JEADV
LETTERS TO THE EDITOR
A case of Becker’s nevus with pityriasis versicolor Editor Becker’s nevus (or Becker’s melanosis) is an acquired, sporadic, persistent, asymmetrical area of skin pigmentation. It usually presents around puberty as asymptomatic, irregular, welldefined, discrete or confluent macules usually with hypertrichosis on the shoulder, anterior chest and scapular region. Pityriasis versicolor localized to Becker’s nevus was first reported by Robert Wright in 1979.1 We recently came across a similar case in our outpatient department, which prompted us to report this interesting clinical situation for its rarity, and possible role of topical azelaic acid in the treatment of Becker’s nevus. A 22-year-old male patient presented with irregular hyperpigmented macular lesions with geographical borders on the right shoulder and chest region since adolescence (Fig. 1). Since the last 2 months, he started developing asymptomatic, faint hypopigmented macules on his earlier lesions. There were no other cutaneous or systemic complaints. On examination, the hypopigmented lesions were found to be finely scaly and were superimposed on the hyperpigmented lesions. A 10% potassium hydroxide (KOH) mount from hypopigmented lesions demonstrated abundant filamentous hyphae and spores of Malassezia species. A skin biopsy from the hyperpigmented lesions for histopathology was taken, which showed mild hyperkeratosis and acanthosis along with hyperpigmentation of epidermis. Few melanophages and smooth muscle bundles were seen in dermis (Fig. 2). The findings were consistent with a diagnosis of Becker’s nevus. Thus, a final clinico-myco-pathological diagnosis of Becker’s nevus with pityriasis versicolor was made. The patient was treated with tablet fluconazole 400 mg single dose stat and topical clotrimazole 1% cream to be applied locally twice a day. At the follow-up visit 3 weeks later, no change in the hypopigmented skin colour was noted. A repeat 10% KOH examination was found to be negative for fungal elements. Becker’s nevus is a distinctive asymptomatic pigmented hamartomatous lesion. Onset is around adolescence (usually coinciding with puberty) with a prevalence of 0.25–0.52%.2,3 The association of Becker’s nevus with pityriasis versicolor was first noted by Wright in 1979. Later, few other workers reported this association.4 Other dermatological conditions which have been anecdotally reported with Becker’s nevus include lichen planus, granuloma annulare, hypohidrosis, lymphangioma, basal cell carcinoma and vitiligo. Acne and acneiform eruptions are more
JEADV 2014, 28, 1827–1836
common on Becker’s nevus and enlargement and alteration of pilosebaceous glands in Becker’s nevus has been described.5,6 It seems likely that the lipophilic nature of Malassezia, due to the
Figure 1 Becker’s nevus on chest and shoulder with interspersed hypopigmented macules.
Figure 2 Histopathology showing hyperpigmentation of epidermis with few melanophages and smooth muscle bundles in dermis (Haematoxylin and Eosin stain, magnification 409).
