Black Macules Research Articles

Asymptomatic Black Macules over the Feet in an Adolescent

Asymptomatic Black Macules over the Feet in an Adolescent

Preoperative multimodal ultrasonic imaging in a case of Peutz-Jeghers syndrome complicated by atypical lobular endocervical glandular hyperplasia: a case report and literature review

BackgroundPeutz-Jeghers syndrome (PJS), an autosomal dominant multiple cancerous disorder, is clinically characterized by mucocutaneous macules and multiple gastrointestinal hamartomatous polyps. Gastric-type endocervical adenocarcinoma (G-EAC), a special subtype of cervical adenocarcinoma with non-specific symptoms and signs, is known to occur in approximately 11% of female patients with PJS.Case presentationHere, we report a case of PJS in a 24-year-old female with multiple mucocutaneous black macules who complained of vaginal discharge and menorrhagia. Moreover, we first described the multimodal ultrasonographical manifestations of PJS-correlated G-EAC. The three-dimensional reconstructed view of G-EAC on 3D realisticVue exhibited a distinctive “cosmos pattern” resembling features on magnetic resonance imaging, and the contrast-enhanced ultrasound displayed a “quick-up and slow-down” pattern of the solid components inside the mixed cervical echoes. We reported the multimodal ultrasonographical characteristics of a case of PJS-related G-EAC, as well as reviewed PJS-related literature and medical imaging features and clinical characteristics of G-EAC to provide insight into the feasibility and potential of utilizing multimodal ultrasonography for the diagnosis of G-EAC.ConclusionsMultimodal ultrasound can visualize morphological features, solid components inside, and blood supplies of the G-EAC lesion and distinguish the G-EAC lesion from normal adjacent tissues. This facilitates preoperative diagnosis and staging of PJS-related G-EAC, thereby aiding subsequent health and reproductive management for patients with PJS.

Linear and zosteriform lichen planus in a tertiary care centre: a case series

Lichen planus (LP) is a common mucocutaneous condition, but its distribution in a zosteriform and linear pattern is rare. Zosteriform LP is a rare variant with dermatomal distribution and can occur at trauma prone sites. Linear distribution of the disease has been described in less than 1% of patients. Treatment options are topical corticosteroids and systemic antihistamines. We hereby present a case series of four cases with linear and zosteriform patterns in which the biopsy findings were corroborative of lichen planus. In the first case report of a 25-year-old female presented to dermatology OPD of tertiary health Centre with hyperpigmented patches confined to left half of trunk, left arm and left leg for 6 months. Brownish black macules involving left breast and adjoining back and abdomen were seen in zosteriform pattern. In the second case report, a 25-year-old male presented for evaluation of hyperpigmented raised and pruritic lesion over the right axilla of 5 months’ duration Third case was of a 26-year-old female patient who presented with pruritic violaceous macules on left leg extending from mid part of leg to medial aspect of knee and medial side of thigh in a discontinuous pattern for last 3 years. A 34-year-old female presented with history of pruritic rash over the left side of trunk in the fourth case report. The case series is rare and hence being reported.

