INTERNATIONAL JOURNAL OF IMMUNOPATHOLOGY AND PHARMACOLOGY
Vol. 26, no. 4, 953-955 (2013)
LETTER TO THE EDITOR
INK SPOT LENTIGO: SINGULAR CLINICAL FEATURES IN A CASE SERIES OF PATIENTS U. BOTTONP, S. NISTICO I , G.F. AMORUSO!, G. SCHIPANP, v. ARCIDIACONO!, E. SCALI I , P. TASSONP, M. GREC03 and A. AMOROSI 4
Dermatology, 2Medical Oncology, 3Plastic Surgery and "Pathology Units, Department ofHealth Sciences, University ojCatanzaro "Magna Gracia", Catanzaro, Italy
J
Received August 28, 2013 - Accepted September 17, 2013 Ink spot lentigo, also known as "reticulated black solar lentigo", is a melanotic macula commonly described in fair-skinned individuals on sun-exposed areas ofthe body. Clinically it is a darkly pigmented type of solar lentigo; herein the term "ink spot" lentigo. In contrast to common solar lentigines, ink spot lentigo is reported as a unique lesion. However usually ink spot lentigo appears among several common solar lentigines. We report a series of 5 patients who presented ink spot lentigo with typical dermoscopic pattern but singular clinical features. Ink spot lentigo is a benign melanotic macular lesion described for the first time by Bolognia in 1992 (1). Its clinical and dermoscopic features are very peculiar. The lesion is usually reported to appear in a small dimension on sun-exposed areas in people with fair skin (1). We reviewed a series of cases. In particular, we report herein, a series of 5 patients who presented ink spot lentigo with typical dermoscopic pattern but singular clinical features.
whereas the other 4 patients were male and aged between 30 and 46 years. All the patients were skin type III (Fitzpatrick classification) with dark skin complexion. All ofthem had black hair. Four ofthem had brown eyes and only one had green eyes. All subjects showed only one ink spot lentigo among many other pigmented lesions. Regarding the site of localization, in 3 patients, the ink spot lentigines appeared on sun exposed areas (Fig. la), whereas in 2 patients (#1 and #2) the lesions were present in areas rarely exposed to the sun: the groin and the buttock, respectively (Fig. 1b). Regarding the dimensions, 4 lesions had a diameter less than 1 em, whereas the fifth case (#5) showed ink spot lentigo with uncommonly large dimensions, that is a diameter> 2cm (Fig. l c). In all the five lesions, dermoscopic features were consistent with the diagnosis ofink spot lentigo: all of them showed a reticular pattern with a characteristic beaded outline. (Fig. 2) In all the patients histological picture revealed
Case reports We observed five patients who presented pigmentary lesions with typical dermoscopic features of ink spot lentigo in the outpatient surgery of the Department of Dermatology at the University of Magna Graecia in Catanzaro between June 2004 and June 2013. In Table I we report the general clinical aspects of these subjects. Three of our patients were male and two were female, mean age was 32, with a range betweenl5 and 46. The 15-year-old was a female
Key words: ink spot lentigo, dermatoscopy. pigmented lesions Mailing address: Prof. Steven Nistico, Dermatologist Associate Professor of Dermatology, University Magna Graecia, Catanzaro Viale Europa, Gennaneto (Cl), 88100 Catanzaro, Italy Tel.fFax: +3909613694001 e-mail: [email protected]
0394-6320 (2013)
953
Copyright © by BIOLlfE, s.a.s. This publication and/or article is for individual use only and may not be further reproduced without written permission from the copyright holder. Unauthorized reproduction may result in financial and other penalties DISCLOSURE: ALL AUTHORS REPORT NO CONFLICTS OF INTEREST RELEVANT TO THIS ARTICLE.
