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Letters to the Editor
Spontaneous partial repigmentation of halo nevi around congenital melanocytic nevus and vitiligo in a 13-year-old boy Sir, Halo nevi (HN) or leukoderma acquisitum centrifugum is a ring of depigmentation that may appear around acquired or congenital melanocytic nevi (CMN) as well as melanoma. In some cases, the hypopigmented halo anticipates the total or partial regression of the melanocytic lesion, while in others it remains stable or eventually undergoes repigmentation.[1] HN is not uncommon, being more frequent around acquired melanocytic nevus.[2] Up to 26% of patients with HN have vitiligo,[3] but in very few instances is there an association of HN around CMN and vitiligo.[4] The exact mechanisms responsible for the development of vitiligo and HN and its resolution are unknown. One of the most accepted hypotheses considers that both phenomena are a result of a self-limited immunologic response to pigmented cells, either in the “‘normal”’ skin or within the melanocytic lesion.[4] We report a case of halo CMN that subsequently developed vitiligo and spontaneous partial repigmentation of both lesions. A 2-week-old Caucasian male came to our clinic for evaluation of a congenital pigmented lesion on the right knee. On physical examination, there was a 3 × 1.5 cm dark brown melanocytic lesion noted. Histopathologic study confirmed a compound CMN and the patient was scheduled for periodic follow-up. The lesion remained stable until the patient was 6 years old; at that time, a hypopigmented halo and partial regression of the lesion was observed. Ten months later, the patient developed achromic macules on the sacral region and both ankles consistent with vitiligo. There was no family history of vitiligo, melanoma, or autoimmune diseases. Treatment with tacrolimus 0.1% ointment for 3 months was ineffective. A year later, the sacral lesion and the halo started to show partial repigmentation while the ankle depigmentation remained stable. When the child was 13 years old, vitiligo lesions of the lower extremities began to show spontaneous resolution, parallel to progressive
a
c
b
d
Figure 1: (a) Halo CMN on the inner aspect of the right knee when the patient was 8 years old. (b) Follow-up at the age of 10 years. Partial regression of the CMN is observed, as well as patchy areas of repigmentation. (c and d) Substantial repigmentation both halo CMN and vitiligo when the patient was 13 years old
repigmentation of the halo and complete resolution of the sacral lesion [Figure 1]. The occurrence of halo CMN is a well-known phenomenon, as is its association with vitiligo,[1-5] but halo repigmentation in congenital melanocytic lesions is exceptional.[4] We have found only two more cases in the literature: A 2-year-old boy with a CMN on the arm who experienced total regression of the CMN and partial repigmentation[5] and another case included in a series of cases of halo CMN and vitiligo in which some repigmentation was observed at the periphery.[4] Additionally, in a series of 52 patients with HN in which no differentiation between acquired and congenital lesions was made, the authors state that partial or complete repigmentation of the HN was observed after an average follow-up of 11.8 and 7.8 years, respectively,[1] so it is possible that repigmentation may occur later in life and regression of HN in all CMN is a question of time. Management of CMN with halo does not differ from cases without peripheral depigmentation, and periodic follow-up is recommended unless worrisome changes occur. In conclusion, it is important to recognise the possibility of spontaneous repigmentation in cases of halo CMN and the associated vitiligo.
Concha-Garzón MJ, Hernández-Martín A1, Faura-Berruga C2, Dávila-Seijo P3,Torrelo A1 Hospital Universitario de La Princesa, Madrid, 1Hospital del Niño Jesús, Madrid, 2Complejo Hospitalario Universitario de Albacete, Albacete, 3Complexo Hospitalario de Pontevedra, Pontevedra, Spain Address for correspondence: Dr. Concha-Garzón MJ, C/ Diego de león 62, CP 28006, Madrid, Spain. E-mail: [email protected]
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2014 | Vol 80 | Issue 1
69
[Downloaded free from http://www.ijdvl.com on Tuesday, January 21, 2014, IP: 202.164.45.14] || Click here to download free Android application for this journal
Letters to the Editor
REFERENCES 1. 2. 3. 4. 5.