© 2014 European Academy of Dermatology and Venereology
Letters to the editor
1828
fact that most species of this organism are obligatory lipiddependant secondary to a defect in synthesis of myristic acid,7 would make the area of Becker’s nevus more appropriate for the growth of the organism. The hypopigmentation of pityriasis versicolor is hypothesized to be due to competitive inhibition of the enzyme tyrosinase by certain dicarboxylic acids (like azelaic acid) produced by the fungus and possibly direct cytotoxic effects of these acids on hyperactive melanocytes.8,9 In addition, several other factors have now been postulated for hypopigmentation, e.g., Malassezia indole A, which inhibits tyrosinase, malassezin which causes induction of apoptosis in melanocytes, pityriacitrin, which acting as a potent ultraviolet light filter might explain the ultraviolet protection in depigmented foci of pityriasis versicolor.7,10 The improvement in pigmentation in our patient with Becker’s nevus brings forth the possible significant therapeutic role of azelaic acid in Becker’s melanosis.4 Current treatment options for Becker’s nevus are mainly lasers, and corrective camouflage. Amongst the lasers, Er:Yag laser (Ellman, Hicksville, NY, USA) seems to give the most promising results; other lasers used for the condition include Q-switched ruby laser (GlobalSpec, Inc., East Greenbush, NY, USA), 694-nm long-pulsed ruby laser, Q-switched Nd:Yag laser (Spectrum Health & Beauty, Mumbai, India) and ablative fractional laser. Recently, successful use of topical flutamide (an antiandrogen) 4% solution in a female patient was reported by Taheri et al. Still, as systemic absorption of topical flutamide can occur, there is possibility of feminization of male fetus in a pregnant female. Second, Becker’s nevus is about five times more common in males and systemic absorption of flutamide may cause unacceptable side-effects like gynaecomastia, decreased libido, etc. Therefore, we suggest that topical azelaic acid would be an easily available option in such settings. In our opinion, long-term trials can find out efficacy of topical azelaic acid as compared to other options like laser and topical flutamide. Topical azelaic acid would also be useful in resource-limited settings. M. Sharma,1,* N.K. Kansal,1 R.K. Gautam2 1
Department of Dermatology and Venereology, 2Department of Orthopaedics, Gian Sagar Medical College and Hospital, Patiala, India *Correspondence: M. Sharma. E-mail: [email protected]
6 7 8 9
10
Oetting WS, Ortonne J-P, eds. The pigmentary system: physiology and pathophysiology, 2nd edn. Blackwell Publishing Ltd, Massachusetts, 2006; 915–917. Urbanek RW, Johnson WC. Smooth muscle hamartoma associated with Becker’s nevus. Arch Dermatol 1978; 114: 104–106. Hort W, Mayser P. Malassezia virulence determinants. Curr Opin Infect Dis 2011; 24: 100–105. Nazzaro-Porro M, Passi S. Identification of tyrosinase inhibitors in cultures of Pityrosporum. J Invest Dermatol 1978; 71: 205–208. De Luca C, Picardo M, Breathnach A, Passi S. Lipoperoxidase activity of Pityrosporum: characterisation of by-products and possible role in pityriasis versicolor. Exp Dermatol 1996; 5: 49–56. Mayser P, Gaitanis G. Physiology and Biochemistry. In Boekhout T, Gueho-Kellermann E, Mayser P, Velegraki , eds. Malassezia and the Skin: Science and Clinical Practice. Springer, Berlin, 2010; 121–138.
DOI: 10.1111/jdv.12375
Good syndrome and lichen planus: case and review Editor In 1954, Dr. Robert Good first described the association between thymoma and combined B-cell and T-cell immunodeficiency.1 As a rare cause of adult immunodeficiency now (a)
(b)
References 1 Wright RC. Another association with Becker’s nevus. Arch Dermatol 1979; 115: 1035. 2 Ingordo V, Gentile C, Iannazzone SS et al. The ‘EpiEnlist’ project: a dermoepidemiologic study on a representative sample of young Italian males. Prevalence of selected pigmentary lesions. J Eur Acad Dermatol Venereol 2007; 21: 1091–1096. 3 Tymen R, Forestier JF, Boutet B, Colomb D. Late Becker’s nevus. One hundred cases. Ann Dermatol Venereol 1981; 108: 41–46. 4 Singal A, Bhattacharya SN, Kumar S, Baruah MC. Hypopigmented pityriasis versicolor on Becker’s naevus: hope for new method of treatment? Indian J Dermatol Venereol Leprol 1998; 64: 137–138. 5 Levine N, Burk C. Becker nevus (section in Chapter 50: Acquired epidermal hypermelanoses). In Nordlund JJ, Boissy RE, Hearing VJ, King RA,
JEADV 2014, 28, 1827–1836
Figure 1 Oral Involvement of Erosive Lichen Planus in a 70-YearOld Woman With Good Syndrome. Linear erosions with fibromembranous slough and surrounding erythema affecting (a) the lateral aspect of the tongue and (b) the buccal mucosa.