RARE CASE OF AN INTRAORAL COMBINED NEVUS

A 13-year-old female patient was referred by her dentist for evaluation of a 5-mm, asymptomatic, black macule in the right buccal mucosa. The patient was unaware of the lesion, and her medical history was noncontributory. A clinical diagnosis of oral melanocytic nevus was made, and the patient was treated by excisional biopsy under local anesthesia. The histologic analysis revealed a proliferation of nevoid cells, organized in small groups and composed of large epithelioid cells with eosinophilic, clear, or dark-brown cytoplasmic melanin granules presenting loose chromatin, prominent nucleoli, and nuclear pleomorphism. In the deeper areas, fusiform nevoid cells presenting dark nuclei with condensed chromatin and dark brown-pigmented cytoplasm were seen intermingled with dense connective tissue. Mitoses were not detected. Based on the findings, a diagnosis of intramucosal combined nevus composed of Spitz and blue nevus was made. No signs of recurrence were observed after 19 months of follow-up. A 13-year-old female patient was referred by her dentist for evaluation of a 5-mm, asymptomatic, black macule in the right buccal mucosa. The patient was unaware of the lesion, and her medical history was noncontributory. A clinical diagnosis of oral melanocytic nevus was made, and the patient was treated by excisional biopsy under local anesthesia. The histologic analysis revealed a proliferation of nevoid cells, organized in small groups and composed of large epithelioid cells with eosinophilic, clear, or dark-brown cytoplasmic melanin granules presenting loose chromatin, prominent nucleoli, and nuclear pleomorphism. In the deeper areas, fusiform nevoid cells presenting dark nuclei with condensed chromatin and dark brown-pigmented cytoplasm were seen intermingled with dense connective tissue. Mitoses were not detected. Based on the findings, a diagnosis of intramucosal combined nevus composed of Spitz and blue nevus was made. No signs of recurrence were observed after 19 months of follow-up.

Acquired Beauty Mark?: New Black Macule on the Face

An otherwise healthy young female patient presented with a new asymptomatic black lesion on her left upper cutaneous lip that developed shortly after spending time in the garden. Clinical examination revealed a 4-mm well-circumscribed black circular macule without associated inflammation (Figure 1). Due to concern for an atypical melanocytic lesion, a punch biopsy was performed. Histopathologic examination disclosed full-thickness epidermal necrosis with an underlying band of neutrophilic inflammation with karyorrhexis (Figure 2).

Cells to Surgery Quiz: April 2019

Cells to Surgery Quiz: April 2019

Frictional melanosis and its clinical and histopathological features

Background: A rippled type of pigmentation is observed on the arms, forearms, and bony prominences, more commonly in women with a history of chronic rubbing. The terminology (commonly referred to as frictional melanosis) and its relation with cutaneous amyloidosis has been debated. Materials and Methods: Twenty one patients with pigmented skin lesions with manifestations suggestive of frictional melanosis were included in the study. Detailed history, clinical and histopathological examination were conducted on all patients. Results: Brownish black macules without rippling were the most prevalent type of presentation. Arm was the most common site of involvement followed by forearm. Histopathology showed basal layer pigmentation, acanthotic epidermis, condensation of collagen and pigmentary incontinence in the dermis. Only six patients showed amyloid deposition on Congo red stain. Conclusion: Amyloid can be demonstrated by Congo red stain in certain cases only, called frictional amyloidosis. Other cases, in whom amyloid cannot be observed may be termed frictional melanosis.

Successful Combination Therapy of Nivolumab and Radiation for Massive Mucosal Melanoma in Patient with Autoimmune-Myasthenia Gravis, Systemic Lupus Erythematosus and Rheumatoid Arthritis

A 58-year-old woman complicated with autoimmune diseases of myasthenia gravis (MG), rheumatoid arthritis, and systemic lupus erythematosus noticed an irregular black macule on her bilateral major labia, which was diagnosed as malignant melanoma. The melanoma lesion involving the vagina, uterus, and ventral side of rectum was not operable and was treated with nivolumab and concurrent radiotherapy with good control of the MG. This resulted in remarkable tumor shrinkage, possibly due to synergistic effects of both treatments. To our knowledge, few reports have described the effectiveness of combination therapy with nivolumab and radiation for malignant melanoma. The present case showed an enhanced anti-tumor effect with combination therapy.

A Widespread Pruritic Rash With Facial Swelling and Black Streaks.