954
U. BOTTONI ET AL.
Table I. Clinical characteristics of 5 patients with ink spot lentigo. Patients
Gender
Age
Phototype
Skin complexion
Hair
Eyes
Site
Size
#1
F
15
III
Dark- skinned
Black
Brown
Groin
0.3 cm
#2
F
37
III
Dark -skinned
Black
Green
Buttock
0.4 cm
#3
M
32
III
Dark- skinned
Black
Brown
Nape
O.4cm
#4
M
30
III
Dark- skinned
Black
Brown
Shoulder
0.7cm
#5
M
46
III
Dark- skinned
Black
Brown
Back
2.1 em
g.28
Fig. 1. a) Patient n 4 with ink spot lentigo on the right shoulder. b) Patient n 2 with ink spot lentigo on a nonexposed area (right buttock). c) Patient n 5 with a large ink spot lentigo un the dorsal area.
Fig. 2. a) Dermoscopic aspect of ink spot lentigo. b) Histopathological aspect ofink spot lentigo (patient n 2).
typical aspects of solar lentigo (Fig. 3), with very dark hyperpigmentation of the tips of rete ridges and presence of many dermal melanophages.
ink spot lentigo is reported as a unique lesion. However usually ink spot lentigo appears among several common solar lentigines. Dermoscopic features are characterized by a wiry or beaded, markedly irregular spider-like outline. Dermoscopy reflects its particular histological architecture characterized by hyperpigmentation ofthe tips of rete ridges (3). This lentiginous hyperplasia of epidermis, with pronounced hyperpigmentation of the basal layer, is associated with a significant increment of melanocytes; sometimes the fusion of rete ridges, a particular feature called "bridging phenomenon" is
DISCUSSION Ink spot lentigo, also known as "reticulated black solar lentigo", is a melanotic macula commonly described in fair-skinned individuals on sun-exposed areas of the body (2). Clinically it is a darkly pigmented type of solar lentigo; herein the term "ink spot" lentigo. In contrast to common solar lentigines,
101.J. Immuoopalhol. Pharmacol.
observed. Often there are several melanophages in the dermis (4). On the basis of clinical and dermoscopical features, ink spot lentigo may be easily diagnosed, and histological findings can confirm the diagnosis. It must be regarded as a distinctive entity and a benign lesion. Like the solar lentigo, ink spot lentigo has been regularly described on fair-skinned people with Fitzpatrick's skin phototype I and II (2). On the contrary, our patients were all skin type III. Regarding the site of localization, ink spot lentigo appears on sun-exposed skin, intermingled with solar lentigines and/or actinic keratoses; however in two of our patients the sites were very uncommon, being respectively the groin and the buttocks. Ink-spot lentigines may suggest melanoma (5) because of their dark colour, irregular border, and unique number. However they are generally small with a diameter less than 6 mm. In our group of patients #5 had ink spot lentigo so unusually large, a diameter more than 2 em, as to propose a differential diagnosis with melanoma. Dermoscopic features were typical for "reticulated black solar lentigo", and the histological exam definitely excluded the possibility of a melanocytic malignant tumour. International literature considers ink spot lentigo as a separated clinico-pathological entity with typical dermoscopic and histopathological features (6-10). To date, also the clinical characteristics are considered as typical. However, our findings seem to contradict some of these features. In fact, all of our patients were ofphototype III whereas in the literature only subjects with phototypes I or II are reported. Moreover, two of our patients had the lesions on atypical areas, the groin and buttocks, instead of the typical localization on sun-exposed areas such as the upper part of back (11). Finally, one of our patients had a lesion so large as to be considered suspicious for malignant melanoma. The unique clinical features that we observed are probably related to geographical aspects. In fact, our Department of Dermatology is located in the Catanzaro province, in Calabria, a region of Southern Italy. In this geographic area, subjects generally have a skin phototype III or IV, with dark skin complexion and dark hair and eyes. As Calabria is an extremely sunny area, the population is commonly
955
overexposed to UV light. Nowadays, the young and adult population prevalently work indoors. On the contrary, their aged parents used to work prevalently outdoors as farmers and were therefore chronically exposed to UV light. This observation could explain the presence of typical ink spot lentigo in young dark-skinned people. REFERENCES I.
