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Dispelling the myth of the “benign hair sign” for melanoma
Dispelling the myth of the ‘‘benign hair sign’’ for melanoma Alon Scope, MD,a Michela Tabanelli, MD,c Klaus J. Busam, MD,b Harold Rabinovitz, MD,d Ralph P. Braun, MD,e and Ashfaq A. Marghoob, MDa New York, New York; Bologna, Italy; Plantation, Florida; and Geneva, Switzerland The vast majority of melanocytic lesions with hair, such as congenital melanocytic nevi, are benign. However, there is a notion that the presence of one or more hairs in a melanocytic lesion is confirmatory for the benign nature of the lesion. To dispel this notion, we present 3 examples of melanocytic lesions that showed terminal hairs on clinical and dermoscopic evaluation, but in which the final diagnosis was invasive melanoma. Thus, integrating all clinical and dermoscopic findings, rather than relying on a single criterion for the lesion at hand should guide clinicians to the correct diagnosis. ( J Am Acad Dermatol 2007;56:413-6.)
he vast majority of melanocytic lesions with hair are benign. In fact, prominent hairs can be observed clinically in approximately 50% of congenital nevi (Changchien et al, manuscript submitted for publication) and can be frequently seen in acquired nevi.1,2 Although hair is not formally listed among the discriminatory criteria,3 there is a notion that the presence of one or more hairs in a melanocytic lesion is confirmatory for the benign nature of the lesion. We would like to dispel this ‘‘myth’’ by highlighting 3 cases of melanocytic lesions that showed terminal hairs on clinical and dermoscopic evaluation, but in which the final diagnosis was invasive melanoma.
T
1.4-cm brown plaque with a central blue nodule measuring 5 mm in diameter. The bluish nodule contained a few visible hairs at its periphery, whereas the brown plaque was studded by multiple terminal hairs (Fig 1, A). Under dermoscopy, the central nodule showed blue-whitish veil with brown globules, and the peripheral plaque showed bluishwhite to pink homogeneous areas as well as peripheral network (Fig 1, B). The histopathologic analysis revealed an invasive melanoma (Fig 1, C ), 2.6 mm in Breslow thickness, not associated with a melanocytic nevus. The epithelium of the infundibular portion of the hair follicle was populated by melanoma cells (Fig 1, D).
CASE REPORTS
Patient 2 A 38-year-old male patient was referred for periodic surveillance of moles. He denied the existence of any nevi during his early childhood years and confirmed that all of his nevi had been acquired later in life. His personal history was negative for melanoma, but the family history was notable for melanoma in his mother. The patient has had multiple moles removed that were found to be dysplastic nevi. On examination, he had multiple large and irregular nevi on the head, neck and trunk regions. On the flank, he presented a 1.6- 3 0.8-cm, hypomelanotic, reddish, firm, raised nodule studded by visible terminal hair follicles (Fig 2, A). Dermoscopy revealed a central pink veil with hairs, irregular dotted and linear-irregular blood vessels, and lightbrown streaks (Fig 2, B). Histopathologic analysis revealed a melanoma (Fig 2, C ), 1.65 mm in Breslow thickness, arising in association with a dysplastic melanocytic nevus. The epithelium of the follicular infundibulum was involved by in-situ melanoma
Patient 1 A 67-year-old male patient presented for evaluation of a lesion on the right side of the occipital scalp. He denied the existence of any nevi during his early childhood. The scalp lesion consisted of a 1.8- 3
From the Departments of Dermatologya and Pathology,b Memorial Sloan-Kettering Cancer Center, New York; the Department of Dermatology, University of Bolognac; Skin and Cancer Associates, Plantationd; and the Department of Dermatology, University Hospital Geneva.e Funding sources: None. Conflicts of interest: None identified. Accepted for publication October 8, 2006. Reprint requests: Ashfaq A. Marghoob, MD, Dermatology Service, Memorial Sloan-Kettering Cancer Center, 160 E 53rd St, 2nd Floor, New York, NY 10022. E-mail: [email protected]. Published online December 12, 2006. 0190-9622/$32.00 ª 2007 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2006.10.009
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Fig 1. Melanoma of the scalp that shows a bluish nodule containing few intact hairs and a peripheral brown-bluish plaque studded by multiple terminal hairs (A). The dermoscopic image shows blue-whitish veil in the center (B, arrow) and ill-marginated bluish brown to pink homogeneous areas at the periphery (B, asterisks). Scanning magnification reveals a melanocytic lesion with an asymmetric silhouette (C), whereas higher power shows follicular infundibular epithelium is involved by in-situ melanoma (D). Final histopathologic diagnosis was melanoma, 2.6 mm in Breslow thickness, not associated with melanocytic nevus. (C and D, Hematoxylin-eosin stain; original magnifications: C, 32; D, 320.)