© 2014 European Academy of Dermatology and Venereology
LETTERS TO THE EDITOR
A case of Becker’s nevus with pityriasis versicolor Editor Becker’s nevus (or Becker’s melanosis) is an acquired, sporadic, persistent, asymmetrical area of skin pigmentation. It usually presents around puberty as asymptomatic, irregular, welldefined, discrete or confluent macules usually with hypertrichosis on the shoulder, anterior chest and scapular region. Pityriasis versicolor localized to Becker’s nevus was first reported by Robert Wright in 1979.1 We recently came across a similar case in our outpatient department, which prompted us to report this interesting clinical situation for its rarity, and possible role of topical azelaic acid in the treatment of Becker’s nevus. A 22-year-old male patient presented with irregular hyperpigmented macular lesions with geographical borders on the right shoulder and chest region since adolescence (Fig. 1). Since the last 2 months, he started developing asymptomatic, faint hypopigmented macules on his earlier lesions. There were no other cutaneous or systemic complaints. On examination, the hypopigmented lesions were found to be finely scaly and were superimposed on the hyperpigmented lesions. A 10% potassium hydroxide (KOH) mount from hypopigmented lesions demonstrated abundant filamentous hyphae and spores of Malassezia species. A skin biopsy from the hyperpigmented lesions for histopathology was taken, which showed mild hyperkeratosis and acanthosis along with hyperpigmentation of epidermis. Few melanophages and smooth muscle bundles were seen in dermis (Fig. 2). The findings were consistent with a diagnosis of Becker’s nevus. Thus, a final clinico-myco-pathological diagnosis of Becker’s nevus with pityriasis versicolor was made. The patient was treated with tablet fluconazole 400 mg single dose stat and topical clotrimazole 1% cream to be applied locally twice a day. At the follow-up visit 3 weeks later, no change in the hypopigmented skin colour was noted. A repeat 10% KOH examination was found to be negative for fungal elements. Becker’s nevus is a distinctive asymptomatic pigmented hamartomatous lesion. Onset is around adolescence (usually coinciding with puberty) with a prevalence of 0.25–0.52%.2,3 The association of Becker’s nevus with pityriasis versicolor was first noted by Wright in 1979. Later, few other workers reported this association.4 Other dermatological conditions which have been anecdotally reported with Becker’s nevus include lichen planus, granuloma annulare, hypohidrosis, lymphangioma, basal cell carcinoma and vitiligo. Acne and acneiform eruptions are more
JEADV 2014, 28, 1827–1836
common on Becker’s nevus and enlargement and alteration of pilosebaceous glands in Becker’s nevus has been described.5,6 It seems likely that the lipophilic nature of Malassezia, due to the
Figure 1 Becker’s nevus on chest and shoulder with interspersed hypopigmented macules.
Figure 2 Histopathology showing hyperpigmentation of epidermis with few melanophages and smooth muscle bundles in dermis (Haematoxylin and Eosin stain, magnification 409).
