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Additional types of nevi do not involve disorders of pigmentation or melanocytes. These additional nevi represent hamartomatous proliferations of the epithelium, connective tissue, and vascular malformations.
Hypermelanotic nevi must be differentiated from other types of pigmented skin lesions, including:
- Lentigo simplex
- Solar lentigo
- Café au lait macule
- Ink-spot lentigo
- Mucosal melanotic macule
- Mongolian spot (dermal melanocytosis)
Café au lait" spots or café au lait" macules are flat, pigmented birthmarks. The name "café au lait" is French for "coffee with milk" and refers to their light-brown color. They are also called "giraffe spots" or "coast of Maine spots".
They are caused by a collection of pigment-producing melanocytes in the epidermis of the skin.
These spots are typically permanent, and may grow or increase in number over time.
Café au lait spots are often harmless, but may be associated with syndromes such as neurofibromatosis type 1 and McCune–Albright syndrome.
Café au lait spots are usually present at birth, permanent, and may grow in size or increase in number over time.
Cafe au lait spots are themselves benign and do not cause any illness or problems. However, they may be associated with syndromes such as Neurofibromatosis Type 1 and McCune-Albright syndrome.
The size and shape of the spots do not have any meaning or implications with regards to diagnosis of associated syndromes.
Phakomatosis pigmentokeratotica is a rare neurocutanous condition characterized by the combination of an organoid sebaceous nevus and speckled lentiginous nevus. It is an unusual variant of epidermal naevus syndrome. It was first described by Happle "et al". It is often associated with neurological or skeletal anomalies such as hemiatrophy, dysaesthesia and hyperhidrosis in a segmental pattern, mild mental retardation, seizures, deafness, ptosis and strabismus.
It presents itself in the mouth, most frequently as a thick, bilateral, symmetrical white plaques with a spongy, corrugated or velvety texture. Most usually, the lesions are on the buccal mucosa, but sometimes on the labial mucosa, alveolar ridge, floor of the mouth, ventral surface of the tongue or soft palate. The gingival margin and dorsum of the tongue are almost never affected. Less commonly, sites outside the mouth are affected, including the nasal, esophageal, laryngeal, anal and genital mucosae. It usually is present from birth, or develops during childhood. Rarely, the lesions may develop during adolescence. Apart from the appearance of the affected areas, there are usually no other signs or symptoms.
Stork bites occur in a significant number of newborns, with estimates ranging from to ; they are reported more frequently for white babies than for infants of other races. They result from a dilation of capillaries in the skin, and may become darker when the child cries or strains.
The birthmarks, which are pinkish and irregularly shaped, occur most frequently on the nape of the neck; however, they are also common on the forehead, eyelids and upper lip. A baby may be born with a stork bite, or the birthmark may appear in the first months of life. They may also be found occasionally on other parts of the body. The skin is not thickened and feels no different from anywhere else on the body; the only difference is in appearance.
Naevus flammeus nuchae, often called stork bite or nevus simplex, is a congenital capillary malformation present in newborns. It is a common type of birthmark in a newborn and is usually temporary.
Since the original identification of Schimmelpenning syndrome, the number of findings has expanded to the point that the syndrome is associated with a considerable constellation of abnormalities. The abnormalities may occur in a variety of combinations, and need not include all three aspects of the classic triad of sebaceous nevus, seizures and mental retardation. In 1998, a literature review by van de Warrenburg et al. found:
- seizures in 67% of cases
- mental retardation in 61% of cases
- ophthalmological abnormalities in 59% of cases
- involvement of other organ systems in 61% of cases
- structural abnormality of cerebrum or cranium in 72% of cases
The major neurological abnormalities include mental retardation to varying extent, seizures, and hemiparesis. Seizures, when present, typically begin during the first year of life. The most common structural central nervous system abnormalities in Schimmelpenning syndrome are hemimegalencephaly and ipselateral gyral malformations.
The major ocular abnormalities are colobomas and choristomas.
Skeletal abnormalities may include dental irregularities, scoliosis, vitamin D-resistant rickets and hypophosphatemia. Cardiovascular abnormalities include ventricular septal defect and co-arctation of the aorta; urinary system issues include horseshoe kidney and duplicated urinary collection system.
White sponge nevus (WSN, or white sponge naevus, Cannon's disease, hereditary leukokeratosis of mucosa, white sponge nevus of Cannon, familial white folded dysplasia, or oral epithelial nevus), is an autosomal dominant condition of the oral mucosa (the mucous membrane lining of the mouth). It is caused by a mutations in certain genes coding for keratin, which causes a defect in the normal process of keratinization of the mucosa. This results in lesions which are thick, white and velvety on the inside of the cheeks within the mouth. Usually, these lesions are present from birth or develop during childhood. The condition is entirely harmless, and no treatment is required.
