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Simple cases
Case 42
15-year-old girl with a few brown spots on her nose
History
How long have you had these spots?
For a few years, and I am getting more.
The age of patient makes a lentigo senilis/solaris impossible.
Do these lesions get darker in the summer?
No, they stay the same.
With this simple question, you have excluded an ephelis or freckle, and made possible the correct diagnosis. Freckles darken with sun exposure and fade over the winter.
Does you mother have similar lesions?
Yes, on her face and hands.
Carefulthe mother may have something entirely different, such as lentigo senilis/solaris
Has anyone in the family had a skin cancer?
Yes, that's why we're here, because my grandmother just had a melanoma on her leg cut off.
Always a good question, but doesn't help here.
Do you remember lots of sunburns when you were a little kid?
Yes, our family sails a lot and I got burned once in a while.
Good question, but these spots are not sun-related.
Do you take the pill?
No.
Good question for melasma, a diffuse facial pigmentation in women, which is hormone-sensitive.
Lesion
Choose the right efflorescences:
Atrophy means a loss of substance to the skin; here the skin looks and feels normal.
Lichenification is caused by persistent rubbing of the skin and features exaggerated skin markings.
These flat circumscribed dark spots are macules.
Diagnosis
Choose the right diagnosis:
Good. Small pigmented lesions, sometimes present at birth, with increased melanin and sometimes small number of excess melanocytes.
Close but wrong. Café-au-lait macules are larger and more tan ; they are most uncommon on the face.
Vitiligo features white spots where the skin has lost all its melanocytes. Just the opposite process.
Most melanocytic nevi are palpable, as they have accumulations of melanocytes in the dermis or epidermis. Some feel a lentigo simplex could represent a very early junctional nevus in some cases.
Therapy
Choose the right therapy(ies):
Since there is no risk of malignant change, destruction without histologic examination is acceptable, if the lesions are cosmetically bothersome. Hypopigmentation is a common complication of this treatment.
Correct! No treatment is needed.
The scar would be worse than the little macule.
Probably the treatment of choicequicker and cheaper than a laser and produces comparable results.
