitis of Youth (ALDY) is recognized as a distinctive lichenoid dermatosis with specific clinical and histological features. The disease occurs mostly in young persons all over the world, runs a chronic course, and has an obscure etiopathogenesis. Clinically, lesions consist of persistent, asymptomatic erythematous macules and round-oval annular patches with a red-violaceous non-scaling border and central hypopigmentation, mostly localized on the groin and flanks. Histology shows a peculiar lichenoid dermatitis characterized by irregular epidermal hyperplasia with an alternation of thinned and quadrangular rete ridges and a dense band-like lichenoid infiltrate of lymphocytes in the papillary dermis. Typically, there is infiltration of lymphocytes into the lower epidermal layers with massive necrosis/apoptosis of keratinocytes, which is limited to the tips of rete ridges. Dermal lymphocytes are usually CD3+, CD4+, while most of the intraepidermal T cells are CD8+. Analysis of TCR-γ-chain gene rearrangement displayed polyclonality in all cases examined. Differential diagnosis mainly includes morphea, mycosis fungoides, annular erythemas and inflammatory lesions of vitiligo. Topical corticosteroids and topical tacrolimus represent the most effective drugs for ALDY treatment.

Agminated blue nevi: a case series and updated dermoscopic review.

Blue nevi, usually presenting as solitary, bluish, asymptomatic macules or nodules, are formed by collections of dermal melanocytes that failed to complete their migration from the neural crest to the dermo-epidermal junction. The term "agminated blue nevi" refers to multiple lesions grouped, linear, or arranged in a blashkoid distribution. It is a relatively rare phenomenon with less than 35 cases reported in the literature, but only 14 cases with dermoscopic features. We report another 4 cases along with an updated dermoscopic review.

Clinical and Dermoscopic Features of Vulvar Melanosis Over the Last 20 Years

Vulvar melanosis is a common pigmentary change that accounts for most pigmented vulvar lesions. It presents as single or multiple asymptomatic macules or patches of varying size and color that may be asymmetric with poorly defined borders. The differential diagnosis of melanocytic lesions includes melanoma, which creates anxiety for patients and the physicians who diagnose the condition and treat the patients. To evaluate the clinical and dermoscopic features of vulvar melanosis and their changes over time. In this cohort study, patients with vulvar melanosis were recruited and followed up in the Department of Dermatology, University of Florence, Florence, Italy, between January 1, 1998, and June 30, 2019. Data on patient characteristics and on both the clinical and dermoscopic features of the vulvar lesions were collected. Each lesion was photographed clinically and dermoscopically at initial evaluation and at annual follow-up visits. The clinical, dermoscopic, and histopathologic features of vulvar melanosis and their changes over time. This cohort study included 129 women (mean age at diagnosis, 46 years [range, 19-83 years]) with vulvar melanosis. A total of 87 patients (67%) with vulvar melanotic lesions were premenopausal, and 84 patients (65%) had received some type of hormone therapy. The most frequent location for vulvar melanosis was the labia minora (55 [43%]), followed by the labia majora (33 [26%]). In 39 of 129 cases (30%), the lesions increased in size and changed color after initial evaluation but ultimately stabilized. No malignant evolution was documented in any patient during a median follow-up of 13 years (range, 5-20 years). This study suggests that vulvar melanosis was a benign entity, and changes in lesions over time did not signify malignant transformation. An association between hormonal status and vulvar melanosis may be hypothesized.

ORAL MELANOCYTIC NEVI: A CASE REPORT

Melanocytic nevi are benign proliferations of nevus cells in the epithelial layer, the submucosal/subepidermal layer, or both. Although melanocytic nevi are frequently found on the skin, oral lesions can also be found. We describe a new case affecting a 13-year-old boy who was referred to our department because of an asymptomatic macule on the retromolar trigone observed several years before. The patient's past medical history was noncontributory, and the intraoral examination revealed a black to brown pigmented lesion measuring approximately 4 cm in size. An incisional biopsy was done, and microscopic analysis showed the presence of ovoid-shaped nevus cells with melanin granules in the connective tissue and overlying epithelium. Some atypical nuclei were also found. Immunohistochemistry was positive for S100, and Ki67 demonstrated a low proliferative index, confirming the diagnosis of oral melanocytic nevi. The patient is under follow-up with no evidence of additional lesion growth. Support: FAPEMIG.

Lymphocytic Thrombophilic Arteritis: A Review.