A healthy girl aged 4 years presented with a 5-day history of a pruritic rash on her arms, neck, axillae, and face. The rash started as small pink bumps on her arms that spread to involve the axillae, neck, and upper chest. Four days prior to arrival, she developed significant rednessandpruritusofher face.Onarrival, herparentsnotedblack streaksonher right arm,promptinganurgentemergencydepartmentevaluation. Treatmentprior topresentation includeddiphenhydramine, cetirizine, and a 20-mg dose of prednisone without improvement. The patient was otherwise healthy with normal development and growth. She had a history of mild atopic dermatitis and was not taking any medications. She had no known history of drug allergy or contact allergy. The patient livedwith her 2 siblings and both parents, whowere all asymptomatic. She had no pets and no recent travel, and her vaccinations were up to date. Onphysical examination, the patientwas actively scratching the involved skin. The bilateral arms, axillae, anterior neck, and facehadpoorlydefined, blanchingpink-redpatches andedematousplaqueswithout epidermal change (Figure, A). Jet black,well-defined, and slightly shiny linear streakswithperipheral erythemawerenotedonher right forearm,with smaller circular, black macules on the ipsilateral biceps and axilla (Figure, B). Quiz at jamapediatrics.com A

Congenital Lingual Melanotic Macule: Rare entity in infants.

A five-month-old male infant presented to the Department of Pediatrics at the Madras Institute of Orthopaedics & Traumatology in Chennai, India, in June 2014 with a pigmented lesion on the tongue that had been observed since birth. The baby was healthy, accepting feeds well and was not taking any medication. There was no associated family history of melanomas, polyposis or mucosal pigmentation. The mother reported that the size of the lesion had been increasing gradually since birth. An oral cavity examination revealed a solitary 6 × 6 mm black macule on the right lateral aspect of the surface of the tongue [Figure 1]. There were no other pigmented lesions found anywhere else on the infant’s body. A dermatological opinion was sought and a diagnosis of a congenital lingual melanotic macule was made. A biopsy was recommended; however, the family moved away and the patient was lost to follow-up. Figure 1: Five-month-old male infant with a solitary black congenital lingual melanotic macule measuring 6 × 6 mm on the right lateral aspect of the surface of the tongue (arrow).

A 16-Year-Old Female with Peutz-Jeghers Syndrome

Peutz-Jeghers syndrome is a rare autosomal dominant disorder of hamartomatous polyposis of the gastrointestinal tract, with pigmentation around lips and macules on the buccal mucosa that typically manifests itself as recurrent colicky abdominal pain and intestinal obstruction due to intussusception. Here we report a case of a 16-year-old girl who presented with abdominal pain, vomiting and previous history of laparotomy for intussusception. Multiple well demarcated black pigmented macules on lips, perioral region, buccal mucosa, digits, palms and soles were noted. She was diagnosed as a case of Peutz-Jeghers syndrome and managed conservatively. DOI: http://dx.doi.org/10.3329/jemc.v4i3.20958 J Enam Med Col 2014; 4(3): 184-187

Spontaneous regression of an epidermolysis bullosa nevus on the sole

Epidermolysis bullosa (EB) is a group of inherited rare diseases characterized by fragility and blistering of the skin and mucous membranes. An EB nevus (EBN) is a very rare acquired nevus that occurs only in patients with EB. An EBN usually arises in an area of previous blistering, and frequently has an atypical appearance that mimics malignant melanoma. We describe an older man with an EBN on the sole. Physical examination revealed irregularly pigmented band-like black macules on his right sole, suggestive of malignant melanoma. Dermoscopic examination showed a parallel furrow pattern with a monotonous area. The histopathological findings were consistent with a benign acquired nevus. Interestingly, the lesion regressed spontaneously within a year. To the best of our knowledge, this is the first reported case of EBN on the sole. Dermoscopy may be a useful addition to histopathological examination to ensure correct diagnosis of EBN.

Trichostasis spinulosa: An overlooked entity.

