Derm Dilemma by Katie Dreher
MD Candidate , Class of 2022 , University of Arkansas for Medical Sciences , Little Rock , Ark .
A 15-year-old African American female presented with a hyperkeratotic , slightly hyperpigmented plaque of the right parietal scalp that had been present since birth . Initially flatter and smoother , it became thicker and rougher around the time of puberty , and a few discrete papules arose on the surface . It is now cosmetically concerning to the patient and is slightly painful to touch and when brushing her hair . What is the most appropriate management ?
A ) Apply 0.05 % clobetasol propionate ointment to the plaque until resolution B ) Obtain a punch biopsy from the edge of the plaque to confirm the diagnosis C ) Obtain a scraping for potassium hydroxide ( KOH ) preparation D ) Educate the patient about the low lifetime risk of cancer arising within the plaque and offer either longitudinal monitoring or excision E ) Reassure the patient about the benign nature of the lesion with no need for follow-up
Answer : D : Educate the patient about the low lifetime risk of cancer arising within the plaque and offer serial monitoring or removal .
This patient has a nevus sebaceous , a relatively uncommon benign hamartomatous birthmark of the skin . They are characterized by immature adnexal structures including hair follicles , sebaceous glands , and apocrine sweat glands , often with overlying epidermal hyperplasia . While some may occur in association with rare syndromic conditions , the majority develop in otherwise healthy infants .
Nevus sebaceous , also called nevus sebaceous of Jadassohn , are most commonly located on the scalp but may also be seen on the face , neck , or ( rarely ) on the trunk . They present as oval , hairless , smooth plaques at birth that are often yellow-orange in color ; they may be difficult to appreciate at this stage . During childhood , they grow proportionally with the patient . At puberty , hormonal changes commonly result in lesion thickening , with development of a bumpy or warty appearance that may be cosmetically concerning to the patient .
Due to their characteristic clinical appearance , biopsy is not usually necessary for diagnostic confirmation . While the majority of sebaceous nevi remain unchanged histologically , the development of secondary neoplasms within them is possible . These proliferations are usually benign hair follicle tumors ; however , rarely basal cell , sebaceous , and squamous cell carcinomas may develop .
Due to the small potential for malignant transformation , both close clinical monitoring over time and prophylactic removal are reasonable approaches to management . Development of concerning papules , nodules , or ulcerations should prompt biopsy . If the patient is concerned aesthetically , complete excision is reasonable even without consideration of the small risk of cutaneous malignancy . The patient should be counseled that a scar from this procedure is inevitable .
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86 • The Journal of the Arkansas Medical Society www . ArkMed . org