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Shehnaz Zaman, MD, A white spot since birth and Richard P. Usatine, MD University of Texas Health The lesion on the patient’s chest was asymptomatic. Science Center at San Antonio [email protected] But what caused it—and could it be a problem? EDITOR Richard P. Usatine, MD University of Texas Health Science Center at San Antonio 13-year-old Hispanic girl came similar lesion. The patient had no fever or into our skin clinic with her chills, nor any neurological, respiratory, A grandmother for evaluation of cardiac, or gastrointestinal problems. The suspicious moles on her arms. The hypopigmented lesion on the patient’s grandmother was also concerned about chest had irregular borders and no scale a hypopigmented lesion on the young (FIGURE 1). woman’s chest. ® DowdenThere was Health no loss of sensation Media at the The patient and her grandmother said site and, upon applying pressure to the that the chest lesion had been there since surrounding skin with a glass slide, the birth, but it had beenCopyright slowly growingFor personalborder between use the onlylesion and normal over the years. The lesion was asymptom- skin disappeared. atic—there was no pruritus, bleeding, or pain. The patient was otherwise healthy ❚ What is your diagnosis? and was not taking any medications. FAST TRACK The patient and her grandmother in- ❚ How would you manage There was no loss dicated that no one in the family had a this condition? of sensation in the hypopigmented FIGURE 1 patch. Hypopigmented patch on chest

A 13-year-old patient had this white spot on her chest since birth, and it had gradually grown

PHOTOS COURTESY OF RICHARD P. USATINE, MD USATINE, OF RICHARD P. PHOTOS COURTESY over the years. She had no pruritus, bleeding, or pain.

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fluoresce. infection will while afungal a nevusanemicus, will notaccentuate A Wood’s lamp FAST PHOTO ROUNDS 490 TRACK erythema. tion intheaffectedareas. or histamine, failstoproducevasodila- choline, 5-hydroxytryptamine, nicotine, such asbradykinin, pilocarpine, acetyl- mentovascularis. Mongolian spotinphakomatosispig- in conjunctionwithnevusfl ammeusand matoses suchasneurofi bromatosis, and it mayoccurinassociationwithgenoder- ed fi ndinginnormalhealthyindividuals, The patienthadanevusanemicus, which ❚ The differential includes the following: The differentialincludesthe following: ❚ blanching ofsurroundingskin. andsurroundingskinislostdueto skin (diascopy), theborderbetween pressure isappliedtothesurrounding persensitivity resultsinskinpallor. When The vasoconstrictioncausedbythishy- ized hypersensitivitytocatecholamines. a congenitalvascularanomalywithlocal- This lesionisnotatruenevus;rather, itis Not atruenevus ing theextremities, head, andneck. However, therehavebeencasesinvolv- trunk—primarily ontheupperchest. ymptomatic. Itisusuallylocatedonthe grow withthechild, and itremainsas- appears shortlythereafter. Itcontinuesto normal skin. hypopigmented patchonsurrounding typically presentsasanirregularlyshaped of pathetic blockandintralesionalinjection rare. Itismorecommoninfemales. States isunknown, butit isnotconsidered prevalence ofthisconditionintheUnited lite macules, aswell. rather avascularanomaly. conclusion thatitisnotatruenevus, but VOL 58,NO9/SEPTEMBER2009 Differential Dxincludes Diagnosis: infectious diseases α Intralesional injectionofvasodilators, Hansen’s disease Although nevusanemicusisanisolat- Nevus anemicus is present at birth or Nevus anemicusispresentatbirthor -adrenergic blocking agents result in -adrenergic blockingagentsresultin 3 These fi These the support ndings 1 Sometimestherearesatel- 1 2 (leprosy), causedby

