lnrernational Journal of Dermatology, Vol. 35, No.

4, April 1996

REVIEW

LENTIGO
SIMEEN BER RAHMAN, M.D., AND

--
JAG BHAWAN, M.D.

다양한 용어들이 작고, 정확히 둥근 형태에 있고, 기관계 이상과 관련이 있을 수도, 또 없을 수도 있다.
황반변적 특성을 지닌 색소 침착성의 피부 점막에
있는 조직을 표현하기 위해 사용되어져 왔는데 이는 LENTIGINES WITHOUT ASSOCIATED SYSTEMIC
흑색점(lentigo), 점막 멜라닌반(melatonic macules), ANOMALIES (기관계 이상과 연관성이 없는 흑색증)
흑색증(melanosis) – 또는 멜라닌증 – 주근깨, 모반 해당 흑색증 그룹의 의학적, 조직학적 특성은 Tables
(ephelides), 경계 모반(junctional nevi) 등의 어휘를 2 와 3 에 요약되어 있음
포함한다. ‘흑색증’이라는 용어는 단수로는 lentigo, Juvenile Lentigo (Lentigo Simplex) – 청소년기
복수로는 lentigines 로 일컬어지는데 이러한 흑색증
조직장애를 묘사하기 위해 언급된 모든 어휘를 의학적 관찰. 이 조직 장애는 수가 적도 아동기에 주로
사용하는 것이 가능하다. 관련된 조직학적 특성에 발생하지만, 어떤 나이에서든지 나타날 수 있다. 조직
대한 묘사는 혼란을 야기하였는데, 그 이유는 장애는 햇빛에 노출된 부위에 편증되지 않고도 신체의
조직학적 특성을 자세히 다루는 연구가 이제껏 몇 모든 곳에 발생할 수 있다. 그 크기는 1mm 에서부터
없었기 때문이다. 더불어, 이러한 연구들은 아주 5mm 에 달하며 색으로는 갈색과 검은색의 색소가
제한된 수의 조직 장애에 대해서만 이루어지는 것이 고르게 침착되어 있다. 또한 이들은 손으로 만져지지
보편적이었다. 해부학적 변이를 고려한 정보의 부족, 않는다.
그리고 이러한 조직 장애의 조직학적 성격을 연구하기 현미경을 통한 발견. 조직학적으로, 망융선이 보통
위해 사용된 방법론과 기술들이 이 문제점을 더욱 정도의 신장을 보이게 된다. 멜라닌 세포는 기저
복잡하게 만들었다. 흑색증은 단독으로 존재하거나 세포층에서 그 수가 증가할 수도 있다. 증가된 색소는
복수로 존재할 수도 있는데, 많은 의학적 기형과 각질형성세포를 비롯한 멜라닌 세포에서도 발견될 수
연관된 형태로 보여질 수도 있다. 본고는 다양한 있으며 멜라닌 소포는 각질층을 포함한 표피의
흑색증의 형상과 그들의 조직학적인 특성을 다룬 상층에서 관찰될 수 있다. 상피에서, 멜라닌 포식
문헌에 대한 논평으로서 이 복잡한 색소 침착에 대한 세포는 단독으로 혹은 단핵 세포가 동반된 침투가
조직 장애를 보다 더 이해하고 헷갈릴 위험성이 있는 보여지기도 한다. 어떤 저자들에 의하면, 이러한
많은 용어들을 명료히 하는 데에 주안점을 두고 있다. 조직 장애는 경계 모반의 전구체가 될 수도
있는데 이는 모반 세포의 소포가 망융선의
DEFINITION (용어 정의) 끝부분에서 보이는 경우도 있기 때문이다. 우리의
흑색증은 1 에서 5mm 정도의 작은 색소가 들어간
의견에 의하면, 이러한 조직 장애는 흑색증이
반점을 의미하나 1cm 보다는 작고 주위에 정상적으로
보이는 피부가 둘러싸고 있는 것을 의미한다. 아니라 초기모반 (nevus incipiens)라고 불리는
조직학적으로, 기저층의 색소 침착 증가 및 변이형 것이 더 맞을 것 같다.
멜라닌 세포의 수 뿐만 아니라 표피의 과다 형성 또한 전자 현미경을 통한 발견. 기저층의 각질 형성
관찰될 수 있다. 후자의 경우는 수적으로는 증가할 수 세포는 초핵 구간에 집중된 멜라닌 과립을
있겠으나, 고치 형태를 띄진 않는다. 흑색증의 다양한 함유하고 있다. 각질 형성 세포는 주로
의학적 변이가 묘사되어 있다. (Table 1). 정상적으로 나타나는 반면 멜라닌 세포는 고르지
않은 핵과 조밀한 세포질을 지니고 있다. 거대한
CLINICAL FEATURES (의학적 특성들) 멜라닌 과립 (macromelanosome) 멜라닌 색소,
흑색증은 몇 년의 기간을 걸쳐 천천히 발달하거나 각질 형성 세포, 그리고 대식세포에서 관찰될 수
갑작스럽게 발진할 수도 있다. 그 색은 갈색에서
있다.
검갈색, 검은색에 이르기까지 다양하고 그 색소화가
동종의 것일 수도, 잡색일 수도 있다. 의학적 변이의 Freckles (Ephelides) – 주근깨 (모반)
