Eruptive blue nevi

Eruptive blue nevi William M. Hendricks, M.D. Asheboro, Ne A 14-year-old boy developed a cluster of blue nevi after a severe sunburn. The relationship between cutaneous injury and the development of blue nevi is discussed. (J AM ACAD DERMATOL 4:50-53, 1981.) CASE REPORT A 14-year-old Caucasian boy was first evaluated for a patch of "blue spots" on the upper central anterior portion of the chest on Nov. 11, 1978. These appeared 3 to 4 years previously as brown "freckles" after the patient suffered a severe sunburn with blistering and peeling of the skin on his shoulders and V of the neck. Over the 5 months prior to the time of writing, some of the brown asymptomatic macules became papular and darker in color. The patient had been in good general health, and there was no history of malignant melanoma or blue nevi in the family. On physical examination, there were over one hundred blue-brown to tan rnacules and papules on the upper anterior central portion of the chest in a cluster measuring 6 by 7 cm (Fig. 1), No other areas of the trunk were affected. Biopsy examination with a 3-mm skin punch was done on two of the blue-brown papules and one of the brown macules. The specimens were fixed in 10% formalin, embedded in paraffin, and stained with hematoxylin and eosin. The biopsies from the papular lesions had a normal epidermis. Within the lower two thirds of the cutis were irregular groups of fusiform and dendritic pigmented cells (Figs. 2 and 3). The brown macule had a moderate increase in epidermal pigmentation with some melanophages within the upper cutis. These biopsies were interpreted respectively as blue nevi and postinftammatory hyperpigmentation. The patient was seen 3 weeks later, and under local anesthesia several of the blue-brown papules were electrodesiccated and curetted. Most of the blue nevi appeared to extend into the reticular dermis, and curettage of adjacent normal skin often uncovered additional blue-brown pigment. In several of the areas examined

From the Asheboro Dermatology Clinic. PA. No reprints available,

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microscopically, small keloidal scars developed, which readily responded to intralesional injections of triamcinolone acetonide (10 mg/ml). DISCUSSION Blue nevi are usually solitary asymptomatic blue or blue-black papules measuring less than 15 mm in diameter. 1 The dorsum of the hands and feet, buttocks, and face are the usual locations. Rarely, blue nevi may be multiple or arranged in plaques [-3 (Table 1). Upshaw et al' reported a plaque 17 em in length and 3 to 6 ern in width on the thorax of a 9year-old boy. The plaque was composed of multiple blue papules with intervening bluish discoloration of the skin. Dorsey and Montgomery" found two plaquetype cellular blue nevi among 200 blue nevi that they studied; 170 of these were blue nevi and 30 were cellular blue nevi. The plaques measured greater than 6 em in diameter and contained many blue nevi along with intervening zones of mongolian spotlike pigmentation. 4 Pittman and Fisher" reported a 6x 8-cm slategray plaque, with multiple dark papules of various sizes within it, on the [eft leg of an l8-year-old man. Clinically, plaguelike blue nevi may be confused with hemangioma, glomus cell tumors, angioma circumscriptum, diffuse malignant proliferation of the vascular endothelium, malignant melanoma, malignant blue nevus, pyogenic granuloma, spindle and epithelioid cell nevi, nevus spilus, and traumatic tattoos. :HJ The diagnosis usually requires a biopsy. Histologically, there are two types of blue nevi. 0190-9622/8\/OlO050+04$OOAO/O © 1981 Am Acad Dermatol

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Fig. 1. A cluster of macules and papules of variable size are present on the upper sternum .

Table I. Plaquelike blue nevi Authors

Upshaw et al' Dorsey et al2 Pittman and Fisher" Hendricks

Locatlnn

Hlstopathelogy

Other

Common blue nevi Cellular blue nevi Common blue nevi Common blue nevi

Congenital

9

M

Thorax

18 14

M M

Left calf Sternum

The common blue nevus is composed of spindleshaped dendritic cells which are separated from the epidermis by a normal cutis . 1•7 The cellular blue nevus usually has features of the common blue nevus plus cellular islands composed of spindle-shaped cells with oval nuclei and pale cytoplasm.? Malignant degeneration has been reported in cellular blue nevi but not in common blue nevi. " There are too few reports of plaquelike blue nevi to determine if they have any special malignant potential. Nevocytic nevi and blue nevi are thought to arise from melanocytic cells.":" Showers of nevo cytic nevi have appeared during pregnancy or puberty, 10-1 3 and cI usrers of them ha ve been reported after bullous eruptions.J '<- " This proliferation may be due to a local abundance of melanocyticstimulating nerve growth factor or to an abnormality in the control mechanisms regulating

