Diagnostic features of acquired dermal melanocytosis of the face and extremities.

Acquired dermal melanocytosis of the face and extremities (ADMFE) is an unusual form of acquired dermal melanocytosis (ADM). In this paper, we report a case of ADMFE and review the published literature. Our review highlights several clinical differences between ADMFE and ADM: (i) more frequent involvement of the nasal alae in ADMFE than in ADM, (ii) less frequent involvement of the cheeks in ADMFE than in ADM, (iii) limbs affected in all cases of ADMFE but in few cases of ADM, and (iv) frequent involvement of conjunctiva and/or gingiva in ADMFE but very rare involvement in ADM. These findings strongly support the hypothesis that ADMFE is clinically distinct from the classic form of ADM, and gaining an understanding of its phenotype will enable accurate diagnosis and early intervention by Q-switched laser therapy, which should benefit those patients with disease-related cosmetic issues.

Natural options for management of melasma, a review.

A blemish free, even-toned skin is universally associated with healthy skin. This reasoning makes people desire to have a flawless skin. Melanin is a naturally occurring pigment in humans. This pigment is responsible for skin, hair, and eye color, therefore determines our race and phenotypic appearance. On darker skin types, it is common that melanin production processes malfunctions. These malfunctions often lead to overproduction and secretion of melanin. As a result, unwanted pigmentary problems such melasma occur. Due to unknown etiology and its recurrence in nature, melasma is challenging to treat. The current available melasma treatment options often produce undesired side effects and suboptimum results. First-line topical treatments usually involve hydroquinone or topical steroids. Apart from the irritant reactions, this treatment mode is not suitable for all skin types. Skin care specialists are in search of an effective long-term cosmetics and cosmeceuticals to address hypermelanosis problems. Understanding of naturally occurring depigmenting agents provides an opportunity for more effective ways to manage melasma in all skin types. This review considers the benefits of naturally occurring ingredients which could help address skin pigmentation problems and broaden the choice for skin-lightening treatments.

Conjunctival Primary Acquired Melanosis: Is It Time for a New Terminology?

PURPOSE: To review the diagnostic categories of a group of conditions referred to as "primary acquired melanosis." DESIGN: Literature review on the subject and proposal of an alternative diagnostic schema with histopathologic and immunohistochemical illustrations. METHODS: Standard hematoxylin-eosin-stained sections and immunohistochemical stains for MART-1, HMB-45, microphthalmia-associated transcription factor (MiTF), and Ki-67 for calculating the proliferation index are illustrated. RESULTS: "Melanosis" is an inadequate and misleading term because it does not distinguish between conjunctival intraepithelial melanin overproduction ("hyperpigmentation") and intraepithelial melanocytic proliferation. It is recommended that "intraepithelial melanocytic proliferation" be adopted for histopathologic diagnosis. Atypical proliferations are characterized either by bloated dendritic melanocytes with enlarged cell components (dendrites, cell bodies, and nuclei) or by epithelioid melanocytes without dendrites. Atypical polygonal or epithelioid pagetoid cells may reach higher levels of the epithelium beyond the basal layer. Immunohistochemistry defines the degree of melanocytic proliferation or the cellular shape (dendritic or nondendritic) (MART-1, HMB-45) or identifies the melanocytic nuclei (MiTF). Intraepithelial melanocytic proliferation without atypia represents increased numbers of normal-appearing dendritic melanocytes (hyperplasia or early neoplasia) that generally remain confined to the basal/basement membrane region. Intraepithelial nonproliferative melanocytic pigmentation signifies the usually small number of conjunctival basal dendritic melanocytes that synthesize increased amounts of melanin that is transferred to surrounding keratinocytes. CONCLUSION: All pre- and postoperative biopsies of flat conjunctival melanocytic disorders should be evaluated immunohistochemically if there is any question regarding atypicality. This should lead to a clearer microscopic descriptive diagnosis that is predicated on an analysis of the participating cell types and their architectural patterns. This approach is conducive to a better appreciation of features indicating when to intervene therapeutically. An accurate early diagnosis should forestall unnecessary later surgery.

Proposed classification of longitudinal melanonychia based on clinical and dermoscopic criteria.