Bolognia JL. Reticulated black solar lentigo ('ink spot' lentigo). Arch Dermatol 1992; 128(7):934-40. 2. Smith SR, O'Grady TC. Reticulated ephelides: 'inkspots' revisited. Arch Dermatol 1996; 132(3):353-4. 3. Kaddu S, Wolf I, Soyer HP, Kerl H Reticulated black solar lentigo. Clinicopathologic features and differential diagnosis. Br J Dermatol 1994; 131 :81. 4. Kaddu S, Wolf I, Soyer HP, Kerl H. Reticulated black solar lentigo (Reticulated melanotic macule) is not a solar lentigo. Dermatopath Pract Concept 1995; 1:225-28. 5. Kaddu S, Soyer HP, Wolf IH, Rieger E, Kerl H. Retikulare Lentigo. Hautarzt 1997; 48(3):181-5. 6. Wheat CM, Wesley NO, Jackson BA. Recognition of skin cancer and sun protective behaviours in skin of color. J Drugs Dermatol2013; 12(9):1029-32. 7. Ji AL, Baze MR, Davis SA, Feldman SR, Fleischer AB Jr. Ambulatory melanoma care patterns in the United States. J Skin Cancer 2013; Epub Aug 21. 8. Chiricozzi S, Zhang A, Dattola, Gabellini M, Chimenti S, Nistico SP. Role of Thl7 in the pathogenesis of cutaneous inflammatory diseases J BioI Regul HomeostAgents 2012; 26 (3):313-8. 9. Chiricozzi S, Zhang A, Dattola MV, Cannizzaro M, Gabellini S, Chimenti S, Nistico SP. New insights in the pathogenesis ofcutaneous autoimmune disorders. J BioI Regul Homeost Agents 2012; 26(2): 165-70. 10. Bottoni U, Nistico S, Amoruso G, Sacco A, Arcidiacono V, Calvieri S. Erythema multiforme major after whole brain radiotherapy: a case of EMAR syndrome? Eur J Inflamm 2013; In press. 11. Nistico S, Saraceno R, Stefanescu S, Chimenti S. 308nm Monochromatic Excimer Light in the treatment of Palmoplantar Psoriasis. J Eur Acad Dermatol Venereol 2006; 20 (5):523-26.
Vol. 26, no. 4, 953-955 (2013)
LETTER TO THE EDITOR
INK SPOT LENTIGO: SINGULAR CLINICAL FEATURES IN A CASE SERIES OF PATIENTS U. BOTTONP, S. NISTICO I , G.F. AMORUSO!, G. SCHIPANP, v. ARCIDIACONO!, E. SCALI I , P. TASSONP, M. GREC03 and A. AMOROSI 4
Dermatology, 2Medical Oncology, 3Plastic Surgery and "Pathology Units, Department ofHealth Sciences, University ojCatanzaro "Magna Gracia", Catanzaro, Italy
J
Received August 28, 2013 - Accepted September 17, 2013 Ink spot lentigo, also known as "reticulated black solar lentigo", is a melanotic macula commonly described in fair-skinned individuals on sun-exposed areas ofthe body. Clinically it is a darkly pigmented type of solar lentigo; herein the term "ink spot" lentigo. In contrast to common solar lentigines, ink spot lentigo is reported as a unique lesion. However usually ink spot lentigo appears among several common solar lentigines. We report a series of 5 patients who presented ink spot lentigo with typical dermoscopic pattern but singular clinical features. Ink spot lentigo is a benign melanotic macular lesion described for the first time by Bolognia in 1992 (1). Its clinical and dermoscopic features are very peculiar. The lesion is usually reported to appear in a small dimension on sun-exposed areas in people with fair skin (1). We reviewed a series of cases. In particular, we report herein, a series of 5 patients who presented ink spot lentigo with typical dermoscopic pattern but singular clinical features.
