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| CASE REPORT |
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| Year : 2016 | Volume
: 3
| Issue : 2 | Page : 111-113 |
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Vitiligo restricted to Becker’s nevus: Is it an isotopic response?
YJ Bhat MD, FACP , I Latief, I Hassan
Postgraduate Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, University of Kashmir, Jammu and Kashmir, India
| Date of Web Publication | 27-Dec-2016 |
Correspondence Address:
Dr. Y J Bhat
Assistant Professor, Postgraduate Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, University of Kashmir, Jammu and Kashmir - 190010
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2349-5847.196304
Becker’s nevus commonly presents as a unilateral hyperpigmented, irregular macule or patch or verrucous plaque with a variable hypertrichotic element located on the shoulder, anterior chest or scapula, and back, and rarely, on the face, neck, and extremities. A number of cutaneous associations were reported with Becker’s nevus. However, coexistence of vitiligo and Becker’s nevus is a rare finding. We report such a finding in a 15-year-old boy who presented with Becker’s nevus on the left side of chest and upper arm and had developed depigmented lesions on the same site over the past 5 months. Diagnosis of both the types of lesions was confirmed by histopathology. Role of cytokines may be proposed in the development of vitiligo and other immunologically mediated diseases on the existing Becker’s nevus on the basis of the concept of ‘Wolf’s isotopic response’ and ‘Ruocco’s immunocompromised district’. Keywords: Becker′s nevus, isotopic response, vitiligo
How to cite this article:
Bhat Y J, Latief I, Hassan I. Vitiligo restricted to Becker’s nevus: Is it an isotopic response?. Pigment Int 2016;3:111-3 |
| Introduction | |  |
Becker’s nevus is a cutaneous hamartoma usually affecting young men. It commonly presents as a unilateral hyperpigmented, irregular macule or patch or verrucous plaque with a variable hypertrichotic element. It is located mainly on the shoulder, anterior chest or scapula, and back, and rarely, on the face, neck, and extremities. The general prevalence is about 0.5%; male to female ratio is 5:1. It is rarely congenital, and may present in childhood, but is usually noticed during adolescence.[1] Various cutaneous anomalies reported to colocalize with Becker’s nevus include tinea versicolor, eczema, granuloma annulare, lymphangioma, and lichen planus.[2],[3],[4] However, coexistence of vitiligo and Becker’s nevus is a rare finding. We report such a finding in a 15-year-old boy who presented with Becker’s nevus on the left chest and upper arm and had developed depigmented lesions on the same site over the past 5 months.
| Case Report | | |
A 15-year-old boy presented to our outpatient department with asymptomatic discoloration of skin on the chest and upper arm since 1 year. The discoloration started as a few hyperpigmented macules that gradually increased in size and coalesced to cover a large area on the chest, left upper arm, and upper aspect of left forearm. The color of the lesions also became darker over a period of 1 year. The patient developed few depigmented lesions on the same site over the past 5 months. There was no history of itching on the same site or application of any topical medication. The patient gave no history pertaining to neurological or musculoskeletal abnormality.
On cutaneous examination, there was a single, well-defined, hyperpigmented macule with irregular borders covering the left thoracic area, left upper arm, and upper part of left forearm. In addition, there were a few well-defined depigmented lesions present on the hyperpigmented area. These lesions were present on the left side of upper chest and the left upper arm [Figure 1] and [Figure 2]. There were no depigmented lesions elsewhere on the body. There were no acneiform lesions on the hyperpigmented area. However, hair growth over the lesion was slightly more than the rest of the body. The oral mucosa, hair, and nails were normal.
General physical examination and systemic examination was normal. There was no muscle hypoplasia or lipoatrophy on the affected side. No disparity in size of limbs was seen. The spine and genital examination was also normal.
Routine investigations included complete blood count, liver and kidney function tests, thyroid function test, electrocardiogram (ECG), and chest X-ray. These examinations showed normal findings. Skin biopsy was taken from the vitiliginous lesions that showed decreased number of melanocytes and dermal lymphocytic inflammatory infiltrate. Skin biopsy from Becker’s nevus showed melanin incontinence and smooth muscle hyperplasia [Figure 3]. | Figure 3: Photomicrograph showing smooth muscle hyperplasia and pigmentary incontinence in Becker’s nevus (hematoxylin and eosin, 400×)
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| Discussion | | |
‘‘Isotopic response’’ also called as ‘‘Wolf’s isotopic response’’ refers to the occurrence of a new dermatosis at the site of a previously healed dermatosis.[5] In 1955, Wyburn-Mason for the first time described the occurrence of a new skin disease at the site of another already healed skin disease.[6] Various theories have been proposed to explain this phenomenon. These theories include viral hypothesis, vascular hypothesis, immunologic hypothesis, and the neural hypothesis.