(Fig 2, D). There was no evidence of a congenitaltype nevus on history, physical examination, dermoscopy, and histopathology. Patient 3 A 69-year-old man presented with an irregularly shaped pigmented lesion on the abdomen that had been present for several years. He denied having a lesion at this location during childhood. On examination, a star-shaped, asymmetric, ill-defined, multicolored pigmented flat lesion, measuring 1.1 cm in diameter, was observed on the abdomen. The lesion was studded by multiple terminal hairs (Fig 3, A). Dermoscopy showed a reticular-homogeneous disorganized pattern (Fig 3, B); there was a nonuniform network that was prominent at the periphery as well as dark structureless areas. In addition, there was a hypopigmented area surrounded by multiple bluish gray dots and granules (‘‘peppering’’), suggestive of regression. Of interest, hair shafts were not seen in the areas with significant regression (Fig 3, D). Histology revealed melanoma, 0.38 mm in Breslow thickness with significant regression, not associated with a melanocytic nevus.
DISCUSSION The presence of hair in a melanocytic lesion is often considered a sign of benignity. It was difficult to retrieve references from recent publications to that effect, but this suggestion has been mentioned at a prominent dermatological meeting in the past year.4 Furthermore, personal experience of the authors and that of physicians (family physicians and dermatologists) that the authors surveyed (unofficially) all recollect hearing and being taught this ‘‘fact.’’ Several articles from the first half of the 20th century suggest this notion has historical roots. In 1940, Traub and Kiel5 performed a survey among 120 American Dermatologic Association members, investigating their perception of the presence of hair in pigmented lesions, and reported that 70% of the participants stated that they had never seen a small common mole with hair become malignant. Weidman,6 describing the features of the common brown mole, stated that ‘‘it is benign, and when traversed by hairs (hairy mole) its benignancy is confirmed; that is, a hairy component is an excellent prognostic sign.’’ The rationale behind this notion that hair speaks of benignity may lie in the fact that in acquired benign
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Fig 2. Melanoma of the trunk, consisting of hypomelanotic reddish nodule studded by intact terminal hairs (A). Dermoscopy shows a central pinkish veil with hairs and irregular blood vessels (B, asterisks), and peripheral light brown streaks (B, arrows). Scanning magnification reveals an asymmetric pigmented lesion with a hair follicle (C). Epithelium of the hair follicle is involved by in-situ melanoma (D). Final histopathologic diagnosis was melanoma, 1.65 mm in Breslow thickness, arising in association with a dysplastic melanocytic nevus. (C and D, Hematoxylin-eosin stain; original magnifications: C, 34; D, 310.)