Congenital Acquired

melanocyte proliferation in the epidermal melanin unit. 11,12.15 Since no nevocytic nevi were identified within this patient's plaque of blue nevi despite multiple biopsies, different control mechanisms probably govern the proliferation of melanocytic cells that develop into blue and nevocytic nevi . The pathogenesis of this patient's blue nevi is unclear . Their sudden appearance following a sunburn may ha ve been coincidental or related to pubescent hormonal stimulation . A localized response to cutaneous injury is another possibility . Blue nevi are thought to arise from dermal melanocytes which fail to complete their migration from the neural crest to the epidermis. H.D Residues of dermal melanocytes have been found in fetuses at sites where, in later life, blue nevi are most likely to develop. v" It is possible that photoinjury may have stimulated a residue of dermal melanocytes on this patient's sternum.

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Hendricks

Journal of the American Academy of Dermatology

Fig. 2. Irregular fusiform dendritic cells are present in the dermis near a hair foIIicIe. In the upper dermis are melanophages and occasional dendritic cells. (Hematoxylin-eosin stain; x 125.) I thank James D. Groseclose, M.D., for referring this patient, and Herbert Z. Lund, M.D., for interpreting the biopsies. REFERENCES I. Upshaw BY, Ghormley RK, Montgomery H: Extensive blue nevus of Jadasson-Tieche , Surgery 22:761-765, 1947. 2. Dorsey CS, Montgomery H: Blue nevus and its distinction from mongolian spot and the nevus of Ota. J Invest Dermatol22:225-236, 1954.

3. Pittman JL, Fisher BK: Plaque-like blue nevus. Arch Dermatol 112: 1127-1128, 1976. 4. Zaynoun ST, Juljulian HH, Kurban AK: Pyogenic granuloma with multiple satellites. Arch Dermatol 109:689691, 1974. 5. Kriner J, Mehregan AH: Multiple agminate juvenile melanoma. J Cutan Pathol 5:90-91, 1978. 6. Kopf AW, Bart RS: Tumor Conference #27: Combined organoid and melanocytic nevus. J Dermatol Surg Oneal 6:28-30, 1980. 7. Lever WF, Schaumburg-Lever G: Histopathology of the

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Fig. 3. Fine granules are seen within the cytoplasm and dendritic processes of some of these fusiform cells . (Hematoxylin-eosin stain; x 650 ,)

8.

9. 10. II.

skin . Philadelphia , 1975 , J. B. Lippincott Co. , pp. 661664. Zimmermann AH , Becker SA : 11/ Gordon M, editor: Pigment cell biology . New York , 1959 , Academic Press, Inc. • p. 159. Leopold JG, Richard DB: The interrelationship of blue and common naevi. J Pathol BactcrioI95:37-48, 1968. Coskey RJ: Eruptive nevi. Arch Dennatol 111: 1658, 1975. Kopf A W, Grupper C, Baer RL, et al: Eruptive nevocytic nevi after severe bullous disease, Arch Dermatol 113:1080-1084, 1977.

12. Sanderson KV: Eruptive telangiectatic cellular naevi. Br j Dermatol 72:303-307 , 1960 . 13. Eady RA, Gilkes JJ, Jones EW : Eruptive naevi: Report of two cases, with enzyme histochemical, light and electron microscopical findings . Br J Dermatol 97:267-278 , 1977. 14. Gocrz G, Tsamb aos D : Eruptive nevocytic nevi after Lyell's syndrome . Arch Derm atol1l4: 1400-1401, 1978 , 15 . Soltani K, Bernstein JE , Lorinc z AL: Eruptive nevocytic nevi following erythema multi forme . J AM ACAD DE RMATOL 1:503-505, 1979.