BACKGROUND: For longitudinal melanonychia, clinical and dermoscopic criteria for differentiating malignant melanoma in situ from benign nevus/lentigo/functional melanonychia have not been fully established. OBJECTIVE: To propose a clinical classification of longitudinal melanonychia that is useful in judging the need for follow-up. METHODS: A total of 137 patients with longitudinal melanonychia referred to our outpatient clinic in the most recent eight years were included. The mean and median lengths of follow-up for patients were 5.0 and 5.5 years, respectively. We classified the 137 lesions into three types by clinical and dermoscopic features of the nail and periungual skin, including Hutchinson sign, variation of color, and borders in the pigmentation band. We observed type I and II lesions with dermoscopy every six months and three months, respectively. RESULTS: After follow-up, all 72 lesions classified as type I were thought to be benign nevus/lentigo/functional melanonychia. Five of the 52 lesions classified as type II showed enlargement during follow-up, and biopsy was performed. Of these five lesions, three were diagnosed as nevus/lentigo, and the other two were diagnosed as malignant melanoma in situ. All 13 lesions classified as type III were diagnosed as malignant melanoma in situ. CONCLUSION: We can expect a type I lesion to be a benign nevus/lentigo/functional melanonychia and a type III lesion to be a malignant melanoma in situ; however, type II lesions fall in a gray zone. We believe this classification is useful in deciding treatment and follow-up.

Melanoacantosis bucal: diagnóstico y tratamiento de un caso clínico / Oral melanoacanthosis: diagnosis and treatment of a clinical case

La melanoacantosis es una lesión pigmentada bucal rara. Al observarse en el microscopio se aprecia una acantosis del epitelio superficial y presencia de melanocitos dendríticos. Las localizaciones más frecuentes son la encía, el paladar, el labio y las mucosas yugales. A pesar de que su patogénesis no se conoce bien, se sugiere que es una lesión de origen reactivo. Es importante realizar la biopsia para hacer el diagnóstico diferencial con otras lesiones pigmentadas, principalmente el melanoma.

Melanoacanthosis is a rare pigmented oral lesion. Under the microscope, acanthosis of the surface epithelium is observed, together with the pres-ence of dendritic melanocytes. The most commonly affected sites are the gums, palate, lips, and oral mucosa. Although the pathogenesis of melanoacanthosis is not well understood, the clinical behavior of lesions is suggestive of a reactive origin. Biopsy is important in order to make a differential diagnosis with other pigmented lesions, primarily melanoma.

Histological classification of melasma with reflectance confocal microscopy: a pilot study in Chinese patients.

OBJECTIVE: To investigate the histological classification of melasma with reflectance confocal microscopy (RCM) in vivo. METHODS: Two hundred and ten cases with facial melasma lesions were enrolled. After informed consent, the target melasma lesion of 10 patients were imaged with RCM and then biopsied as well. Under the RCM scanning, the distribution of the melanin determined the histological types, and then, the results of RCM images were compared with those of the histopathology. The other 200 cases were tested only with RCM. RESULTS: For the 10 cases imaged and biopsied, compared with that of the perilesional normal skin, the amount of melanin was significantly increased in the epidermis in all lesions under RCM, while three cases also found melanin in the dermis. Thus, seven of the 10 patients were categorized as the epidermal type while the other three as mixed ones, and the results were well correlated with those of the histopathology. Of the other 200 patients, 143 cases 71.5%) were categorized as the epidermal type while the other 57 (28.5%) cases as mixed ones. LIMITATIONS: If more melasma cases are biopsied, the data will be more convincing. CONCLUSION: RCM in vivo analysis shows complete coherence with histopathology results, which could be an alternative for the classification of melasma, and based on the results of RCM imaging, melasma is classified into two major types: the epidermal type and mixed type.

Characterization and evaluation of pigment distribution and response to therapy in melasma using in vivo reflectance confocal microscopy: a preliminary study.

BACKGROUND: Melasma is a frequent skin disorder characterized by the appearance of abnormal pigment (melanin) deposits in different layers of the skin. Melasma has been classified into epidermal, dermal and mixed types using Wood's lamp, and the type and extent of the pigment deposits determine the type and invasiveness of the treatment. AIMS: The aims of this study were to carry out a preliminary evaluation of the effective usefulness of reflectance confocal microscopy (RCM) in pigment distribution definition and subsequent re-classification of melasma types. Moreover, RCM therapeutical follow-up efficiency to combination therapy with pyruvic acid and hydroquinone was also tested. MATERIALS AND METHODS: A small group (n=15) of patients previously diagnosed with facial melasma were selected and their pigment distribution was evaluated by RCM. In seven of these patients therapeutical follow-up was performed. RESULTS: The results of the study suggest that RCM is more accurate than techniques previously used in the diagnosis of melasma, thus providing precise information on the location and extent of pigment deposits. DISCUSSION AND CONCLUSION: The non-invasive nature of this technique suggests that RCM may be a suitable tool for treatment monitoring, providing additional information not only on the evolution of the disorder but also on the possible occurrence of therapeutical side or adverse effects.

Conjunctival melanoma and melanosis: a reappraisal of terminology, classification and staging.