A 50-year-old female visited our department for the treatment of rosacea. Dermatological examination revealed erythematous papules and plaques over both cheeks. Black macules were found on the nose [Figure 1], but the patient was not worried about the lesions. Dermoscopic (×25 and ×60) examination revealed that the black macules were vellus hairs [Figure 2]. The hairs were plucked and observed under dermascope which showed multiple vellus hairs bundled in a funnel-like structure [Figure 3]. The above findings were suggestive of trichostasis spinulosa (TS). Patient refused treatment for the lesions.Figure 1: Multiple black macules on noseFigure 2: Dermoscopic (×25 and ×60) examination revealing vellus hairsFigure 3: Plucked hairs observed under dermascope (×25 and ×60) showing multiple vellus hairs bundled in a funnel-like structureTS is a very common but unrecognized disorder of pilosebaceous unit. It is a midfacial disease that occurs in younger age in female patients with Fitzpatrick skin type III or higher. It may also occur in light-skinned older people with excessive ultraviolet-exposure.[12] TS was first recognized by the German dermatologist Felix Franke in 1901, who named it “Pinselhaar” (paintbrush hair). In 1913, Noble first coined the term “trichostasis spinulosa.”[1] The exact etiology of this disease is not known. Abnormal angulation of the hair follicle may lead to the entrapment of vellus hairs. Follicular hyperkeratosis of a dilated vellus hair follicle leading to retention of successive telogen hairs is another explanation. Number of retained hairs may range from 5 to 60.[12] TS occurs sporadically, but many trigger factors have been identified. These include topical minoxidal, topical steroids, chronic renal failure, dust, oils, ultraviolet light, heat, and irritants.[12] Two variants of TS have been described: Nonpruritic type, which is classical and often seen in the elderly as asymptomatic blackhead-like lesions located on the face. The other variant is the pruritic type, characterized by multiple pinhead-sized papules on the trunk and upper extremities in young adults.[3] The present case is a classical type with the involvement of nose. Various modalities of treatment are tried with variable results which includes emollients, hydroactive adhesive tapes, local keratolytics, local and oral retinoids.[1] Repeated peeling with capryloyl salicylic acid has given good result.[2] Herein we present a classical case of TS to increase the awareness of this common disease.

Recurrent acral lentiginous melanoma in situ suggesting the field cell theory.

Dear Editor: Acral lentiginous melanoma (ALM) is the most common type of cutaneous melanoma in Asians. Traditionally, ALM is believed to have a poor prognosis because of its aggressive behavior and a short radial growth phase, compared with that of lentigo maligna melanoma1. We describe a case of recurrent ALM in situ around the primary site during 8 years. A 56-year-old female patient presented with a black macule having an irregular border and color variegation on the left heel, which started 8 years ago (Fig. 1A). Dermoscopic examination showed a parallel ridge pattern and irregular pigmentation. She had undergone excisional biopsy (3-mm margin), which revealed only a few scattered melanocytes along the basal layer. She had returned after 2 years (Fig. 1B) and then after 4 years (Fig. 1C) because of newly appearing brown patches around the first location. Serial punch biopsies revealed mild melanocytic hyperplasia without marked cytologic atypia again. The results made a pathologist hesitant to diagnose ALM in situ instead of atypical melanocytic At that time, the patient didn't want additional surgery; we recommended regular follow-up considering the possibility of melanocytic proliferation. Most recently, she presented with further enlarged, multiple pigmented patches (Fig. 1D). She was treated with wide excision (1-cm margin) and split-thickness skin graft under the consideration of malignant melanoma. Bland lentiginous proliferation of melanocytes confined to the epidermis prompted the final diagnosis of ALM in situ (Fig. 1E). Immunohistochemically, melanocytes were stained positively for Melan-A, HMB-45, and anti-S-100 (Fig. 1F). Fig. 1 Acral lentiginous melanoma in situ. Clinical and histopathological feature. (A) Initial presentation 8 years ago. (B) Second presentation 6 years ago. (C) Third presentation 4 years ago. (D) Last presentation. Left, gross picture of the lesion; center, ... ALM was believed to have an aggressive biological behavior. However, in Asians, the specific population was reported inconsistent with the classical concept. After Nogita et al.2 described melanosis of the foot, acral melanocytic lesions have been described with histopathologically subtle melanocytic proliferation, despite clinically malignant melanoma3. These lesions did not show invasive behavior over a decade; though some of them reappeared around the primary site even after the surgical excision. There has been debate about the nature of these lesions; however, they are now considered as the precursor of ALM that fulfills both the clinical and dermoscopic criteria4. The most notable feature of our case was the recurrent melanocytic lesions appearing around the primary site in the absence of invasion during 8 years. Takata et al.5 suggested that acral and mucosal melanomas could originate from field melanocytes detected in normallooking skin extending over the obvious lesion. These field cells harbor mutations of the KIT gene and amplifications of cyclin D1 or cyclin-dependent kinase 4 gene. Although our case initially showed only bland melanocytic proliferation without marked atypia or invasion, local melanoma could reappear from the residual field cells. Therefore, we recommend that the clinician should consider these lesions as ALM in situ and treat with early complete excision. Also, it is better to perform an excisional biopsy for a review of the entire lesion in the suspicious acral melanocytic lesions. Finally, regular follow-up for several years is important for the detection of reappearing melanoma around the primary site, even after the surgical excision.