whereas the other 4 patients were male and aged between 30 and 46 years. All the patients were skin type III (Fitzpatrick classification) with dark skin complexion. All ofthem had black hair. Four ofthem had brown eyes and only one had green eyes. All subjects showed only one ink spot lentigo among many other pigmented lesions. Regarding the site of localization, in 3 patients, the ink spot lentigines appeared on sun exposed areas (Fig. la), whereas in 2 patients (#1 and #2) the lesions were present in areas rarely exposed to the sun: the groin and the buttock, respectively (Fig. 1b). Regarding the dimensions, 4 lesions had a diameter less than 1 em, whereas the fifth case (#5) showed ink spot lentigo with uncommonly large dimensions, that is a diameter> 2cm (Fig. l c). In all the five lesions, dermoscopic features were consistent with the diagnosis ofink spot lentigo: all of them showed a reticular pattern with a characteristic beaded outline. (Fig. 2) In all the patients histological picture revealed
Case reports We observed five patients who presented pigmentary lesions with typical dermoscopic features of ink spot lentigo in the outpatient surgery of the Department of Dermatology at the University of Magna Graecia in Catanzaro between June 2004 and June 2013. In Table I we report the general clinical aspects of these subjects. Three of our patients were male and two were female, mean age was 32, with a range betweenl5 and 46. The 15-year-old was a female
Key words: ink spot lentigo, dermatoscopy. pigmented lesions Mailing address: Prof. Steven Nistico, Dermatologist Associate Professor of Dermatology, University Magna Graecia, Catanzaro Viale Europa, Gennaneto (Cl), 88100 Catanzaro, Italy Tel.fFax: +3909613694001 e-mail: [email protected]
0394-6320 (2013)
953
Copyright © by BIOLlfE, s.a.s. This publication and/or article is for individual use only and may not be further reproduced without written permission from the copyright holder. Unauthorized reproduction may result in financial and other penalties DISCLOSURE: ALL AUTHORS REPORT NO CONFLICTS OF INTEREST RELEVANT TO THIS ARTICLE.
954
U. BOTTONI ET AL.
Table I. Clinical characteristics of 5 patients with ink spot lentigo. Patients
Gender
Age
Phototype
Skin complexion
Hair
Eyes
Site
Size
#1
F
15
III
Dark- skinned
Black
Brown
Groin
0.3 cm
#2
F
37
III
Dark -skinned
Black
Green
Buttock
0.4 cm
#3
M
32
III
Dark- skinned
Black
Brown
Nape
O.4cm
#4
M
30
III
Dark- skinned
Black
Brown
Shoulder
0.7cm
#5
M
46
III
Dark- skinned
Black
Brown
Back
2.1 em
g.28
Fig. 1. a) Patient n 4 with ink spot lentigo on the right shoulder. b) Patient n 2 with ink spot lentigo on a nonexposed area (right buttock). c) Patient n 5 with a large ink spot lentigo un the dorsal area.
Fig. 2. a) Dermoscopic aspect of ink spot lentigo. b) Histopathological aspect ofink spot lentigo (patient n 2).
typical aspects of solar lentigo (Fig. 3), with very dark hyperpigmentation of the tips of rete ridges and presence of many dermal melanophages.
ink spot lentigo is reported as a unique lesion. However usually ink spot lentigo appears among several common solar lentigines. Dermoscopic features are characterized by a wiry or beaded, markedly irregular spider-like outline. Dermoscopy reflects its particular histological architecture characterized by hyperpigmentation ofthe tips of rete ridges (3). This lentiginous hyperplasia of epidermis, with pronounced hyperpigmentation of the basal layer, is associated with a significant increment of melanocytes; sometimes the fusion of rete ridges, a particular feature called "bridging phenomenon" is
DISCUSSION Ink spot lentigo, also known as "reticulated black solar lentigo", is a melanotic macula commonly described in fair-skinned individuals on sun-exposed areas of the body (2). Clinically it is a darkly pigmented type of solar lentigo; herein the term "ink spot" lentigo. In contrast to common solar lentigines,
101.J. Immuoopalhol. Pharmacol.