Aouthmany M, Weinstein M, Zirwas MJ, Brodell RT. The natural history of halo nevi: A retrospective case series. J Am Acad Dermatol 2012;67:582-6. Kim HS, Goh BK. Vitiligo occurring after halo formation around congenital melanocytic nevi. Pediatr Dermatol 2009;26:755-6. Stierman SC, Tierney EP, Shwayder TA. Halo congenital nevocellular nevi associated with extralesional vitiligo: A case series with review of the literature. Pediatr Dermatol 2009;26:414-24. Guerra-Tapia A, Isarría MJ. Periocular vitiligo with onset around a congenital divided nevus of the eyelid. Pediatr Dermatol 2005;22:427-9. Kikuchi I, Inoue S, Ogata K, Idemori M. Disappearance of a nevocellular nevus with depigmentation. Arch Dermatol 1984;120:678-9. Access this article online Quick Response Code:
Website: www.ijdvl.com
Figure 1: Mitochondrial pattern of pigmentation on the patient’s back after phototherapy
DOI: 10.4103/0378-6323.125539 PMID: *****
Pigmentation resembling crosssection of a mitochondrion Sir, An 8-year-old girl presented with an asymptomatic hyperpigmented area in the back since 2 days. There was no preceding history of any cutaneous lesions at the site of the hyperpigmentation or similar lesions elsewhere on the body. The patient was a known case of acral vitiligo and had received 10 sittings of narrow band ultraviolet-B (NB-UVB) prior to the onset of the lesions. The patient used to cover her trunk with two sets of clothes, one on top of the other during the NB-UVB irradiation and the same set of clothes were worn during each session. On examination, a 25 × 6 cm hyperpigmented macule was present in the midline of the back with criss-cross lines of normal skin in between, giving the appearance of a mitochondrial cross-section [Figure 1]. Depigmented macules of vitiligo were present on the face and acral regions. Examination of the clothes worn during the sessions revealed a thin outer garment which covered the trunk completely, whereas the thicker inner garment had strings passing in the midline leading to a noncovered area which corresponds to the area of hyperpigmentation [Figure 2]. The UV-B transmissibility of the fabrics was measured using 70
Figure 2: Inner fabric worn by the patient during narrow band ultraviolet-B therapy
the spectrophotometer. The outer fabric had 4.1% transmissibility, whereas the inner fabric had 8.3%, thus exposing the back to 50% more irradiation than the rest of the trunk. Patterns of dermatoses often give a clue to the diagnosis especially the etiology but are perplexing at times. In our patient, the midline of the back was not adequately protected from UV rays as the rest of the trunk, thus exposing it to tanning. In view of the gap in the inner garment and strings running across the gap, a bizzare pattern of tanning was produced which resembled that of a mitochondrion. Both UV-A and UV-B induce tanning.[1] Clothes provide protection from the harmful effects of ultraviolet rays especially tanning. The measurement of the protective effect of clothes is measured by fabric ultraviolet protection (UPF).[2] Various parameters influence the UPF viz., fabric type/composition, weave, number of
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2014 | Vol 80 | Issue 1
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Letters to the Editor
Spontaneous partial repigmentation of halo nevi around congenital melanocytic nevus and vitiligo in a 13-year-old boy Sir, Halo nevi (HN) or leukoderma acquisitum centrifugum is a ring of depigmentation that may appear around acquired or congenital melanocytic nevi (CMN) as well as melanoma. In some cases, the hypopigmented halo anticipates the total or partial regression of the melanocytic lesion, while in others it remains stable or eventually undergoes repigmentation.[1] HN is not uncommon, being more frequent around acquired melanocytic nevus.[2] Up to 26% of patients with HN have vitiligo,[3] but in very few instances is there an association of HN around CMN and vitiligo.[4] The exact mechanisms responsible for the development of vitiligo and HN and its resolution are unknown. One of the most accepted hypotheses considers that both phenomena are a result of a self-limited immunologic response to pigmented cells, either in the “‘normal”’ skin or within the melanocytic lesion.[4] We report a case of halo CMN that subsequently developed vitiligo and spontaneous partial repigmentation of both lesions. A 2-week-old Caucasian male came to our clinic for evaluation of a congenital pigmented lesion on the right knee. On physical examination, there was a 3 × 1.5 cm dark brown melanocytic lesion noted. Histopathologic study confirmed a compound CMN and the patient was scheduled for periodic follow-up. The lesion remained stable until the patient was 6 years old; at that time, a hypopigmented halo and partial regression of the lesion was observed. Ten months later, the patient developed achromic macules on the sacral region and both ankles consistent with vitiligo. There was no family history of vitiligo, melanoma, or autoimmune diseases. Treatment with tacrolimus 0.1% ointment for 3 months was ineffective. A year later, the sacral lesion and the halo started to show partial repigmentation while the ankle depigmentation remained stable. When the child was 13 years old, vitiligo lesions of the lower extremities began to show spontaneous resolution, parallel to progressive
a
c
b
d
Figure 1: (a) Halo CMN on the inner aspect of the right knee when the patient was 8 years old. (b) Follow-up at the age of 10 years. Partial regression of the CMN is observed, as well as patchy areas of repigmentation. (c and d) Substantial repigmentation both halo CMN and vitiligo when the patient was 13 years old
repigmentation of the halo and complete resolution of the sacral lesion [Figure 1]. The occurrence of halo CMN is a well-known phenomenon, as is its association with vitiligo,[1-5] but halo repigmentation in congenital melanocytic lesions is exceptional.[4] We have found only two more cases in the literature: A 2-year-old boy with a CMN on the arm who experienced total regression of the CMN and partial repigmentation[5] and another case included in a series of cases of halo CMN and vitiligo in which some repigmentation was observed at the periphery.[4] Additionally, in a series of 52 patients with HN in which no differentiation between acquired and congenital lesions was made, the authors state that partial or complete repigmentation of the HN was observed after an average follow-up of 11.8 and 7.8 years, respectively,[1] so it is possible that repigmentation may occur later in life and regression of HN in all CMN is a question of time. Management of CMN with halo does not differ from cases without peripheral depigmentation, and periodic follow-up is recommended unless worrisome changes occur. In conclusion, it is important to recognise the possibility of spontaneous repigmentation in cases of halo CMN and the associated vitiligo.