Macular lymphocytic arteritis or lymphocytic thrombophilic arteritis (LTA) is a recently described cutaneous arteritis that is characterized by asymptomatic macules and patches of the extremities associated with lymphocytic arteritis at the deep dermal/subcuticular junction for which little information exists on demographics, evaluation, and management. There has been recent debate in the literature whether this disease is a new distinct entity, misdiagnosed cutaneous polyarteritis nodosa (cPAN), or a disease on a spectrum with cPAN. We systematically review the literature on demographic information, medical history, histopathology findings, and treatment management to analyze trends and clarify controversies in characterizations of LTA. Forty detailed cases of LTA have been published. We submit that, although literature is limited, a review of the data still suggests that LTA is distinct from cPAN and systemic PAN. In addition, to better reflect the pathophysiologic natural history of this condition and correct for the historical artifact of how the disease was identified, we encourage the disease to be referred to as LTA and discourage ongoing use of macular lymphocytic arteritis.

Persistent dermatomal eruption on a leg

Unilateral linear capillaritis (ULC) is a rare variant of pigmented purpuric dermatoses (PPD) that is characterized by a linear or pseudo-dermatomal eruption on a single extremity. Although clinically distinct from the other PPD, it shares histopathologic features with this group. Herein, we present a man in his 50s who presented with asymptomatic macules and scaly papules on the left lower extremity in a linear distribution. The eruption persisted despite treatment with topical triamcinolone 0.1% and oral rutocide.

The role of interleukins in vitiligo: a systematic review.

Vitiligo is a disorder of the skin that causes depigmentation and asymptomatic macules whose exact cause is still unclear. Although its aetiology is not fully elucidated, the main theory of its pathomechanism is that it is associated with the autoimmune process. There is few summarized information about the role of inflammatory mediators, as interleukins, in vitiligo, so our aim was to present a systematic review of the role of interleukins in vitiligo, focusing on interleukins. In this review, we included all studies assessing interleukin levels in vitiligo patients conducted up to June 2017. Quality assessment of these studies was performed using the Newcastle-Ottawa Scale (NOS). The interleukins mainly involved were IL-2, IL-4, IL-6, IL-10 and IL-17. The studies highlight the crucial role of IL-17 in the onset and progression of the disease, and its synergistic action with IL-2, IL-6 and IL-33. Dysregulated levels of the interleukins were also correlated with the stage of disease, the affected skin surface area, and indicated as the main factor for lymphocyte infiltration found in depigmented regions. These findings illustrate the growing need for new therapies targeting vitiligo and further research into the role of interleukins as an area of particular interest.

Patch-type granuloma annulare: a case report

Granuloma annulare (GA) is a benign, self-limited condition which the etiology remains unknown. It is clinically characterized as annularly, erythematous papules on the extremities. Histologically, it shows as palisading granulomas with central degenerated collagen and mucin deposits. The patient in this case report had a rare GA variant named patch-type GA. It appeared as asymptomatic erythematous macules with central clarification on the upper portion of thighs. Histopathology was compatible with interstitialtype GA. We highlight that a high index of suspicion is necessary to make the diagnosis of patch-type GA and confirmation can only be achieved through histopathology study

An uncommon macular rash: Here is the culprit!

An 8-year-old white female presented with several scattered light blue to purple, oval to round asymptomatic macules on her entire trunk that had appeared a few days before consultation (Fig 1). The lesions measured approximately 0.5 to 1 cm in diameter and did not disappear on diascopy.

Dermatoscopic findings of atrophic dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon locally aggressive mesenchymal tumor with a high local recurrence rate. Atrophic DFSP is a rare variant of DFSP characterized by a non-protuberant lesion. We report on a 23-year-old female, who presented with an atrophic, asymptomatic macule on the right side of her back 2 cm in diameter. Dermatoscopic examination revealed homogenous pigment network on a purplish erythematous background. The histopathological finding of the incisional biopsy material was consistent with DFSP. To our knowledge, this is the second case of atrophic DFSP discussing the dermatoscopic features of this relatively rare condition.

Genç bir kızda Bier lekeleri

Bier’s Spots in a Young Girl Bier’s spots are transient anemic macules. They may be either physiological or pathological manifestation. Here we present a patient who had multiple asymptomatic anemic macules on the forearms and dorsum of the hands. A clinician should examine for features of thrombophilia, vasculopathy and aortic malformations when a patient presents with Bier’s spots.

Vitiligo with Ichthyosis and Conjunctivitis in a 5 year old boy

Vitiligo is a common, acquired, pigmentary disorder of skin and hair resulting from the destruction of functional melanocytes. It is characterized by well-circumscribed, asymptomatic depigmented macules. Ichthyosis is a group of genetic skin disorders characterized by dry, scaly skin that may be thick or very thin. Conjunctivitis is an inflammation or infection of the conjunctiva, the thin transparent layer of tissue that lines the inner surface of the eyelid and covers the white part of the eye. Here we report an unusual case of vitiligo with icthyosis and conjunctivitis in a 5 yr old boy.