observed. Often there are several melanophages in the dermis (4). On the basis of clinical and dermoscopical features, ink spot lentigo may be easily diagnosed, and histological findings can confirm the diagnosis. It must be regarded as a distinctive entity and a benign lesion. Like the solar lentigo, ink spot lentigo has been regularly described on fair-skinned people with Fitzpatrick's skin phototype I and II (2). On the contrary, our patients were all skin type III. Regarding the site of localization, ink spot lentigo appears on sun-exposed skin, intermingled with solar lentigines and/or actinic keratoses; however in two of our patients the sites were very uncommon, being respectively the groin and the buttocks. Ink-spot lentigines may suggest melanoma (5) because of their dark colour, irregular border, and unique number. However they are generally small with a diameter less than 6 mm. In our group of patients #5 had ink spot lentigo so unusually large, a diameter more than 2 em, as to propose a differential diagnosis with melanoma. Dermoscopic features were typical for "reticulated black solar lentigo", and the histological exam definitely excluded the possibility of a melanocytic malignant tumour. International literature considers ink spot lentigo as a separated clinico-pathological entity with typical dermoscopic and histopathological features (6-10). To date, also the clinical characteristics are considered as typical. However, our findings seem to contradict some of these features. In fact, all of our patients were ofphototype III whereas in the literature only subjects with phototypes I or II are reported. Moreover, two of our patients had the lesions on atypical areas, the groin and buttocks, instead of the typical localization on sun-exposed areas such as the upper part of back (11). Finally, one of our patients had a lesion so large as to be considered suspicious for malignant melanoma. The unique clinical features that we observed are probably related to geographical aspects. In fact, our Department of Dermatology is located in the Catanzaro province, in Calabria, a region of Southern Italy. In this geographic area, subjects generally have a skin phototype III or IV, with dark skin complexion and dark hair and eyes. As Calabria is an extremely sunny area, the population is commonly
955
overexposed to UV light. Nowadays, the young and adult population prevalently work indoors. On the contrary, their aged parents used to work prevalently outdoors as farmers and were therefore chronically exposed to UV light. This observation could explain the presence of typical ink spot lentigo in young dark-skinned people. REFERENCES I.
Bolognia JL. Reticulated black solar lentigo ('ink spot' lentigo). Arch Dermatol 1992; 128(7):934-40. 2. Smith SR, O'Grady TC. Reticulated ephelides: 'inkspots' revisited. Arch Dermatol 1996; 132(3):353-4. 3. Kaddu S, Wolf I, Soyer HP, Kerl H Reticulated black solar lentigo. Clinicopathologic features and differential diagnosis. Br J Dermatol 1994; 131 :81. 4. Kaddu S, Wolf I, Soyer HP, Kerl H. Reticulated black solar lentigo (Reticulated melanotic macule) is not a solar lentigo. Dermatopath Pract Concept 1995; 1:225-28. 5. Kaddu S, Soyer HP, Wolf IH, Rieger E, Kerl H. Retikulare Lentigo. Hautarzt 1997; 48(3):181-5. 6. Wheat CM, Wesley NO, Jackson BA. Recognition of skin cancer and sun protective behaviours in skin of color. J Drugs Dermatol2013; 12(9):1029-32. 7. Ji AL, Baze MR, Davis SA, Feldman SR, Fleischer AB Jr. Ambulatory melanoma care patterns in the United States. J Skin Cancer 2013; Epub Aug 21. 8. Chiricozzi S, Zhang A, Dattola, Gabellini M, Chimenti S, Nistico SP. Role of Thl7 in the pathogenesis of cutaneous inflammatory diseases J BioI Regul HomeostAgents 2012; 26 (3):313-8. 9. Chiricozzi S, Zhang A, Dattola MV, Cannizzaro M, Gabellini S, Chimenti S, Nistico SP. New insights in the pathogenesis ofcutaneous autoimmune disorders. J BioI Regul Homeost Agents 2012; 26(2): 165-70. 10. Bottoni U, Nistico S, Amoruso G, Sacco A, Arcidiacono V, Calvieri S. Erythema multiforme major after whole brain radiotherapy: a case of EMAR syndrome? Eur J Inflamm 2013; In press. 11. Nistico S, Saraceno R, Stefanescu S, Chimenti S. 308nm Monochromatic Excimer Light in the treatment of Palmoplantar Psoriasis. J Eur Acad Dermatol Venereol 2006; 20 (5):523-26.