THE JOURNALOFFAMILY PRACTICE 6 Axillary sym- Axillary 5

4 3 The The the . the inhibitionofenzymetyrosinasein mentation intineaversicolorresultsfrom ghetti andmeatballs” pattern. Hypopig- positive, revealingthewell-known “spa- hydroxide (KOH) preparation willbe under a Wood’s lamp, andapotassium popigmented patch. The lesionfl uoresces sezia furfur, the involvedareas. or heatapplication, induceserythemain and normalsurroundingskin), norcold scratching alineacrossboththelesion fl uoresce. micus fromfungalinfectionsthattendto lesion, helpingtodistinguish nevusane- a Wood’s lampdoesnotaccentuatethe demonstrate thislossinborder. Shining granulomas aroundthedermalnerves. a veryspecifi cpatternofepithelioidcell nerve involvement. Histopathology yields mentation. This lossofsensationisdueto loss ofsensationatthesitehypopig- Mycobacterium leprae, ing skin. the hypopigmentedpatchandsurround- result inthelossofborderbetween It isatruenevusanddiascopywillnot normal skin. border betweennevusanemicusand the diagnosesmentionedabove. ing thediagnosisandexcludingsomeof A numberoftechniquesaidinconfi rm- primarily basedonthehistoryandexam. The diagnosisofnevusanemicusismade ❚ there is no loss of sensation at the site of there isnolossofsensation atthesiteof nevus achromicus, isawell-demarcated ties inadermatomalpattern( occur onthetrunkorproximalextremi- patch ofhypopigmentationthattendsto present atbirth. sence ofmelanocytes. israrely Make thediagnosis based ontheexam Neither friction (produced by Neither friction(producedby , Vitiligo Tinea versicolor, Diascopy results in the loss of the Diascopy resultsinthelossof 5 resultsfromthecompleteab- has afi nescaleonthehy- 4,5 Anatomic nevidonot 7

2 And unlikeleprosy, caused by presents with a presentswitha also known as also knownas FIGURE 2 Malas- 7 8/17/09 12:10:28 PM 12:10:28 PM

). A white spot since birth

FIGURE 2 Don't be fooled: This is not nevus anemicus

This is a typical nevus depigmentosus on the leg of an 11-year-old girl. Unlike nevus anemicus, it is a true nevus and diascopy will not result in the loss of the border between the hypopigmented patch and surrounding skin.

the . A biopsy of the Correspondence lesion is not needed, but would reveal Shehnaz Zaman, MD, 420 Elmington Avenue, #417, normal histology. Melanocytes are pre- Nashville, TN 37205; [email protected] served and normally distributed. Electron Disclosure microscopy, while not needed, would not The authors reported no potential confl ict of interest rel- detect any abnormalities in the vascular evant to this article. 4 structure. References 1. Ahkami RN, Schwartz RA. Nevus anemicus. Der- Nothing to worry about matology. 1999;198:327-329. for our patient 2. Requena L, Sangueza OP. Cutaneous vascular FAST TRACK anomalies. Part 1. Hamartomas, malformations, Our patient required no treatment. We and dilation of preexisting vessels. J Am Acad Der- While no treatment simply provided her with some informa- matol. 1997;37:523-549. tion on the benign nature of nevus ane- 3. Mountcastle EA, Diestelmeier MR, Lupton GP. Ne- is needed for vus anemicus. J Am Acad Dermatol. 1986;14:628- micus. (In addition, we dealt with the 632. nevus anemicus, moles on her arms that prompted her 4. Knoepp TG, Davis L. Nevus anemicus. e Medicine the patient may visit. They turned out to be normal me- Web site. Available at: http://www.emedicine.com/ opt to cover it up lanocytic nevi.) derm/topic292.htm. Accessed October 13, 2007. 5. Hsu S. Photo quiz: white patch on back. Am Fam with a cosmetic We told the patient that if the lesion Physician. 1999;60:1489-1490. on her chest bothered her, she could hide 6. Greaves MW, Birkett D, Johnson C. Nevus ane- concealer. it with concealer make-up.1,2 Our patient micus: a unique catecholamine-dependent nevus. and her grandmother were happy with Arch Dermatol. 1970;102:172-176. 7. Wolff K, Johnson R, Suurmond R. Fitzpatrick’s Col- the explanation and did not seek further or Atlas & Synopsis of Clinical . 5th ed. care. ■ New York: McGraw Hill; 2005. We want to hear from you! Have a comment? Drop us a line and let us know what you think. You can send a letter 1 of 3 ways. Please take a moment to share your opinion! 1 E-mail [email protected] 2 Fax 201-391-2778 3 Mail The Journal of Family Practice 110 Summit Ave. Montvale, NJ 07645

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