nevi, the nevus cells infrequently involve the hair follicle. An analysis of 91 acquired nevi showed hair follicle involvement in only 7 lesions (7.7%).7 In contrast, Woodburne, Philpott, and Philpott8 in 1954 described a patient with two histologically confirmed melanomas that contained hairs. Herein, we provide 3 examples of invasive melanomas in which intact terminal hairs were present. In addition, the clinical and dermoscopic examination revealed features consistent with invasive melanoma within the area of the terminal hairs.9 In the first patient, the scalp lesion included terminal hairs emerging from the peripheral portion (Fig 1, A and B). Of note, in the central nodule, there was an area devoid of hairs, probably obliterated by neoplastic infiltration. In the second and third patients, the melanoma was studded by intact terminal hairs (Figs 2 and 3). All 3 patients denied a history of a nevus present at birth or early infancy. Furthermore, a review of the images of 133 consecutive melanomas demonstrated that 73 lesions (55%) had no hair, 59 (44%) had some hair, and 1 (0.7%) appeared to be hypertrichotic (Alfred Kopf, written communication, March 16, 2006). Another analysis comparing dermoscopic features of 62 invasive melanomas with 159
nonmelanoma pigmented lesions, of which 108 were benign nevi, did not find the presence of hair to be significantly discriminatory.10 A plausible explanation for the long-standing notion of the ‘‘benign hair sign’’ is that in the past melanoma was diagnosed at a more advanced stage when it was large and thick, thus obliterating the follicles. These melanomas were contrasted with congenital nevi that were also large and thick, but had multiple terminal hairs. Nowadays, melanomas are frequently diagnosed at a thinner, much earlier stage, and therefore this rule is probably less applicable. It is possible that some melanomas that are associated with nevi, particularly congenital nevi, may have evidence of terminal hairs. However, in the present series, all 3 patients denied any history of a congenital nevus. Another hypothesis for the origin of this concept is that the presence of hairs was originally used to distinguish between facial basal cell carcinoma (BCC) and intradermal nevi/Miescher’s nevi—these lesions are at times difficult to differentiate clinically. However, whereas hairs are not seen in BCC, they are not infrequent in facial intradermal nevi. Perhaps over time, this notion for ‘‘BCC’’ was generalized to ‘‘skin cancer,’’ which included
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Fig 3. This melanoma on the abdomen presented as an irregular pigmented patch with illdefined margins and multiple shades of black, brown, blue, and red (A); terminal hairs can be seen within the lesion. With dermoscopic analysis, the lesion has a multicomponent pattern, irregular distribution of dermoscopic structures and colors, and a large blue-gray regression area (B). The periphery of the lesion shows intact hairs (white arrows) protruding from an area with blue-grayish regression structure (C, magnification of area shown in lower box in B). At the center, there is regression with absence of visible hair follicles (D, magnification of area shown in upper box in B). Histopathologic diagnosis was melanoma, 0.38 mm in Breslow thickness with significant regression, not associated with a melanocytic nevus.
melanoma; thus, the ‘‘myth’’ was born that hair in a nevus speaks for a benign diagnosis. It is not our intention to refute the following reality—the vast majority of melanocytic lesions that do have hair are indeed benign. Of course, the presence of hairs is by no means a bad sign or a risk factor. However, we have shown invasive melanomas in which terminal hair shafts can be clearly seen to protrude from the tumor. This may be due to the fact that the melanoma arose on a hair-bearing surface or arose in association with a nevus with hair without causing destruction of the hair follicles. Thus detection of hair in a lesion should not overrule other features that suggest the diagnosis of melanoma. Rather, clinical and dermoscopic criteria should guide clinicians to the correct diagnosis.
REFERENCES 1. Barnhill RL, Llewellyn K. Benign melanocytic neoplasms. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. New York: Mosby; 2003. pp. 1768-71.
2. Maize JC, Ackerman AB. Benign proliferation of melanocytes. In: Pigmented lesions of the skin. Philadelphia: Lea & Febiger; 1987. pp. 85-95. 3. Argenziano G, Soyer HP, Chimenti S, Talamini R, Corona R, Sera F, et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet. J Am Acad Dermatol 2003;48:679-93. 4. Advanced dermoscopy course. Presented at the 64th Annual Meeting of the American Academy of Dermatology, San Francisco, California, March 6, 2006. 5. Traub EF, Keil H. ‘‘The common mole.’’ Arch Dermatol Syphilol 1940;41:214-53. 6. Weidman FD. Malignant melanomas of the skin. NY State J Med 1951;51:2022-4. 7. Urso C, Rongioletti F, Innocenzi D, Batolo D, Chimenti S, Fanti PL, et al. Histological features used in the diagnosis of melanoma are frequently found in benign melanocytic naevi. J Clin Pathol 2005;58:409-12. 8. Woodburne AR, Philpott OS, Philpott JA Jr. Hairy moles do become malignant. Rocky Mt Med J 1954;51:280-2. 9. Malvehy J, Puig S. Breslow depth prediction by dermoscopy. In: Marghoob AA, Braun RP, Kopf AW, editors. Atlas of dermoscopy. New York: Taylor & Francis; 2005. pp. 257-70. 10. Menzies SW, Ingvar C, McCarthy WH. A sensitivity and specificity analysis of the surface microscopy features of invasive melanoma. Melanoma Res 1996;6:55-62.
