Giant Bilateral Becker Nevus: A Rare Presentation

Giant Bilateral Becker Nevus: A Rare PresentationAlireza Khatami, M.D., Mehran Heydari Seradj, M.D., Farzam Gorouhi, M.D.,
Alireza Firooz, M.D., and Yahya Dowlati, M.D., Ph.D.
Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences,
Tehran, Iran
Abstract: A 14-year-old boy had giant confluent brown patches that were
bilaterally distributed on his back, chest, and upper arms, and partially
covered by dark coarse hairs. A clinical diagnosis of Becker nevuswasmade
and confirmed histopathologically. We report this patient for the rarity of
presentation. Different clinical features of Becker nevi, associated findings,
differential diagnoses, and treatment options are discussed.
First described as ‘‘concurrent melanosis and
hypertrichosis in the distribution of the nevus unius
lateralis’’ by the late Dr. S.W. Becker in 1949 (1), Becker
nevus is considered as a cutaneous hamartoma that
characteristically manifests itself as a unilateral, local-
ized, hyperpigmented patch covered more or less by
terminal hairs (2,3) Also known as Becker melanosis
and pigmented hairy epidermal nevus, it most often
involves a limited area on the upper trunk of young
adolescent men (4,5). Multiple, ipsilateral giant, and
bilateral Becker nevi have been reported separately (6–
8); however, the patient reported herein has a very rare
form of this condition.
Research and Training in Skin Diseases and Leprosy,
Tehran, in February 2005 for evaluation of widespread
dark patches on his skin. From the age of 8 years, the
patient noted a change in the color of the skin overlying
his left anterior chest. During the following 3 years the
lesions progressively extended to involve large areas of
his skin. The patient also mentioned the gradual
appearance of dark coarse hairs on some parts of the
lesions during the last 3 years. Except for some transient
episodes of pruritus during exertion, the lesions were
asymptomatic. His past medical history was nonsignifi-
cant, and his family had no history of similar disorders.
The patient was a cooperative young man in perfect
health. The cutaneous examination disclosedwidespread
tan to brown patches in a roughly symmetrical distri-
bution on the skin of his anterior chest, upper abdomen,
back, and both upper arms, with some extension to the
forearms (Fig. 1). The total involved surface area was
estimated to be around 3870 cm2. Terminal hairs were
observed on the areas of hyperpigmentation. The hair
growth was most obvious on the right anterior chest. A
general physical examinationwas performed and did not
reveal any problems. A clinical diagnosis of an unusual
form of Becker nevus was made and a skin biopsy was
performed.
Address correspondence to Alireza Khatami, M.D., Center for Research and Training in Skin Diseases and Leprosy, No. 79, Taleghani Avenue, Tehran 14166 I.R. Iran, or e-mail: akhatami@ tums.ac.ir.
DOI: 10.1111/j.1525-1470.2007.00581.x
2008 The Authors. Journal compilation 2008 Blackwell Publishing, Inc. 47
Pediatric Dermatology Vol. 25 No. 1 47–51, 2008
Histopathology
affected tissue of the left upper back. Hematoxylin–eosin
staining was performed. Light microscopic examination
showed slight acanthosis, regular elongation of the rete
ridges, hyperkeratosis, and hyperpigmentation of the
basal layer cells.Hair structures appeared to be increased
in number (Fig. 2).
ized, unilateral hyperpigmented patch on the upper
chest, scapular region, or proximal upper extremities of
youngmen. Inmore than half of those affected the lesion
is covered by coarse dark hairs (9,10). Although the le-
sions may have various shapes, they consistently have a
geographic or blocklike configuration in an irregular
fashion; a linear pattern has rarely been reported (11).
Epidemiology
According to a study of 19,302 men aged 17–26 years,
the prevalence of Becker nevus is estimated to be around
0.5% in this age group (12). Most authors believe that
isolated Becker nevus occurs more frequently in men
than in women, with a 2:1 ratio. A recent study (13),
however, suggested that the true sex ratio may in fact be
1:1, because Becker nevus tends to be less conspicuous in
women (14).
This nevus can occur in all races. It usually appears
around puberty and in 75% of instances it has appeared
before the age of 15 years (9).Although in its classic form
it is considered tobe an acquired disorder, the occurrence
of congenital Becker nevus has been reported (15–18).
