Letters to the Editor
Spitz nevus on the palm with crista transverse dots/dotted lines revealed by dermoscopic examination Dear Editor, Spitz nevus is a variant of melanocytic nevus characterized by spindle and/or epithelioid tumor cells. It usually develops on the face or neck; only three cases of Spitz nevus on the palm have been reported.1–3 Herein, we describe a case of Spitz nevus on the palm, in which crista dots/dotted lines were observed by dermoscopic examination. A 16-year-old male presented to our hospital for evaluation of an asymptomatic pigmented lesion, located on the right palm (Fig. 1a). He had noticed a pigmented spot 1 year previously but received no treatment. Afterwards, the spot enlarged gradually and comprised a striated pigmented lesion that measured 1 mm 9 5 mm. By dermoscopic examination, we detected non-typical parallel furrow pattern (PFP) with crista transverse dots/dotted lines and three subtle spike projections adjacent to the cristae cutis (Fig. 1b). We resected the lesion, and histopathological examination revealed several small nests in the lower half of the epidermis, composed of large epithelioid-shaped melanocytes. Artifactual clefts were observed between tumor nests and epidermal cells (Fig. 1c,d). No melanocytes were seen in the dermis. Based on these findings, we diagnosed the lesion as junctional Spitz nevus. Spitz nevus was first described by Sophie Spitz in 1948. It is also known as spindle and epithelioid cell nevus. It usually develops on the face or neck in the first two decades and consists of a dome-shaped; hairless; and red, skin-colored, brown or black nodule.4 Because our case indicated a brown-colored striated lesion and melanin pigment in histopathological examination, a more precise diagnosis may be Reed nevus, a variant
Figure 1. Spitz nevus on the palm. (a) Clinical features of the lesion. (b) Dermoscopic findings comprised non-typical parallel furrow pattern with crista transverse dots/dotted lines and three subtle spike projections (arrow). (c) Histopathological findings were tumor cell nests scattered in the epidermis (hematoxylin– eosin [HE] staining, original magnification 920). (d) Tumor nests were composed of large epithelioid-shaped melanocytes and artifactual clefts (arrowheads; HE, 9200).
of Spitz nevus. Some cases of Spitz nevus are difficult to differentiate from malignant melanoma based on clinical and/or histopathological manifestation. Dermoscopic examination is useful in differentiating Spitz nevus and malignant melanoma.2 Dermoscopic patterns most commonly associated with Spitz nevus are starburst; negative network; and thickened dark reticular, globular and homogenous patterns.5 However, we could not detect these typical patterns; rather, we observed only PFP with crista transverse dots/dotted lines and subtle projections. In addition, dermoscopy showed dots/dotted lines on both furrows and ridges, which would correlate with nests of melanin-laden melanocytes on both cristae profundae limitans and intermedia. Dermoscopic examination was performed in two previous cases of Spitz nevus on the palm. Yasuma et al. described a 9year-old girl with a pigmented macule of 1-year duration on her palm. Dermoscopic examination revealed blackish diffuse pigmentation with starburst and PFP.2 Histopathological examination revealed compound Spitz nevus. Vaccaro et al. described a 28-year-old woman with a 2-month history of a rapidly growing Spitz nevus on her palm.3 PFP, large radial projections and a globular pattern were observed by dermoscopic examination. Histopathologically, this case was junctional Spitz nevus, similar to ours. In our case, PFP and radial projection were also observed, although these features were subtle. Because Spitz nevus on the palm is rare, a characteristic pattern upon dermoscopic examination has not been described. However, clinicians should keep in mind that crista transverse dots/dotted line may be observed in Spitz nevi on the palm.
(a)
(c)
(b)
(d)
Correspondence: Koichi Nakagawa, M.D., Department of Dermatology, Saiseikai Tondabayashi Hospital, 1-3-36 Koyodai, Tondabayashi City, Osaka 584-0082, Japan. Email: [email protected]
© 2015 Japanese Dermatological Association
649
Letters to the Editor
CONFLICT OF INTEREST:
The authors declare no finan-
REFERENCES
cial or other conflict of interest. 1
1
Koichi NAKAGAWA, Masaru KISHIDA, Aya OKABAYASHI,1 Nami SHIMIZU,1 Mari TAGUCHI,1 Rie KINOSHITA,1 Masaru TANAKA,2 Hisayoshi IMANISHI,3 Daisuke TSURUTA3 1
2
Department of Dermatology, Saiseikai Tondabayashi Hospital, Osaka, Department of Dermatology, Tokyo Women’s Medical University Medical Center East, Tokyo, and 3Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
1 Banba K, Fujioka A, Takasu H, Ishibashi A, Ohta M. Spitz nevus on the palmar surface. J Dermatol 2000; 27: 333–336. 2 Yasuma A, Hara H, Hukuda N, Terui T. Usefulness of dermoscopy for diagnosing pigmented Spitz nevus occurring on the glabrous skin. J Eur Acad Dermatol Venereol 2006; 20: 1362–1363. 3 Vaccaro M, Borgia F, Cannavo SP. Dermoscopy of pigmented variant of acral Spitz nevus. J Am Acad Dermatol 2015; 72: s11–s12. 4 Mackie RM, Champion RH, Burton JL, Burns DA, Breathnach SM, eds. Textbook of Dermatology, 6th edn. London: Blackwell Science, 1998; 1717–1752. 5 Kerner M, Jaimes N, Scope A, Marghoob AA. Spitz nevi: a bridge between dermoscopic morphology and histopathology. Dermatol Clin 2013; 31: 327–335.