Schimmelpenning syndrome is a neurocutaneous condition characterized by one or more sebaceous nevi, usually appearing on the face or scalp, associated with anomalies of the central nervous system, ocular system, skeletal system, cardiovascular system, and genitourinary system.
Synonyms include: "Linear nevus sebaceous syndrome (LNSS)", "Schimmelpenning-Feuerstein-Mims syndrome", "Feuerstein-Mims syndrome", "sebaceous nevus syndrome", "Solomon syndrome", and "Jadassohn's nevus phakomatosis". "Nevus" is sometimes spelled "naevus" and "sebaceous" may also be spelled "sebaceus". "Epidermal nevus syndrome" is sometimes used as a synonym, but more often as a broader term referring to Schimmelpenning syndrome in addition to nevus comedonicus syndrome, CHILD syndrome, Becker's nevus syndrome, and phakomatosis pigmentokeratotica.
The classic Schimmelpenning syndrome diagnosis comprises a triad of sebaceous nevi, seizures, and mental retardation. The condition was first reported by Gustav Schimmelpenning in 1957 and independently reported by Feuerstein and Mims in 1962.
Often, this disease evolves from a precursor lesion, usually a dysplastic nevus. Otherwise it arises in previously normal skin. A prolonged radial growth phase, where the lesion remains thin, may eventually be followed by a vertical growth phase where the lesion becomes thick and nodular. As the risk of spread varies with the thickness, early SSM is more frequently cured than late nodular melanoma.
The microscopic hallmarks are:
- Large melanocytic cells with nest formation along the dermo-epidermal junction.
- Invasion of the upper epidermis in a pagetoid fashion (discohesive single cell growth).
- The pattern of rete ridges is often effaced.
- Invasion of the dermis by atypical, pleomorphic melanocytes
- Absence of the 'maturation' typical of naevus cells
- Mitoses
Superficial spreading melanoma (also known as "superficially spreading melanoma") (SSM) is usually characterized as the most common form of cutaneous melanoma in Caucasians. The average age at diagnosis is in the fifth decade, and it tends to occur on sun-exposed skin, especially on the backs of males and lower limbs of females.
CVG is classified according to the presence, or lack of underlying cause. Studies suggest that CVG often occurs in individuals in a secondary form to other ailments. However, the condition can also be present on its own. CVG can be classified into two forms: ‘primary’ (essential and non-essential) and ‘secondary’.
The classifications are:
Primary essential CVG is where the cause of the condition in unknown. It has no other associated abnormalities. This occurs mainly in men, with a male:female ratio of 5 or 6:1, and develops during or soon after puberty. Because of the slow progression of the condition, which usually occurs without symptom, it often passes unnoticed in the early stage
Primary non essential CVG can be associated with neuropsychiatric disorders including cerebral palsy, epilepsy, seizures and ophthalmologic abnormalities, most commonly cataracts.
Secondary CVG occurs as a consequence of a number of diseases or drugs that produce changes in scalp structure. These include: acromegaly (excessive growth hormone levels due to pituitary gland tumours), excessive drug use that mimics acromegaly (including the injection of growth hormone itself and drugs that stimulate growth hormone output, such as GHRP-6 and CJC-1295), melanocytic naevi (moles), birthmarks (including connective tissue naevi, fibromas and naevus lipomatosus), and inflammatory processes (e.g., eczema, psoriasis, Darier disease, folliculitis, impetigo, atopic dermatitis, acne).
There is no diagnosis as yet for Cutis verticis gyrata (CVH), but it can generally be found out by self, when the person is applying oil to the scalp or getting the hair fully shaven. The ripples are present either in identical form, mostly in the posterior direction, sometimes horizontally also, but it looks more like the ripples of the brain.
There is no clinical diagnosis for CVG as these cases are rarely seen and is often comorbid with other conditions.
Macrocephaly-capillary malformation (M-CM) is a multiple malformation syndrome causing abnormal body and head overgrowth and cutaneous, vascular, neurologic, and limb abnormalities. Though not every patient has all features, commonly found signs include macrocephaly, congenital macrosomia, extensive cutaneous capillary malformation (naevus flammeus or port-wine stain type birthmark over much of the body; a capillary malformation of the upper lip or philtrum is seen in many patients with this condition), body asymmetry (also called hemihyperplasia or hemihypertrophy), polydactyly or syndactyly of the hands and feet, lax joints, doughy skin, variable developmental delay and other neurologic problems such as seizures and low muscle tone.