Concha-Garzón MJ, Hernández-Martín A1, Faura-Berruga C2, Dávila-Seijo P3,Torrelo A1 Hospital Universitario de La Princesa, Madrid, 1Hospital del Niño Jesús, Madrid, 2Complejo Hospitalario Universitario de Albacete, Albacete, 3Complexo Hospitalario de Pontevedra, Pontevedra, Spain Address for correspondence: Dr. Concha-Garzón MJ, C/ Diego de león 62, CP 28006, Madrid, Spain. E-mail: [email protected]
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2014 | Vol 80 | Issue 1
69
[Downloaded free from http://www.ijdvl.com on Tuesday, January 21, 2014, IP: 202.164.45.14] || Click here to download free Android application for this journal
Letters to the Editor
REFERENCES 1. 2. 3. 4. 5.
Aouthmany M, Weinstein M, Zirwas MJ, Brodell RT. The natural history of halo nevi: A retrospective case series. J Am Acad Dermatol 2012;67:582-6. Kim HS, Goh BK. Vitiligo occurring after halo formation around congenital melanocytic nevi. Pediatr Dermatol 2009;26:755-6. Stierman SC, Tierney EP, Shwayder TA. Halo congenital nevocellular nevi associated with extralesional vitiligo: A case series with review of the literature. Pediatr Dermatol 2009;26:414-24. Guerra-Tapia A, Isarría MJ. Periocular vitiligo with onset around a congenital divided nevus of the eyelid. Pediatr Dermatol 2005;22:427-9. Kikuchi I, Inoue S, Ogata K, Idemori M. Disappearance of a nevocellular nevus with depigmentation. Arch Dermatol 1984;120:678-9. Access this article online Quick Response Code:
Website: www.ijdvl.com
Figure 1: Mitochondrial pattern of pigmentation on the patient’s back after phototherapy
DOI: 10.4103/0378-6323.125539 PMID: *****
Pigmentation resembling crosssection of a mitochondrion Sir, An 8-year-old girl presented with an asymptomatic hyperpigmented area in the back since 2 days. There was no preceding history of any cutaneous lesions at the site of the hyperpigmentation or similar lesions elsewhere on the body. The patient was a known case of acral vitiligo and had received 10 sittings of narrow band ultraviolet-B (NB-UVB) prior to the onset of the lesions. The patient used to cover her trunk with two sets of clothes, one on top of the other during the NB-UVB irradiation and the same set of clothes were worn during each session. On examination, a 25 × 6 cm hyperpigmented macule was present in the midline of the back with criss-cross lines of normal skin in between, giving the appearance of a mitochondrial cross-section [Figure 1]. Depigmented macules of vitiligo were present on the face and acral regions. Examination of the clothes worn during the sessions revealed a thin outer garment which covered the trunk completely, whereas the thicker inner garment had strings passing in the midline leading to a noncovered area which corresponds to the area of hyperpigmentation [Figure 2]. The UV-B transmissibility of the fabrics was measured using 70
Figure 2: Inner fabric worn by the patient during narrow band ultraviolet-B therapy
the spectrophotometer. The outer fabric had 4.1% transmissibility, whereas the inner fabric had 8.3%, thus exposing the back to 50% more irradiation than the rest of the trunk. Patterns of dermatoses often give a clue to the diagnosis especially the etiology but are perplexing at times. In our patient, the midline of the back was not adequately protected from UV rays as the rest of the trunk, thus exposing it to tanning. In view of the gap in the inner garment and strings running across the gap, a bizzare pattern of tanning was produced which resembled that of a mitochondrion. Both UV-A and UV-B induce tanning.[1] Clothes provide protection from the harmful effects of ultraviolet rays especially tanning. The measurement of the protective effect of clothes is measured by fabric ultraviolet protection (UPF).[2] Various parameters influence the UPF viz., fabric type/composition, weave, number of
Indian Journal of Dermatology, Venereology, and Leprology | January-February 2014 | Vol 80 | Issue 1
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