Bullous Annular Erythema as a Cutaneous Sign of Vaginal Stump Adenocarcinoma

Dear Editor: A 76-year-old Korean woman presented with a 5-day history of asymptomatic, slightly expanding cutaneous lesions. She had hypertension, diabetes mellitus, and a history of total hysterectomy. Physical examination revealed bullous annular reddish patches on the abdomen and right thigh (Fig. 1A, B). Interestingly, each patch had a tiny ring-shaped black macule at its center (Fig. 1A, B inset). Histopathological analysis revealed intraepidermal blister, diffuse dyskeratosis, and karyopyknosis in the epidermis (Fig. 2A, B). Also, dense perivascular lymphocytic infiltrates presented in the upper dermis (Fig. 2C). Several days after, she was diagnosed with vaginal stump adenocarcinoma with multiple metastases including lung, liver, urinary bladder, and abdominal wall. The vaginal tumor was completely removed and then the cutaneous lesions spontaneously disappeared. Therefore, we suspected these lesions might be associated with her primary tumor. Till now, she has received supportive treatments without recurrence of skin lesions. Fig. 1 (A, B) Multiple bullous annular reddish patches on the center of the abdomen and anterolateral aspect of the right thigh. The patches have bullous rims and central tiny ring-shaped black macules (inset). Fig. 2 (A) Intraepidermal and focal suprabasal detachment of the epidermis due to blister formation (H&E, ×100). (B) Detached epidermis with dyskeratosis and karyopyknosis (H&E, ×200). (C) Rete ridge flattening and dense perivascular ... Paraneoplastic dermatoses are the signs of internal malignancy1. There are various types of paraneoplastic dermatoses including annular erythema. Annular erythema described in the context of malignancy is usually erythema annulare centrifugum (EAC) or erythema gyratum repens. EAC appears as multiple polycyclic lesions simulating urticarial papules that enlarge centrifugally. Some reports of malignancy-associated EAC have been presented. According to the reports, EAC is related with solid and hematologic malignancies such as breast cancer, leukemia, and lymphoma2,3. Histopathologically, it is characterized by perivascular tightly cuffed 'coat-sleeve-like' lymphohistiocytic infiltrates. Occasionally, focal epidermal spongiosis and parakeratosis may be founded. Erythema gyratum repens is the annular erythema most consistently associated with cancer. It is characterized by multiple concentric, erythematous, scaly bands and migrates over the skin, leaving a 'wood grain' appearance. The histopathological findings are non-specific. Both dermatoses commonly improve or resolve after successful treatment of the underlying illness. The pathogenesis of paraneoplastic dermatoses is not understood. However, because of frequent improvement upon treatment of the tumor, underlying malignancy is thought to play a role. Recent literatures suggest paraneoplastic dermatoses are the result of interaction between the tumor, involved tissue, and some mediators such as polypeptides, hormones, cytokines, antibodies and growth factors4,5. These factors interfere with cell to cell communication, resulting in an increase of cellular activity. Interestingly, paraneoplastic dermatoses often disappear in the terminal stage of malignancy. This is purported by immune compromise due to the progression of the tumor. In our current report, despite the presence of dense perivascular lymphocytic infiltrates, other histological and clinical findings were not consistent with EAC. In addition, they also were not consistent with other dermatoses including erythema gyratum repens. Considering the clinical course of the lesions, the erythema might be associated with the patient's internal malignancy. However, despite the remaining metastatic tumors, the skin lesions completely resolved. It is thought that the remission was induced by the patient's immune-compromised condition rather than removal of the primary tumor. Therefore, we herein report that this unique annular erythema may be an atypical type of EAC or a new kind of paraneoplastic dermatoses. Thus, in cases of unusual annular erythema, dermatologists should consider evaluation of internal malignancy.