The birth defect is diagnosed by the presence of a combination of these symptoms (often on approximately ¼ of the body, though some cases may present more or less affected tissue):
- One or more distinctive port-wine stains with sharp borders
- Varicose veins
- Hypertrophy of bony and soft tissues, that may lead to local gigantism or shrinking, most typically in the lower body/legs.
- An improperly developed lymph system
In some cases, port-wine stains (capillary port wine type) may be absent. Such cases are very rare and may be classified as "atypical Klippel–Trenaunay syndrome".
KTS can either affect blood vessels, lymph vessels, or both. The condition most commonly presents with a mixture of the two. Those with venous involvement experience increased pain and complications, such as venous ulceration in the lower extremities.
Those with large AVMs are at risk of formation of blood clots in the vascular lesion, which may migrate to the lungs (pulmonary embolism). If there is large-volume blood flow through the lesion, "high-output heart failure" may develop due to the inability of the heart to generate sufficient cardiac output.
Diagnosis is usually based on clinical observation. Various sets of criteria have been suggested to identify the disorder in an individual patient, all of which include macrocephaly and a number of the following: somatic overgrowth, cutis marmorata, midline facial birthmark, polydactyly/syndactyly, asymmetry (hemihyperplasia or hemihypertrophy), hypotonia at birth, developmental delay, connective tissue defect and frontal bossing. Currently no consensus exists about which diagnostic criteria are definitive and so evaluation by a medical geneticist or other clinician with familiarity with the syndrome is usually needed to provide diagnostic certainty. It is not clear if there are some features which are mandatory to make the diagnosis, but macrocephaly appears essentially universal though may not be congenital. The distinctive vascular abnormalities of the skin often fade over time, making the diagnosis challenging in older children with this condition.
The brain can be affected in several ways in this syndrome. Some children are born with structural brain anomalies such as cortical dysplasia or polymicrogyria. While developmental delay is nearly universal in this syndrome it is variable in severity, with the majority having mild to moderate delays and a minority having severe cognitive impairment. Some patients are affected with a seizure disorder. White matter abnormalities on magnetic resonance imaging (MRI), suggesting a delay in white matter myelination, is commonly seen in early childhood. Some patients may have asymmetry of the brain, with one side being noticeably larger than the other.
One interesting phenomenon that seems very common in this syndrome is the tendency for disproportionate brain growth in the first few years of life, with crossing of percentiles on the head circumference growth charts. A consequence of this disproportionate brain growth appears to be a significantly increased risk of cerebellar tonsillar herniation (descent of the cerebellar tonsils through the foramen magnum of the skull, resembling a Chiari I malformation neuroradiologically) and ventriculomegaly/hydrocephalus. Such cerebellar tonsil herniation may occur in up to 70% of children with M-CM.
The medical literature suggests that there is a risk of cardiac arrhythmias in early childhood. The cause for this is unknown. In addition, a variety of different congenital cardiac malformations have been reported in a small number of patients with this disorder.
Like other syndromes associated with disproportionate growth, there appears to be a slightly increased risk of certain types of childhood malignancies in M-CM (such as Wilms' tumor). However, the precise incidence of these malignancies is unclear.
Klippel–Trénaunay syndrome (KTS or KT), formerly Klippel–Trénaunay–Weber syndrome and sometimes angioosteohypertrophy syndrome and hemangiectatic hypertrophy, is a rare congenital medical condition in which blood vessels and/or lymph vessels fail to form properly. The three main features are nevus flammeus (port-wine stain), venous and lymphatic malformations, and soft-tissue hypertrophy of the affected limb. It is similar to, though distinctly separate from, the less common Parkes-Weber syndrome.
The classical triad of Klippel-Trenaunay syndrome consists of:
1. vascular malformations of the capillary, venous and lymphatic vessels;
2. varicosities of unusual distribution, particularly the lateral venous anomaly; and
3. unilateral soft and skeletal tissue hypertrophy, usually the lower extremity.
Goldman states that "numerous inherited or congenital conditions display cutaneous telangiectasia".
These include:
- Naevus flammeus (port-wine stain)
- Klippel-Trenaunay syndrome
- Maffucci's syndrome (multiple enchondromas & hemangiomas)
- Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
- Ataxia-telangiectasia
- Sturge-Weber syndrome, a nevus formation in the skin supplied by the trigeminal nerve and associated with facial port-wine stains, glaucoma, meningeal angiomas and mental retardation
- Hypotrichosis–lymphedema–telangiectasia syndrome, caused by mutation in transcription factor "SOX18"
Individuals with a basal-cell carcinoma typically present with a shiny, pearly skin nodule. However, superficial basal-cell cancer can present as a red patch similar to eczema. Infiltrative or morpheaform basal-cell cancers can present as a skin thickening or scar tissue – making diagnosis difficult without using tactile sensation and a skin biopsy. It is often difficult to visually distinguish basal-cell cancer from acne scar, actinic elastosis, and recent cryodestruction inflammation.