© 2014 European Academy of Dermatology and Venereology
Letters to the editor
1828
fact that most species of this organism are obligatory lipiddependant secondary to a defect in synthesis of myristic acid,7 would make the area of Becker’s nevus more appropriate for the growth of the organism. The hypopigmentation of pityriasis versicolor is hypothesized to be due to competitive inhibition of the enzyme tyrosinase by certain dicarboxylic acids (like azelaic acid) produced by the fungus and possibly direct cytotoxic effects of these acids on hyperactive melanocytes.8,9 In addition, several other factors have now been postulated for hypopigmentation, e.g., Malassezia indole A, which inhibits tyrosinase, malassezin which causes induction of apoptosis in melanocytes, pityriacitrin, which acting as a potent ultraviolet light filter might explain the ultraviolet protection in depigmented foci of pityriasis versicolor.7,10 The improvement in pigmentation in our patient with Becker’s nevus brings forth the possible significant therapeutic role of azelaic acid in Becker’s melanosis.4 Current treatment options for Becker’s nevus are mainly lasers, and corrective camouflage. Amongst the lasers, Er:Yag laser (Ellman, Hicksville, NY, USA) seems to give the most promising results; other lasers used for the condition include Q-switched ruby laser (GlobalSpec, Inc., East Greenbush, NY, USA), 694-nm long-pulsed ruby laser, Q-switched Nd:Yag laser (Spectrum Health & Beauty, Mumbai, India) and ablative fractional laser. Recently, successful use of topical flutamide (an antiandrogen) 4% solution in a female patient was reported by Taheri et al. Still, as systemic absorption of topical flutamide can occur, there is possibility of feminization of male fetus in a pregnant female. Second, Becker’s nevus is about five times more common in males and systemic absorption of flutamide may cause unacceptable side-effects like gynaecomastia, decreased libido, etc. Therefore, we suggest that topical azelaic acid would be an easily available option in such settings. In our opinion, long-term trials can find out efficacy of topical azelaic acid as compared to other options like laser and topical flutamide. Topical azelaic acid would also be useful in resource-limited settings. M. Sharma,1,* N.K. Kansal,1 R.K. Gautam2 1
Department of Dermatology and Venereology, 2Department of Orthopaedics, Gian Sagar Medical College and Hospital, Patiala, India *Correspondence: M. Sharma. E-mail: [email protected]
6 7 8 9
10
Oetting WS, Ortonne J-P, eds. The pigmentary system: physiology and pathophysiology, 2nd edn. Blackwell Publishing Ltd, Massachusetts, 2006; 915–917. Urbanek RW, Johnson WC. Smooth muscle hamartoma associated with Becker’s nevus. Arch Dermatol 1978; 114: 104–106. Hort W, Mayser P. Malassezia virulence determinants. Curr Opin Infect Dis 2011; 24: 100–105. Nazzaro-Porro M, Passi S. Identification of tyrosinase inhibitors in cultures of Pityrosporum. J Invest Dermatol 1978; 71: 205–208. De Luca C, Picardo M, Breathnach A, Passi S. Lipoperoxidase activity of Pityrosporum: characterisation of by-products and possible role in pityriasis versicolor. Exp Dermatol 1996; 5: 49–56. Mayser P, Gaitanis G. Physiology and Biochemistry. In Boekhout T, Gueho-Kellermann E, Mayser P, Velegraki , eds. Malassezia and the Skin: Science and Clinical Practice. Springer, Berlin, 2010; 121–138.
DOI: 10.1111/jdv.12375
Good syndrome and lichen planus: case and review Editor In 1954, Dr. Robert Good first described the association between thymoma and combined B-cell and T-cell immunodeficiency.1 As a rare cause of adult immunodeficiency now (a)
(b)
References 1 Wright RC. Another association with Becker’s nevus. Arch Dermatol 1979; 115: 1035. 2 Ingordo V, Gentile C, Iannazzone SS et al. The ‘EpiEnlist’ project: a dermoepidemiologic study on a representative sample of young Italian males. Prevalence of selected pigmentary lesions. J Eur Acad Dermatol Venereol 2007; 21: 1091–1096. 3 Tymen R, Forestier JF, Boutet B, Colomb D. Late Becker’s nevus. One hundred cases. Ann Dermatol Venereol 1981; 108: 41–46. 4 Singal A, Bhattacharya SN, Kumar S, Baruah MC. Hypopigmented pityriasis versicolor on Becker’s naevus: hope for new method of treatment? Indian J Dermatol Venereol Leprol 1998; 64: 137–138. 5 Levine N, Burk C. Becker nevus (section in Chapter 50: Acquired epidermal hypermelanoses). In Nordlund JJ, Boissy RE, Hearing VJ, King RA,
JEADV 2014, 28, 1827–1836
Figure 1 Oral Involvement of Erosive Lichen Planus in a 70-YearOld Woman With Good Syndrome. Linear erosions with fibromembranous slough and surrounding erythema affecting (a) the lateral aspect of the tongue and (b) the buccal mucosa.
© 2014 European Academy of Dermatology and Venereology