Cutaneous amalgam tattoo in a dental professional: an unreported occupational argyria

Funding sources: This work was supported by the Brazilian Federal Agency of Support and Evaluation of Postgraduate Education (CAPES). Conflicts of interest: none declared. Madam, Amalgam tattoo is the most common exogenous pigmentation of the oral mucosa1, 2; surprisingly, there are no reports of similar lesions on the skin. It is caused by traumatic implantation of amalgam fragments into the oral mucosa following dental treatment, particularly when amalgam fillings are removed with high‐speed instruments. Amalgam tattoo occurs mostly in the gingiva and alveolar mucosa. Clinically it presents as an asymptomatic bluish to black macule, eventually observed by the patient or discovered during routine dental treatment. Histologically it shows brown to black aggregates of granules interspersed among collagen fibres and around blood vessels. Most cases show a slight inflammatory response, and eventually a foreign body granulomatous reaction is found.1–4 Cases of cutaneous localized argyria are uncommon, and are usually attributed to trauma, acupuncture, topical silver‐based medication or use of pieces of jewellery such as earrings.5–7 We report a case of cutaneous amalgam tattoo caused by implantation of amalgam particles on the skin of the eyebrow of a dental surgeon.

Peutz-Jegher’s Syndrome – A Case Report / Peutz-Jegher’s sindrom - prikaz slučaja

Abstract Peutz-Jegher’s syndrome is a hereditary disorder characterized by melanocytic macules on the lips and buccal mucosa and multiple gastrointestinal hamartomatous polyps. It is caused by a mutation localized on chromosome 19p13.3. Skin and mucosal pigmentation may be present at birth and usually occur in early childhood, but occasionally may develop later. It is associated with an increased risk of malignancy for gastrointestinal carcinoma and also for breast, ovarian, testiscular, pancreatic and gallbladder cancer. We report a 12-year-old girl who presented with disseminated petty yellowish macules on the bridge of her nose, numerous brown to bluish black macules on her lips and buccal mucosa. Mucocutaneous pigmentation has been present from the age of five, with a negative family history. In our patient, esophageal endoscopy was normal, while the endoscopy of stomach and duodenum revealed multiple diminutive polyps. After clinical evaluation, there were no indications for therapy. Further follow up was suggested. Continuous surveillance is very important for patients with Peutz-Jegher’s syndrome in order to reduce risks of cancer and prevent other morbidity and mortality.