According to immunological theory, when a dermatosis affects a certain body site, it may lead to changes in the regional immune system or formation of memory T-cells, which when triggered at a later date may give rise to a new dermatosis.
Becker’s nevus is an acquired and persistent asymmetrical area of skin pigmentation, sometimes showing increased androgen sensitivity and colocalizing with other developmental anomalies.[7] Becker’s nevus starts as an area of irregular macular pigmentation spreading to a diameter of several centimeters. Increased terminal hairs may appear on and around the lesion. Central area may show thickening. Various anomalies associated include breast hypoplasia, supernumerary nipples, lipoatrophy,[8],[9] and various cutaneous anomalies.
Becker’s nevus with vitiligo has been rarely reported. Becker’s nevus was associated with the lichen planus in the isolated reports previously.[10] In a case reported by Puri et al.,[4] lesions of LP developed in a congenital Becker’s nevus. Vitiligo was reported in a Becker’s nevus by Pavithran in 1983.[11] Coexistence of Becker’s nevus with lichen planus and vitiligo was reported by Gupta et al.[12] However, in this case, the lesions of lichen planus and vitiligo were in the vicinity of the nevus and not over it. Pityriasis versicolor was also reported in association with Becker’s nevus by Sugathan and Riyaz.[13] Keratinocyte hyperplasia and an increased number of epidermal CD1a-positive dendritic cells in Becker’s nevus mediate a cytotoxic T-cell response and initiate a cascade of cytokine release that may explain the cause of coexistence of immunologically mediated diseases like lichen planus and vitiligo.
According to by definition, isotopic response is the occurrence of a new dermatoses at the site of already healed dermatoses,[5] but whether the occurrence of vitiliginous patches over Becker’s nevus can be called as isotopic response is still debatable. Another novel concept that can explain the coexistence of these two conditions is ‘‘Ruocco’s immunocompromised district,’’[14] wherein the first disease causes an immunological alteration in an area that predisposes to the development of second disease. The immunological alterations by Becker’s nevus like an increased number of dendritic cells and a cytotoxic T-cell response may be responsible for the coexistence of another immunologically mediated disease like vitiligo.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Lockshin BN, Brogan B, Billings S. Eczematous dermatitis and prurigo nodularis confined to a Becker’s nevus. Int J Dermatol 2006;45:1465-6. |
| 3. | Oyler RM, Davis DA, Woosley JT. Lymphangioma associated with Becker’s nevus: A report of coincident hamartomas in a child. Pediatr Dermatol 1997;14:376-9. |
| 4. | Puri S, Nanda S, Grover C, Batra VV, Garg VK, Reddy BS. Congenital becker nevus with lichen planus. Pediatr Dermatol 2005;22:328-30. |
| 5. | Ruocco V, Ruocco E, Ghersetich I, Bianchi B, Lotti T. Isotopic response after herpesvirus infection: An update. J Am Acad Dermatol 2002;46:90-4. |
| 6. | Wyburn-Mason R. Malignant change arising in tissues affected by herpes. Br Med J 1955;2:1106-9. |
| 7. | Becker SW. Concurrent melanosis and hypertrichosis in distribution of nevus unius lateris. Arch Derm Syphilol 1949;60:155-60. |
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| 9. | Urbani CE. Paradominant inheritance, supernumerary nipples and Becker’s nevus: Once again! Eur J Dermatol 2001;11:597. |
| 10. | Terheyden P, Hornschuh B, Karl S, Becker JC, Bröcker EB. Lichen planus associated with Becker’s nevus. J Am Acad Dermatol 1998;38:770-2. |
| 11. | Pavithran K. Vitiligo in a pigmented nevus. Indian J Dermatol Venereol Leprol 1983;49:287-9.  |
| 12. | Gupta S, Gupta S, Aggarwal K, Jain VK. Becker nevus with vitiligo and lichen planus: Cocktail of dermatoses. N Am J Med Sci. 2010;2:333-5. |
| 13. | Sugathan P, Riyaz N. A new treatment for Becker’s naevus. Indian J Dermatol Venerol Leprol 1992;58:105-7. |
| 14. | Ruocco V, Brunetti G, Puca RV, Ruocco E. The immunocompromised district: A unifying concept for lymphoedematous, herpes-infected and otherwise damaged sites. J Eur Acad Dermatol Venereol 2009;23:1364-73. |
[Figure 1], [Figure 2], [Figure 3]
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