Telangiectasias, also known as spider veins, are small dilated blood vessels near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter.
These dilated blood vessels can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin. Dilated blood vessels can also develop on the legs, although when they occur on the legs, they often have underlying venous reflux or "hidden varicose veins" (see "Venous reflux" below). When found on the legs, they are found specifically on the upper thigh, below the knee joint, and around the ankles.
Many patients who suffer with spider veins seek the assistance of physicians who specialize in vein care or peripheral vascular disease. These physicians are called vascular surgeons or phlebologists. More recently, interventional radiologists have started treating venous problems.
Some telangiectasias are due to developmental abnormalities that can closely mimic the behaviour of benign vascular neoplasms. They may be composed of abnormal aggregations of arterioles, capillaries, or venules. Because telangiectasias are vascular lesions, they blanch when tested with diascopy.
Telangiectasia is a component of the CREST variant of scleroderma, also known today as limited scleroderma (CREST is an acronym that stands for calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia).
The histopathologic classification includes:
- "Nodular basal cell carcinoma" (also known as "classic basal-cell carcinoma") most commonly occurs on the sun-exposed areas of the head and neck.
- "Cystic basal cell carcinoma" is morphologically characterized by dome-shaped, blue-gray cystic nodules.
- "Cicatricial basal cell carcinoma" (also known as "morpheaform basal cell carcinoma," and "morphoeic basal cell carcinoma") is an aggressive variant with a distinct clinical and histologic appearance.
- "Infiltrative basal cell carcinoma" is an aggressive type characterized by deep infiltration.
- "Micronodular basal cell carcinoma" is characterized by a micronodular growth pattern.
- "Superficial basal cell carcinoma" (also known as "superficial multicentric basal-cell carcinoma") occurs most commonly on the trunk and appears as an erythematous patch.
- "Pigmented basal cell carcinoma" exhibits increased melanization. About 80% of all basal-cell carcinoma in Chinese are pigmented while this subtype is uncommon in white people.
- "Rodent ulcer" (also known as a "Jacob's ulcer") is a large skin lesion of nodular basal-cell carcinoma with central necrosis. Almost all cancers can metastasize except glioma (maligancy of the central nervous system) and the rodent ulcer.
- "Fibroepithelioma of Pinkus" most commonly occurs on the lower back.
- "Polypoid basal cell carcinoma" is characterized by exophytic nodules (polyp-like structures) on the head and neck.
- "Pore-like basal cell carcinoma" resembles an enlarged pore or stellate pit.
- "Aberrant basal cell carcinoma" is characterized by the formation of basal-cell carcinoma in the absence of any apparent carcinogenic factor, occurring in odd sites such as the scrotum, vulva, perineum, nipple, and axilla.
See also:
- Nevoid basal-cell carcinoma syndrome
These are polyps which are associated with inflammatory conditions such as Ulcerative Colitis and Crohns disease.
They are tumours , like growths found in organs as a result of faulty development. They are normally made up of a mixture of tissues. They contain mucus-filled glands, with retention cysts, abundant connective tissue, and a chronic cellular infiltration of eosinophils. They grow at the normal rate of the host tissue and rarely cause problems such as compression. A common example of a hamartomatous lesion is a strawberry naevus. Hamartomatous polyps are often found by chance; occurring in syndromes such as Peutz-Jegher Syndrome or Juvenile Polyposis Syndrome.
"Peutz-Jeghers syndrome" is associated with polyps of the GI tract and also increased pigmentation around the lips, genitalia, buccal mucosa feet and hands. People are often diagnosed with Peutz-Jegher after presenting at around the age of 9 with an intussusception. The polyps themselves carry little malignant potential but because of potential coexisting adenomas there is a 15% chance of colonic malignancy.
"Juvenile polyps" are hamartomatous polyps which often become evident before twenty years of age, but can also be seen in adults. They are usually solitary polyps found in the rectum which most commonly present with rectal bleeding. Juvenile polyposis syndrome is characterised by the presence of more than five polyps in the colon or rectum, or numerous juvenile polyps throughout the gastrointestinal tract, or any number of juvenile polyps in any person with a family history of juvenile polyposis. People with juvenile polyposis have an increased risk of colon cancer.