Trichostasis Spinulosa Confirmed by Standard Skin Surface Biopsy

Trichostasis spinulosa (TS) is a common but rarely diagnosed disease. For diagnosis, it's sufficient to see a bundle of vellus hair located in a keratinous sheath microscopically. In order to obtain these vellus hair settled in comedone-like openings, Standard skin surface biopsy (SSSB), a non-invasive method was chosen. It's aimed to remind the differential diagnosis of TS in treatment-resistant open comedone-like lesions and discuss the SSSB method in diagnosis. A 25-year-old female patient was admitted with a complaint of the black spots located on bilateral cheeks and nose for 12 years. In SSSB, multiple vellus hair bundles in funnel-shaped structures were observed under the microscope, and a diagnosis of ‘TS’ was made. After six weeks of treatment with tretinoin 0.025% and 4% erythromycin jel topically, the appearance of black macules was significantly reduced. Treatment had to be terminated due to her pregnancy, and the lesions recurred within 1 month. It's believed that TS should be considered in the differential diagnosis of treatment-resistant open comedone-like lesions, and SSSB might be an inexpensive and effective alternative method for the diagnosis of TS.

A Subungual Blue Naevus Showing Expansile Growth

A 64-year-old woman presented with a 3-year history of brownish, longitudinal melanonychia on the left third fingernail with no associated symptoms. Physical examination revealed that approximately 25% of the nail plate was covered with scattered, brownish, longitudinal, pigmented streaks. There were no visible nail plate changes, and periungual pigmentation was not evident. Lymphadenopathy was not present. After nail avulsion, a 0.2 × 0.3 cm irregular pigmented macule and peripheral scattered tiny macules were observed (Fig. 1a). Routine laboratory investigations and physical examination were unremarkable. The punch biopsy demonstrated a poorly circumscribed, dermal spindle cell proliferation separated from the overlying epidermis by a Grenz zone. There were bipolar melanocytes with elongated dendritic processes, some containing cytoplasmic melanin, along with scattered melanophages (Fig. 2a). Mitotic figures were not present and there was no pleomorphism. The dendritic cells were positive for S-100, HMB 45, and MART-1. These findings were consistent with a common blue naevus, and regular follow-up of the lesion was recommended. The size of the melanonychia increased over time, until approximately 80% of the nail plate was involved at a 3-year follow-up. The lesion remained asymptomatic. After repeated nail avulsion, a 1 × 0.7 cm homogenous dark black macule was observed in the nail bed (Fig. 1b), which did not involve the periungual skin or proximal nail fold. We conducted a second biopsy under local anaesthesia. The specimen demonstrated an increased cellular infiltration of dermal dendritic cells (Fig. 2b), which extended into the mid-dermis, but did not involve the subcutaneous adipose tissue. There were no mitotic figures or atypical cells. These findings were also consistent with a common blue naevus. We recommended excising the lesion because of its enlargement, but the patient declined. Ten months later, the lesion involved the entire nail bed (Fig. 1c), although it had not spread to the periungual skin or proximal nail fold. A third punch biopsy was performed and demonstrated pigmented dendritic cells with scattered epithelioid cells with vesicular nuclei (Fig. 2c). These dendritic cells were vertically oriented and penetrated into the deep mid-dermis. Pigmented, round, epithelioid cells with variable melanophages were present. This sample demonstrated some biphasic pattern of dermal cells, but did not have the typical dumbbell pattern of a cellular blue naevus. There was no significant cytological atypia, and there were no mitotic figures. The lesional cells were positive for S-100, HMB 45 and MART-1, but negative for Ki-67. As the vertically-oriented dendritic cells were increasing in depth penetration over time, removal of the entire lesion was strongly recommended. The lesion was subsequently excised completely and the patient received a nail bed graft.

Laugier-hunziker syndrome: A rare cause of oral and acral pigmentation

Laugier–Hunziker syndrome (LHS) is an acquired, benign pigmentary skin condition involving oral cavity including lower lip in the form of brown black macules 1–5 mm in size, frequently associated with longitudinal melanonychia. There is no underlying systemic abnormality or malignant predisposition associated with LHS, and therefore the prognosis is good. Important differential diagnoses include Peutz Jeghers syndrome and Addison’s disease among other causes of oral and acral pigmentation. Treatment is sought mainly for cosmetic reasons and Q-switched Nd-Yag laser/ Q-switched alexandrite therapy and cryosurgery have been tried with varying success.