A
B
Figure 1. Extensive bilateral hyperpigmented patches on different parts of the trunk and upper extremities of an Iranian boy. (A) Anterior view, (B) posterior view.
Figure 2. Left: Acanthosis, elongation of the rete ridges, and some follicular plugs (hematoxylin–eosin stain, ·100). Right: Acanthosis, elongation of the rete ridges, and some follicular plugs as well as a relative increase in basal layer keratinocyte pigmentation (hematoxylin–eosin stain, ·250).
48 Pediatric Dermatology Vol. 25 No. 1 January ⁄February 2008
Familial occurrence of Becker nevus has also been doc-
umented (18–21).
Happle (22). Some evidence exists that abnormal
androgenmetabolismmayplaya role in thepathogenesis
of Becker nevus (3,23,24). A history of severe sunburn at
the site of lesion is obtained in around 25% of patients
(9). Although not proved, an association with BCG
vaccination has been suggested (25).
Dermoscopic Features
pigmentation, hair follicles, perifollicular hypopigmen-
tation, and vesselswere themain dermoscopic features of
Becker nevus (26).
Panizzon et al had classified Becker nevi according to
their clinical presentation into melanotic, hypertrichotic,
andmixedtypes(27).Anoccult typehasbeensuggested in
amild folliculitis develops (28) but this is not accepted by
all experts. Becker nevus has been reported to occur on
atypical sites such as the hands or feet (9,29–31). It may
additionally be accompanied by some other cutaneous
and extra-cutaneous involvements. Happle and Koop-
man (13) reviewed 23 cases and proposed the new term
‘‘Becker’s nevus syndrome’’ for a simultaneous occur-
rence ofBecker nevus andunilateral breast hypoplasia or
othercutaneous,muscular,orskeletaldefects.Allof these
nevus and are mostly ipsilateral (14,31). Extensive, mul-
tiple, and bilateral lesions have been reported (6–8,32).
Associations
It is very well documented that Becker nevus can be
associated with several clinical conditions (33,34). Some
of these associations are listed in Table 1.
Differential Diagnosis
ocytic nevi, hyperpigmented lesions of Albright syn-
drome, smoothmuscle hamartoma, cafe-au-laitmacules,
mentation (2,9,66).
Treatment Options
It is generally accepted that Becker nevus has no effec-
tive treatment (9). However, many patients seek therapy
to improve their condition. Although reassurance may
be all that is needed for a limited lesion on a covered
area, lesions on exposed areas may need an interven-
tion. Traditional surgical excision usually is unsuccess-
ful and may result in unacceptable scars. Lasers have
been used for improving the pigmentary component as
well as for reducing the associated hypertrichosis and
have been variably successful for some patients (67). In
a recent study, one-pass Er:YAG laser had better results
than three treatment sessions with the Nd:YAG laser
(68).
CONCLUSIONS
Our patient had giant and bilateral Becker nevus, a rel-
atively common cutaneous hamartoma. Although in its
characteristic form it is considered as a benign lesion, in
many instances the lesion can cause cosmetic problems.
It must also be remembered that it may be associated
with a wide spectrum of clinical entities, some of which
canbepotential threats to thepatient’s health. Inorder to
detect any associated condition, detailed history taking
and careful physical examination are recommended.
TABLE 1. Conditions Associated with Becker Nevus
Acanthosis nigricans (35) Accessory scrotum (36) Acneiform eruption (37–40) Bowen’s disease (41) Breast hypoplasia (40,42–45) Chest abnormalities (40,42) Congenital adrenal hyperplasia (46) Connective tissue nevus (47) Epidermal nevus (48) Extramammary fatty tissue hypoplasia (49) Fibrous dysplasia (50) Lichen planus (51) Limb asymmetry (52) Lipoatrophy (49) Localized cranial defects (53) Localized scleroderma (54) Lymphangioma (55) Malignant melanoma (56) Multiple leiomyoma cutis (57) Odontomaxillary dysplasia (58) Perforating granulomatous folliculitis (38) Pectus excavatum (59) Polythelia (supernumerary nipples) (60) Port-wine stain (61) Scoliosis (39) Smooth muscle hamartoma (62,63) Spina bifida (39) Spinal epidural lipomatosis (64) Unilateral dermatomal superficial telangiectasia (65)
Khatami et al: Giant Bilateral Becker Nevus 49
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