he vast majority of melanocytic lesions with hair are benign. In fact, prominent hairs can be observed clinically in approximately 50% of congenital nevi (Changchien et al, manuscript submitted for publication) and can be frequently seen in acquired nevi.1,2 Although hair is not formally listed among the discriminatory criteria,3 there is a notion that the presence of one or more hairs in a melanocytic lesion is confirmatory for the benign nature of the lesion. We would like to dispel this ‘‘myth’’ by highlighting 3 cases of melanocytic lesions that showed terminal hairs on clinical and dermoscopic evaluation, but in which the final diagnosis was invasive melanoma.
T
1.4-cm brown plaque with a central blue nodule measuring 5 mm in diameter. The bluish nodule contained a few visible hairs at its periphery, whereas the brown plaque was studded by multiple terminal hairs (Fig 1, A). Under dermoscopy, the central nodule showed blue-whitish veil with brown globules, and the peripheral plaque showed bluishwhite to pink homogeneous areas as well as peripheral network (Fig 1, B). The histopathologic analysis revealed an invasive melanoma (Fig 1, C ), 2.6 mm in Breslow thickness, not associated with a melanocytic nevus. The epithelium of the infundibular portion of the hair follicle was populated by melanoma cells (Fig 1, D).
CASE REPORTS
Patient 2 A 38-year-old male patient was referred for periodic surveillance of moles. He denied the existence of any nevi during his early childhood years and confirmed that all of his nevi had been acquired later in life. His personal history was negative for melanoma, but the family history was notable for melanoma in his mother. The patient has had multiple moles removed that were found to be dysplastic nevi. On examination, he had multiple large and irregular nevi on the head, neck and trunk regions. On the flank, he presented a 1.6- 3 0.8-cm, hypomelanotic, reddish, firm, raised nodule studded by visible terminal hair follicles (Fig 2, A). Dermoscopy revealed a central pink veil with hairs, irregular dotted and linear-irregular blood vessels, and lightbrown streaks (Fig 2, B). Histopathologic analysis revealed a melanoma (Fig 2, C ), 1.65 mm in Breslow thickness, arising in association with a dysplastic melanocytic nevus. The epithelium of the follicular infundibulum was involved by in-situ melanoma
Patient 1 A 67-year-old male patient presented for evaluation of a lesion on the right side of the occipital scalp. He denied the existence of any nevi during his early childhood. The scalp lesion consisted of a 1.8- 3
From the Departments of Dermatologya and Pathology,b Memorial Sloan-Kettering Cancer Center, New York; the Department of Dermatology, University of Bolognac; Skin and Cancer Associates, Plantationd; and the Department of Dermatology, University Hospital Geneva.e Funding sources: None. Conflicts of interest: None identified. Accepted for publication October 8, 2006. Reprint requests: Ashfaq A. Marghoob, MD, Dermatology Service, Memorial Sloan-Kettering Cancer Center, 160 E 53rd St, 2nd Floor, New York, NY 10022. E-mail: [email protected]. Published online December 12, 2006. 0190-9622/$32.00 ª 2007 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2006.10.009
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J AM ACAD DERMATOL MARCH 2007
Fig 1. Melanoma of the scalp that shows a bluish nodule containing few intact hairs and a peripheral brown-bluish plaque studded by multiple terminal hairs (A). The dermoscopic image shows blue-whitish veil in the center (B, arrow) and ill-marginated bluish brown to pink homogeneous areas at the periphery (B, asterisks). Scanning magnification reveals a melanocytic lesion with an asymmetric silhouette (C), whereas higher power shows follicular infundibular epithelium is involved by in-situ melanoma (D). Final histopathologic diagnosis was melanoma, 2.6 mm in Breslow thickness, not associated with melanocytic nevus. (C and D, Hematoxylin-eosin stain; original magnifications: C, 32; D, 320.)
