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Simple cases
Case 32
38-year-old well-tanned women asks about several brown spots on her back.
History
How long have you had these spots?
Many years.
Acquired pigmented lesions are by definition not present at birth. They usually appear during childhood and may slowly grow.
Have they been there since you were born?
No, not this one on my back.
Most individuals develop a number of nevi during puberty. Already present nevi become larger and darker. The maximum nevus count is reached in the 3rd or 4th decade. Later some lesions regress or at least lose pigment.
Do you regularly go to a tanning studio?
Yes, twice a week.
Important exogenous stimuli of melanocytic nevi are female hormones and UV light.
Does they itch?
No.
Nevi should not itch. If they do, they are likely inflamed. A melanoma is more likely to itch than a nevus, but this is not a very reliable clinical sign.
Have any of them changed?
Yes, all are a little bit larger.
Yes, all are a little bit larger.Melanocytic nevi usually appear during childhood and may slowly grow.
Over what period of time have they changed?
The last 10 years.
Pigmented lesions that appear after age 30 are somewhat more likely to be melanomas.
Have the lesions developed multiple colors, an irregular border, or a raised center? Are any new ones there?
No, no new lesions. They seem to have grown regularly and just gotten a bit darker.
You have asked about the ABCDE rule. In most instances, a patient is not able to answer this concisely and you will need patience.
Lesion
Choose the right efflorescences:
False. No evidence of a defect.
False. Hives are transient; not present for 10 years.
False. A pustule is a papule filled with pus.
False. A rhagade is a fine tear or fissure.
Correct. These lesions are flat and pigmented.
Diagnosis
Choose the right diagnosis:
Wrong. A seborrheic keratosis usually does not appear before the 4th decade. It is rough, elevated and may itch.
Wrong. A keloid is one form of excess scar tissue, always appeared a papule or nodule at a site of trauma.
Wrong. A lipoma is a subcutaneous accumulation of fat. It can be palpated, but does not have overlying pigment changes.
Correct. Melanocytic nevi (or nevus cell nevi) are benign accumulations of melanocytes, usually in nests. Since this lesion is flat, it is likely to be a junctional nevus.
Therapy
Choose the right therapy(ies):
While sunscreens are a good idea, they do not protect against developing nevi. UV light is just one possible trigger.
Not every melanocytic nevus must be removed. Most can be comfortably identified as benign. If there is a suspicion of melanoma, then excision and histopathological study is wise.
It is always wise to remove an irritated or traumatized nevus. The problem rarely goes away by itself, and once in a while, a melanoma becomes irritated.
When a melanocytic nevus is removed, simple surgical excision and histopathological examination is the standard.
Test
The following questions are related to the current case. Try to solve them.