Patch testing in symmetrical drug‐related intertriginous and flexural exanthema (sdrife)

Herein we present a case of a 38-year-old female Caucasian who developed exanthema four days after surgical dental intervention. Skin symptoms included asymptomatic confluent erythematous papules and macules on the buttocks, lateral aspects of the abdomen, and axillas. After the dental surgery she was prescribed clindamycin for 7 days as a routine antibiotic prophylaxis. The patient had suffered from similar complaints upon previous intake of antibiotics. She was in otherwise general good health with no further complaints. Upon admittance, clidnamycin was stopped and symptomatic treatment with 40mg/day methylprednisolone was initiated, with tapering the dose within the next 7 days. No laboratory abnormalities were documented in the blood and urine analysis, liver, kidney and pulmonary function. The patients improved in a week with complete resolution of symptoms within 10 days. Six weeks after resolution of skin symptoms patch test was performed with European standard series and antibiotic prepared in our laboratory. Patch test result revealed positive reactions to nickel sulfate and clindamycin (10% in petrolatum). No positive reaction to the antibiotic was witnessed in the following testing of 5 healthy volunteers. Detailed discussion revealed that our patient has used topical clindamycin vaginal globules in the past without history of any topical or systemic reaction at the time. Upon the case history, the clinical picture, and the patch testing we set the diagnosis of Baboon syndrome also known as symmetrical drug-related intertriginous and flexural exanthema (SDRIFE). We discuss the need for patch testing the possible etiological agents and the pathophysiological mechanism of this drug reaction.

Diffuse Telangiectasias on the Lower Extremities

Awoman in her 40s presented with a 5-year history of spreading blanchable, purple, asymptomatic macules on her bilateral lower extremities. Her medical history was notable for an undifferentiated connective tissue disorder with associated joint pain, and she was receiving chloroquine phosphate and nonsteroidal antiinflammatory drugs. Physical examination revealed telangiectasias coalescing into purple-blue patches on bilateral dorsal feet and toes (Figure, A). The telangiectasias extended up to her knees bilaterally. She had palpable pulses bilaterally. The patient had normal arterial brachial indexes bilaterally and minimal reflux in the right common femoral vein on a venous duplex. The antinuclear antibody value was 1:320, but factor V Leiden, protein C, protein S, and partial thromboplastin time were normal. She also had negative cryoglobulins, cryofibrinogens, and cold agglutinins. A 4-mm punch biopsy was performed of a sample from her left forefoot (Figure, B and C). What is your diagnosis?

Idiopathic eruptive macular pigmentation

Idiopathic eruptive macular pigmentation (IEMP) is an uncommon, rather under-reported disease entity of the pediatric age characterized by asymptomatic, brownish hyperpigmented macules involving the neck and trunk with no preceding inflammation or exposure to drug. Here we report this case to increase awareness of this entity among dermatologists, dermatopathologists and pediatricians. A 11-year-old healthy boy presented with brownish-gray to dark, discrete, asymptomatic macules on the face, trunk, neck and limbs of insidious onset. Histopathologic examination showed melanophages, mild perivascular lymphohistiocytic infiltrate in the papillary dermis and papillomatosis. The natural course of the disease is spontaneous remission without treatment, which was so even in our patient. IEMP is a benign entity with an excellent prognosis as it exhibits spontaneous resolution. It falls into the differential diagnoses of asymptomatic hyperpigmentatory disorders in pediatric population. Awareness of the entity leads to avoidance of unnecessary aggressive damaging treatment.

The first report of krt5 mutation underlying acantholytic dowling-degos disease with mottled hypopigmentation in an Indian family

Galli Galli disease (GGD) is the name given to a rare form of acantholytic Dowling-Degos disease. (DDD), the latter itself being a rare condition. We believe we are describing for the first time in Indian dermatologic literature a case of GGD in a family where 25 persons have DDD and have been able to document a KRT5 mutation in four members of the family. Whereas reticulate pigmentation is a hallmark of DDD there are rare reports of mottled pigmentation with multiple asymptomatic hypopigmented macules scattered diffusely along with the pigmentation. All the cases described here show a mottled pigmentation comprising hypo and hyperpigmented asymptomatic macules. After the clinical diagnosis was made by one of the authors (SV) in India, the German authors repeated histological examination and successfully demonstrated a heterozygous nonsense mutation, c.C10T (p.Gln4X), in exon 1 of the KRT5 gene, from various centers in Munich, Bonn, Dusseldorf and Friedrichschafen in Germany.