(Fig 2, D). There was no evidence of a congenitaltype nevus on history, physical examination, dermoscopy, and histopathology. Patient 3 A 69-year-old man presented with an irregularly shaped pigmented lesion on the abdomen that had been present for several years. He denied having a lesion at this location during childhood. On examination, a star-shaped, asymmetric, ill-defined, multicolored pigmented flat lesion, measuring 1.1 cm in diameter, was observed on the abdomen. The lesion was studded by multiple terminal hairs (Fig 3, A). Dermoscopy showed a reticular-homogeneous disorganized pattern (Fig 3, B); there was a nonuniform network that was prominent at the periphery as well as dark structureless areas. In addition, there was a hypopigmented area surrounded by multiple bluish gray dots and granules (‘‘peppering’’), suggestive of regression. Of interest, hair shafts were not seen in the areas with significant regression (Fig 3, D). Histology revealed melanoma, 0.38 mm in Breslow thickness with significant regression, not associated with a melanocytic nevus.
DISCUSSION The presence of hair in a melanocytic lesion is often considered a sign of benignity. It was difficult to retrieve references from recent publications to that effect, but this suggestion has been mentioned at a prominent dermatological meeting in the past year.4 Furthermore, personal experience of the authors and that of physicians (family physicians and dermatologists) that the authors surveyed (unofficially) all recollect hearing and being taught this ‘‘fact.’’ Several articles from the first half of the 20th century suggest this notion has historical roots. In 1940, Traub and Kiel5 performed a survey among 120 American Dermatologic Association members, investigating their perception of the presence of hair in pigmented lesions, and reported that 70% of the participants stated that they had never seen a small common mole with hair become malignant. Weidman,6 describing the features of the common brown mole, stated that ‘‘it is benign, and when traversed by hairs (hairy mole) its benignancy is confirmed; that is, a hairy component is an excellent prognostic sign.’’ The rationale behind this notion that hair speaks of benignity may lie in the fact that in acquired benign
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Fig 2. Melanoma of the trunk, consisting of hypomelanotic reddish nodule studded by intact terminal hairs (A). Dermoscopy shows a central pinkish veil with hairs and irregular blood vessels (B, asterisks), and peripheral light brown streaks (B, arrows). Scanning magnification reveals an asymmetric pigmented lesion with a hair follicle (C). Epithelium of the hair follicle is involved by in-situ melanoma (D). Final histopathologic diagnosis was melanoma, 1.65 mm in Breslow thickness, arising in association with a dysplastic melanocytic nevus. (C and D, Hematoxylin-eosin stain; original magnifications: C, 34; D, 310.)
nevi, the nevus cells infrequently involve the hair follicle. An analysis of 91 acquired nevi showed hair follicle involvement in only 7 lesions (7.7%).7 In contrast, Woodburne, Philpott, and Philpott8 in 1954 described a patient with two histologically confirmed melanomas that contained hairs. Herein, we provide 3 examples of invasive melanomas in which intact terminal hairs were present. In addition, the clinical and dermoscopic examination revealed features consistent with invasive melanoma within the area of the terminal hairs.9 In the first patient, the scalp lesion included terminal hairs emerging from the peripheral portion (Fig 1, A and B). Of note, in the central nodule, there was an area devoid of hairs, probably obliterated by neoplastic infiltration. In the second and third patients, the melanoma was studded by intact terminal hairs (Figs 2 and 3). All 3 patients denied a history of a nevus present at birth or early infancy. Furthermore, a review of the images of 133 consecutive melanomas demonstrated that 73 lesions (55%) had no hair, 59 (44%) had some hair, and 1 (0.7%) appeared to be hypertrichotic (Alfred Kopf, written communication, March 16, 2006). Another analysis comparing dermoscopic features of 62 invasive melanomas with 159