This paper aims to stimulate debate on the terminology, classification, grading and staging of conjunctival melanosis and melanoma. We audited our results with 76 invasive conjunctival melanomas. Staging according to the sixth edition of the Tumour Node Metastasis (TNM) system did not correlate well with tumour extent and outcome. Approximately 50% of invasive melanomas were associated with 'primary acquired melanosis with atypia', a term which in our opinion underestimates the gravity of this disease. We also found deficiencies in the grading, terminology and classification of conjunctival melanocytic abnormalities. In summary, we suggest that the term 'primary acquired melanosis' be reserved for clinical diagnosis. Histologically, this abnormality can be categorized more precisely as either 'hypermelanosis' or 'conjunctival melanocytic intraepithelial neoplasia (C-MIN)'. 'Primary acquired melanosis without atypia' can be termed more accurately as 'C-MIN without atypia'. In view of the high risk of invasive melanoma, we suggest that 'primary acquired melanosis with atypia' be termed 'C-MIN' with atypia, with the more severe changes regarded as melanoma in situ. To improve objectivity in the reporting of C-MIN, we propose a scoring system based on horizontal and vertical spread and degree of severity of melanocytic atypia. We suggest that the TNM staging system for conjunctival melanoma be revised to: (i) include a Tis stage; (ii) take account of tumour size, quadrant and caruncular involvement; and (iii) improve staging of any local invasion beyond conjunctiva.

Therapeutical approaches in melasma.

Melasma (cloasma) is a typical hypermelanosis and a common dermatologic skin disease that involves sun-exposed areas of the skin. It mostly affects women of reproductive age. Solar and ultraviolet exposure are the most crucial etiologic factors. Pregnancy, certain endocrine disorders and hormonal treatments, cosmetics, phototoxic drugs, and antiseizure medications are well-known inducing and exacerbating factors. A classification of melasma is based on Wood's light examination, classifying it in four major clinical types and patterns: epidermal, dermal, mixed, and indeterminate. Different treatment options are currently available for melasma. The choice of proper treatment should take into account the type of melasma to be treated, the skin complexion of the patient, possible previous treatments, the expectations and compliance of the patient, and the season in which the treatment is started.

Pigmentary disorders in India.

This article addresses pigmentary disorders relevant to India. Many of these disorders are easily spotted because of the Indians' darker complexion. The authors examine hypopigmentary and hyperpigmentary disorders, defining the main characteristics of each and their relevance to the people of India, including social as well as physical ramifications. The authors propose the treatments available to Indians exhibiting these skin disorders.

Pigmentary disorders in the South East.

In this article, new information is introduced regarding vitiligo and melasma based on clinical studies of Korean patients and specific pigmentary disorders that occur in Asians. These disorders can be psychologically distressing because of their visible nature. They are especially resistant to various kinds of conventional treatments and tend to have a chronic progression that makes patients doubt the results and the prognosis.

Pigmentary disorders in China.

Because variations in the degrees of pigmentation occur in various regions of the body, there are different pigmentary diseases in various ethnic groups. We usually divide the disorders of melanin pigmentation into two types: hypermelanosis and hypomelanosis. These disorders may be due to genetic and environmental factors. Pigmentary disorders are more visible on the Chinese skin and are of great cosmetic concern to patients. In this article we introduce characteristic pigmentary disorders in China.

Predictive value of exfoliative cytology in pigmented conjunctival lesions.

PURPOSE: Pigmented lesions of the conjunctiva are often difficult to classify clinically. Exfoliative cytology may be helpful, but reliable data regarding the sensitivity and specificity of this test are currently lacking. We determined the value of exfoliative cytology with regard to pigmented conjunctival lesions. METHODS: A total of 294 smears from 182 patients were screened for malignancy within 6 months of exfoliative cytology. Smears were classified according to the following categories: grade 0 = insufficient material for diagnosis; grade 1 = normal conjunctival cells; grade 2 = melanocytes with mild atypia; grade 3 = melanocytes with moderate atypia, and grade 4 = melanocytes with severe atypia. RESULTS: The sensitivity, specificity, positive predictive value and negative predictive value of exfoliative cytology were 85%, 78%, 59% and 93%, respectively. CONCLUSION: Exfoliative cytology is a fast, easy and non-invasive technique that may be used in the evaluation of patients with a pigmented conjunctival lesion.

Melasma: a review.

OBJECTIVE: To better understand melasma, a review of its etiologic factors, classification, pathogenesis, and treatment was undertaken. METHODS: Articles discussing the above aspects of melasma were used to demonstrate what is currently known about the disease and how to treat it. RESULTS: Melasma is associated with many etiologic factors, most importantly, sun exposure. It occurs in three distributions and has four reported patterns of pigmentation. Among the many differences between melasma and normal skin, melasma skin contains increased melanin, melanocytes, and melanosomes, as well as increased synthesis of tyrosinase. Its pathogenesis remains largely unknown. Treatment consists of phenolic and nonphenolic depigmenting agents, chemical peels, lasers, and dermabrasion. CONCLUSION: Melasma is a common skin disorder. Although melasma has been studied, its pathogenesis remains largely unknown and its treatment is still met with difficulty. Randomized controlled trials involving larger numbers of patients and comparing treatments, as well as studying combination therapies, would be beneficial.