Bartonella quintana in Cimex hemipterus, Rwanda

The common bed bug species Cimex lectularius, which has a worldwide distribution, and C. hemipterus, which has tropical climate distribution, are hematophagous arthropods.1 The bugs are attracted to the human host by warmth and carbon dioxide, and bed bug infestations are rapidly increasing worldwide. Moreover, bed bugs are likely to be more problematic in the future because of travel, immigration, and insecticide resistance. Reactions to bites vary, and some patients present only asymptomatic macules, whereas others develop indurated, bulbous lesions that resemble erythema multiforme.2 Although no case of bed bug-borne infection has been reported yet, bed bug infestations can have an adverse effect on health and quality of life in the general population, particularly among homeless persons living in shelters.1,3 The transmission of more than 45 human diseases has been attributed to bed bugs; however, there is little evidence that they are vectors of communicable disease.1 The objective of this study was to analyze with molecular assays a large number of bed bugs from Rwanda, where epidemiological and clinical studies on zoonosis are scarce. Bed bugs were collected from two prisons in Rwanda (Miyove and Muhanga prisons) (Figure 1) from May to January of 2011 and taken to a local laboratory. Bed bugs were preserved in sterile conditions at room temperature and then sent to our reference center in Marseille to test for lice-borne infections. Before DNA isolation, each bug was rinsed two times in sterile water for 15 minutes. Overall, 100 bed bugs were tested. DNA was extracted from each bug using a QIAamp tissue kit (Qiagen, Hilden, Germany) and then used as template in a real-time polymerase chain reaction (PCR) assay targeting a portion of the Bartonella 16S–23S intergenic spacer region (ITS) as described previously.4 Two specific B. quintana genes (fabF3 and yopP) encode for 3-oxoacyl-[acyl-carrier-protein] synthase and a hypothetical intracellular effector, respectively.5 All three sets were positive by real-time PCR for one bed bug. Amplicons were then purified using the QIAquick Spin PCR Purification Kit (Qiagen, Courtaboeuf, France) and sequenced on an ABI 3100 Automated Sequencer (Perking Elmer, Courtaboeuf, France) using the dRhodamine Terminator Cycle-Sequencing Ready Reaction Kit (PE Applied Biosystems, Les Ulis, France) according to the manufacturer's instructions. Sequences obtained after sequencing of the ITS gene shared 100% similarity to the corresponding ITS fragment of the genome of B. quintana (Toulouse strain; GenBank accession number {type:entrez-nucleotide,attrs:{text:BX897700,term_id:49239191,term_text:BX897700}}BX897700). B. quintana-positive bugs were further studied by PCR amplification and DNA sequencing of the mitochondrial (16S DNA) gene as previous described.6 Sequences obtained shared 99.7% similarity to the corresponding 16S DNA fragment of the genome of C. hemipterus (GenBank accession number {type:entrez-nucleotide,attrs:{text:GU985560.1,term_id:294999274,term_text:GU985560.1}}GU985560.1). Moreover, B. quintana-positive bugs were triturated in brain–heart medium before inoculation onto Columbia 5% sheep blood agar plates (BioMerieux, Marcy l'Etoile, France). Plates were placed in polyethylene bags and incubated at 37°C in 5% CO2 (Genbag CO2 system; BioMerieux). The agar plates were examined weekly. After 1 month, no evidence of growth was observed. Figure 1. The two areas in Rwanda where the bed bugs were collected. In this study, we identified the presence of B. quintana in C. hemipterus collected from a prison in Rwanda. B. quintana and Rickettsia prowazekii have been previous identified in body lice collected from a similar jail in Rwanda,7 and recently, B. quintana was found in head and body lice in Ethiopia.8 To avoid the potential of misinterpretation of the PCR data caused by laboratory contamination, three different genes were assessed, and all of them were successfully detected. However, we were not able to cultivate B. quintana from this bug. This result suggests that living microorganisms may be dead before testing or that only DNA but no living organisms were present in the bug. C. hemipterus might be contaminated when they feed on the blood of prisoners infected with B. quintana. Unfortunately, a human blood sample was not collected at the time of sampling the bugs. There are few data to support bed bugs as vectors for transmission of human disease agents, and older studies consist of only logical and not evidence-based postulates.9 Recently, Delaunay and others1 found no published evidence for completion of all the necessary steps leading to the conclusion that bed bugs transmit a pathogen. It is possible that the bed bug might only play the role of vector in pathogen transmission, and consequently, it may be involved in human disease in special circumstances not yet discovered.1 Nonetheless, the role of the bed bugs in the maintenance and transmission of B. quintana remains to be determined, and it is currently being tested in our laboratory.