nonmelanoma pigmented lesions, of which 108 were benign nevi, did not find the presence of hair to be significantly discriminatory.10 A plausible explanation for the long-standing notion of the ‘‘benign hair sign’’ is that in the past melanoma was diagnosed at a more advanced stage when it was large and thick, thus obliterating the follicles. These melanomas were contrasted with congenital nevi that were also large and thick, but had multiple terminal hairs. Nowadays, melanomas are frequently diagnosed at a thinner, much earlier stage, and therefore this rule is probably less applicable. It is possible that some melanomas that are associated with nevi, particularly congenital nevi, may have evidence of terminal hairs. However, in the present series, all 3 patients denied any history of a congenital nevus. Another hypothesis for the origin of this concept is that the presence of hairs was originally used to distinguish between facial basal cell carcinoma (BCC) and intradermal nevi/Miescher’s nevi—these lesions are at times difficult to differentiate clinically. However, whereas hairs are not seen in BCC, they are not infrequent in facial intradermal nevi. Perhaps over time, this notion for ‘‘BCC’’ was generalized to ‘‘skin cancer,’’ which included
416 Scope et al
J AM ACAD DERMATOL MARCH 2007
Fig 3. This melanoma on the abdomen presented as an irregular pigmented patch with illdefined margins and multiple shades of black, brown, blue, and red (A); terminal hairs can be seen within the lesion. With dermoscopic analysis, the lesion has a multicomponent pattern, irregular distribution of dermoscopic structures and colors, and a large blue-gray regression area (B). The periphery of the lesion shows intact hairs (white arrows) protruding from an area with blue-grayish regression structure (C, magnification of area shown in lower box in B). At the center, there is regression with absence of visible hair follicles (D, magnification of area shown in upper box in B). Histopathologic diagnosis was melanoma, 0.38 mm in Breslow thickness with significant regression, not associated with a melanocytic nevus.
melanoma; thus, the ‘‘myth’’ was born that hair in a nevus speaks for a benign diagnosis. It is not our intention to refute the following reality—the vast majority of melanocytic lesions that do have hair are indeed benign. Of course, the presence of hairs is by no means a bad sign or a risk factor. However, we have shown invasive melanomas in which terminal hair shafts can be clearly seen to protrude from the tumor. This may be due to the fact that the melanoma arose on a hair-bearing surface or arose in association with a nevus with hair without causing destruction of the hair follicles. Thus detection of hair in a lesion should not overrule other features that suggest the diagnosis of melanoma. Rather, clinical and dermoscopic criteria should guide clinicians to the correct diagnosis.
REFERENCES 1. Barnhill RL, Llewellyn K. Benign melanocytic neoplasms. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. New York: Mosby; 2003. pp. 1768-71.
2. Maize JC, Ackerman AB. Benign proliferation of melanocytes. In: Pigmented lesions of the skin. Philadelphia: Lea & Febiger; 1987. pp. 85-95. 3. Argenziano G, Soyer HP, Chimenti S, Talamini R, Corona R, Sera F, et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet. J Am Acad Dermatol 2003;48:679-93. 4. Advanced dermoscopy course. Presented at the 64th Annual Meeting of the American Academy of Dermatology, San Francisco, California, March 6, 2006. 5. Traub EF, Keil H. ‘‘The common mole.’’ Arch Dermatol Syphilol 1940;41:214-53. 6. Weidman FD. Malignant melanomas of the skin. NY State J Med 1951;51:2022-4. 7. Urso C, Rongioletti F, Innocenzi D, Batolo D, Chimenti S, Fanti PL, et al. Histological features used in the diagnosis of melanoma are frequently found in benign melanocytic naevi. J Clin Pathol 2005;58:409-12. 8. Woodburne AR, Philpott OS, Philpott JA Jr. Hairy moles do become malignant. Rocky Mt Med J 1954;51:280-2. 9. Malvehy J, Puig S. Breslow depth prediction by dermoscopy. In: Marghoob AA, Braun RP, Kopf AW, editors. Atlas of dermoscopy. New York: Taylor & Francis; 2005. pp. 257-70. 10. Menzies SW, Ingvar C, McCarthy WH. A sensitivity and specificity analysis of the surface microscopy features of invasive melanoma. Melanoma Res 1996;6:55-62.