Diagnosis of arsenicosis.

Arsenicosis is chronic subclinical or clinical toxicity due to high level of arsenic in body. Diagnosis of arsenicosis was derived by chronological establishment of facts: (a) arsenic as the cause of malady, (b) drinking water (tubewell water) as the vehicle of arsenic, (c) soil as the source of arsenic, (d) mechanism of leaching of arsenic from soil, and (e) cause of prevalence in particular areas of the country. Arsenicosis has been classified by the author into 4 stages, 7 grades and 20 subgrades. Stage I is pre-clinical or grade 0. While clinical features were not found at this stage, high level of arsenic metabolites was observed in urine. As disease progressed to stable phase of grade 0, high level of arsenic was also found in nails, hair, and skin scales. Stage II or clinical stage is divided into 4 grades, (1) Melanosis, (2) Spotted keratosis in palms/soles, (3) Diffuse keratosis in palms/soles, and (4) Dorsal keratosis. Clinical complications are grouped in stage III and grade 5. Malignancy is considered in stage IV and grade 6. There is a concern of both underdiagnosis and overdiagnosis. Therefore, cases of arsenicosis should be cautiously evaluated. Melanosis was the earliest cutaneous sign of clinical arsenicosis. Mild cases of melanosis could only be revealed by a thorough comparison with normal palms. Similarly mild cases of keratosis might not be visible and could only be revealed by careful palpation of palms and soles. Combination of melanosis and keratosis in adults indicated clinical diagnosis of arsenical dermatosis (ASD) that should be confirmed by showing high arsenic concentration in body tissues e.g., nails, hair, skin scales. Isolated melanosis or keratosis in newborn or children below 2 years almost negated the diagnosis of arsenicosis. Genetic melanosis or keratosis is often present since birth. Isolated melanosis or keratosis in adults should be differentiated from non-arsenical dermatosis and proven by absence of high arsenic level in nails and hair. Non arsenical causes of diffuse melanosis, spotted melanosis or leucomelanosis and localized or generalized keratosis can be clinically differentiated from arsenicosis by absence of pigmentation and keratosis in palms/soles.

Differential diagnosis of the conjunctival melanoses.

The conjunctival melanoses are a group of diseases that share the common clinical findings of flat granular melanin-pigmentation of the conjunctival epithelium. Because differential diagnosis of these lesions is difficult, there is much confusion in the literature regarding taxonomy of these lesions. A histopathologic classification of benign melanosis; primary acquired melanosis with atypia, and primary acquired melanosis with melanoma is proposed. Benign melanosis should be divided based on clinical findings into complexion-associated melanosis, secondary melanosis, ephelis, and primary acquired melanosis without atypia.

Acurácia do exame sob a lâmpada de Wood na classificaçäo dos cloasmas / Accurary of the exam with Wood's lamp in the classification of chloasmas

O cloasma é uma hipermelanose adquirida que ocorre, predominantemente, na face, sendo exacerbado pela luz. Está associado à gravidez, anovulatórios e outros medicamentos, podendo ser idiopático e ocorrer em homens. Clinicamente podemos classificá-lo em central ou periférico, conforme sua distribuiçäo topográfica e, histologicamente, em epidérmicos, dérmicos e mistos, de acordo com a localizaçäo predominante do pigmento. A identificaçäo näo invasiva do sítio do pigmento tem sido proposta pela utilizaçäo da lâmpada de Wood (observa-se tonalidade mais escura quando a melanina está situada mais superficialmente). Objetivo - Estabelecer a proporçäo de acertos na classificaçäo dos cloasmas pelo exame da pele sob a lâmpada de Wood, tendo como padräo ouro o exame histopatológico. Material e métodos - Sessenta e uma pacientes portadoras de cloasma foram submetidas ao exame sob a lâmpada de Wood e à biópsia de pele para identificar a principal localizaçäo do pigmento melânico. Os dados foram compilados e os resultados dispostos numa tabela 2 x 2, para cálculo da sensibilidade, especificidade e acurácia do teste, tendo por comparaçäo o exame histopatológico. Resultados - No cloasma epidérmico a acurácia foi de 52 por cento, a sensibilidade 61 por cento e a especificidade 40 por cento; no dérmico encontramos acurácia de 46 por cento, sensibilidade 70 por cento e especificidade 41 por cento e, no misto, 41 por cento, 53 por cento e 37 por cento, respectivamente. Conclusöes - Concluimos que, na amostra estudada, o exame da pele sob a lâmpada de Wood, para classificaçäo dos cloasmas, mostrou-se medianamente sensível, porém com baixa especificidade, resultando em uma acurácia média de 46 por cento, aquém da expectativa