doi: 10.1111/1346-8138.12860
Late-onset pyoderma gangrenosum following surgical operation in a patient with malignant melanoma Dear Editor, Pyoderma gangrenosum (PG) is a rare skin condition known to be precipitated by minor trauma and surgical procedures. We herein describe an elderly patient with malignant melanoma, who developed PG 8 months after surgical operation at the recipient as well as donor sites. An 83-year-old male visited our hospital, complaining of pigmented eruptions on the nose. Physical examination showed
(a)
(b)
(c)
several black-colored irregular-shaped, asymmetrical macules on the right side of the nose (Fig. 1a). A skin biopsy revealed proliferation of atypical melanocytes in the upper dermis (Fig. 1b), which were immunoreactive for S-100, MART-1 and HMB-45. After total resection, his nose was reconstructed using a forehead flap, nasolabial flap and costal cartilage graft. His right forehead was covered by full-thickness skin graft from the groin. After taking the cartilage, the surface skin of the
(e)
(d) Figure 1. (a) Pigmented patches on the nose. (b) Histological features showing atypical melanocytes in the dermis (hematoxylin–eosin [HE], original magnification 9100). Pyoderma gangrenosum lesion showing large ulceration with edematous borders and erythema on the (c) forehead and (d) chest. (e) Histological features showing prominent neutrophil infiltration (insert) (HE, 9200).
Correspondence: Tatsuhiko Mori, M.D., Department of Dermatology, Fukushima Medical University, 1 Hikarigaoka, Fukushima City, Fukushima 960-1247, Japan. Email: [email protected]
650
© 2015 Japanese Dermatological Association
Spitz nevus on the palm with crista transverse dots/dotted lines revealed by dermoscopic examination Dear Editor, Spitz nevus is a variant of melanocytic nevus characterized by spindle and/or epithelioid tumor cells. It usually develops on the face or neck; only three cases of Spitz nevus on the palm have been reported.1–3 Herein, we describe a case of Spitz nevus on the palm, in which crista dots/dotted lines were observed by dermoscopic examination. A 16-year-old male presented to our hospital for evaluation of an asymptomatic pigmented lesion, located on the right palm (Fig. 1a). He had noticed a pigmented spot 1 year previously but received no treatment. Afterwards, the spot enlarged gradually and comprised a striated pigmented lesion that measured 1 mm 9 5 mm. By dermoscopic examination, we detected non-typical parallel furrow pattern (PFP) with crista transverse dots/dotted lines and three subtle spike projections adjacent to the cristae cutis (Fig. 1b). We resected the lesion, and histopathological examination revealed several small nests in the lower half of the epidermis, composed of large epithelioid-shaped melanocytes. Artifactual clefts were observed between tumor nests and epidermal cells (Fig. 1c,d). No melanocytes were seen in the dermis. Based on these findings, we diagnosed the lesion as junctional Spitz nevus. Spitz nevus was first described by Sophie Spitz in 1948. It is also known as spindle and epithelioid cell nevus. It usually develops on the face or neck in the first two decades and consists of a dome-shaped; hairless; and red, skin-colored, brown or black nodule.4 Because our case indicated a brown-colored striated lesion and melanin pigment in histopathological examination, a more precise diagnosis may be Reed nevus, a variant
Figure 1. Spitz nevus on the palm. (a) Clinical features of the lesion. (b) Dermoscopic findings comprised non-typical parallel furrow pattern with crista transverse dots/dotted lines and three subtle spike projections (arrow). (c) Histopathological findings were tumor cell nests scattered in the epidermis (hematoxylin– eosin [HE] staining, original magnification 920). (d) Tumor nests were composed of large epithelioid-shaped melanocytes and artifactual clefts (arrowheads; HE, 9200).
of Spitz nevus. Some cases of Spitz nevus are difficult to differentiate from malignant melanoma based on clinical and/or histopathological manifestation. Dermoscopic examination is useful in differentiating Spitz nevus and malignant melanoma.2 Dermoscopic patterns most commonly associated with Spitz nevus are starburst; negative network; and thickened dark reticular, globular and homogenous patterns.5 However, we could not detect these typical patterns; rather, we observed only PFP with crista transverse dots/dotted lines and subtle projections. In addition, dermoscopy showed dots/dotted lines on both furrows and ridges, which would correlate with nests of melanin-laden melanocytes on both cristae profundae limitans and intermedia. Dermoscopic examination was performed in two previous cases of Spitz nevus on the palm. Yasuma et al. described a 9year-old girl with a pigmented macule of 1-year duration on her palm. Dermoscopic examination revealed blackish diffuse pigmentation with starburst and PFP.2 Histopathological examination revealed compound Spitz nevus. Vaccaro et al. described a 28-year-old woman with a 2-month history of a rapidly growing Spitz nevus on her palm.3 PFP, large radial projections and a globular pattern were observed by dermoscopic examination. Histopathologically, this case was junctional Spitz nevus, similar to ours. In our case, PFP and radial projection were also observed, although these features were subtle. Because Spitz nevus on the palm is rare, a characteristic pattern upon dermoscopic examination has not been described. However, clinicians should keep in mind that crista transverse dots/dotted line may be observed in Spitz nevi on the palm.
(a)
(c)
(b)
(d)
Correspondence: Koichi Nakagawa, M.D., Department of Dermatology, Saiseikai Tondabayashi Hospital, 1-3-36 Koyodai, Tondabayashi City, Osaka 584-0082, Japan. Email: [email protected]
© 2015 Japanese Dermatological Association
649
Letters to the Editor
CONFLICT OF INTEREST:
The authors declare no finan-
REFERENCES
cial or other conflict of interest. 1
1
Koichi NAKAGAWA, Masaru KISHIDA, Aya OKABAYASHI,1 Nami SHIMIZU,1 Mari TAGUCHI,1 Rie KINOSHITA,1 Masaru TANAKA,2 Hisayoshi IMANISHI,3 Daisuke TSURUTA3 1
2
Department of Dermatology, Saiseikai Tondabayashi Hospital, Osaka, Department of Dermatology, Tokyo Women’s Medical University Medical Center East, Tokyo, and 3Department of Dermatology, Osaka City University Graduate School of Medicine, Osaka, Japan
1 Banba K, Fujioka A, Takasu H, Ishibashi A, Ohta M. Spitz nevus on the palmar surface. J Dermatol 2000; 27: 333–336. 2 Yasuma A, Hara H, Hukuda N, Terui T. Usefulness of dermoscopy for diagnosing pigmented Spitz nevus occurring on the glabrous skin. J Eur Acad Dermatol Venereol 2006; 20: 1362–1363. 3 Vaccaro M, Borgia F, Cannavo SP. Dermoscopy of pigmented variant of acral Spitz nevus. J Am Acad Dermatol 2015; 72: s11–s12. 4 Mackie RM, Champion RH, Burton JL, Burns DA, Breathnach SM, eds. Textbook of Dermatology, 6th edn. London: Blackwell Science, 1998; 1717–1752. 5 Kerner M, Jaimes N, Scope A, Marghoob AA. Spitz nevi: a bridge between dermoscopic morphology and histopathology. Dermatol Clin 2013; 31: 327–335.
doi: 10.1111/1346-8138.12860
Late-onset pyoderma gangrenosum following surgical operation in a patient with malignant melanoma Dear Editor, Pyoderma gangrenosum (PG) is a rare skin condition known to be precipitated by minor trauma and surgical procedures. We herein describe an elderly patient with malignant melanoma, who developed PG 8 months after surgical operation at the recipient as well as donor sites. An 83-year-old male visited our hospital, complaining of pigmented eruptions on the nose. Physical examination showed
(a)
(b)
(c)
several black-colored irregular-shaped, asymmetrical macules on the right side of the nose (Fig. 1a). A skin biopsy revealed proliferation of atypical melanocytes in the upper dermis (Fig. 1b), which were immunoreactive for S-100, MART-1 and HMB-45. After total resection, his nose was reconstructed using a forehead flap, nasolabial flap and costal cartilage graft. His right forehead was covered by full-thickness skin graft from the groin. After taking the cartilage, the surface skin of the
(e)
(d) Figure 1. (a) Pigmented patches on the nose. (b) Histological features showing atypical melanocytes in the dermis (hematoxylin–eosin [HE], original magnification 9100). Pyoderma gangrenosum lesion showing large ulceration with edematous borders and erythema on the (c) forehead and (d) chest. (e) Histological features showing prominent neutrophil infiltration (insert) (HE, 9200).
Correspondence: Tatsuhiko Mori, M.D., Department of Dermatology, Fukushima Medical University, 1 Hikarigaoka, Fukushima City, Fukushima 960-1247, Japan. Email: [email protected]
650
© 2015 Japanese Dermatological Association