대다수 중에서는 그 크기는 1mm 부터 5mm 까지 의학적 관찰. 의학적으로, 주근깨는 얼굴, 손등,
존재한다. 양성 흑색증 (lentigo benigna)라고도 그리고 밝거나 (특히 붉은 계열의) 머리카락과
불리우는 그 하위 종은 주로 얼굴에 발현되며, 직경이 밝은 피부를 가진 사람들의 팔 앞 부분의 햇빛에
몇 센티미터에 이르기도 한다. 이러한 조직 장애는 노출된 부위에서 나타난다. 그러나, 주근깨는
의학적으로는 악성 흑색증과 혼동될 수 있으나 조직적 또한 금발이거나 갈색 머리칼을 가진
형태를 들여다 보면 비전형적 멜라닌 세포가 없다는 사람들에게서도 나타날 수 있으며 어두운
사실을 알 수 있다. 흑색종의 가장자리에는 선명히, 머리카락과 어두운 피부도 예외가 아니다. 이러한
혹은 부드럽거나 들쭉날쭉한 경계가 있다. 그 숫자는 사람들에게서 나타나는 주근깨는 더 작고 더
몇 개 정도에서 수 천 개까지도 가능한데, 인체의
적다. 주근깨는 주로 여름 달에 나타나지만
손바닥, 발바닥, 그리고 점막으로 이루어진 표면을
포함한 모든 부위에 발현될 수 있다. 흑색증의 표현은 일생동안 유지된다.
어떤 경우에는 벗겨져 나갈 수도 있다. 흑색증은
From the Dermatopathology Section, Department of
Dermatology, Boston University School of Medicine, Boston,
Massachusetts.
Address for correspondence: Jag Bhawan, M.D., Boston
Uni versity School of Medicine, Department of
Dermatology, 609 Albany Street, Boston, MA 02118.
229
may be eruptive, appearing rather suddenly. The color
ranges from brown to brown-black to black and the
pigmentation may be homogeneous or variegated.1,2 In
the majority of the clinical variants, the size ranges
from 1 to 5 mm. The subtype, sometimes referred to as
lentigo benigna and often seen on the face, may spread
up to a few centimeters in diameter.1,3 These lesions
may be clinically confused with lentigo maligna, but
the histologic features lack melanocytic atypia. The
margins of the lentigines are sharply defined or may be
smooth or jagged. Their number varies from a few to
thousands and they can occur anywhere on the body
including the palms, soles, and the mucosa! surfaces.1
The surface of the lentigines can sometimes be scaly.2
The lentigines may or may not be associated with sys
temic anomalies.
LENTTGINES WITHOUT ASSOCIATED SYSTEMIC ANOMALIES
The clinical and histologic features of this group of
lentigines are summarized in Tables 2 and 3.
Juvenile Lentigo (Lentigo Simplex)
Clinical Picture. These lesions are few in number and
arise most often in childhood, but can appear at any
age. The lesions are scattered and can occur anywhere
on the body4 without predilection to areas of sun ex
posure. The size varies from 1 to 5 mm. The lesions are
evenly pigmented and are brown to black in color.
They are not palpable.5
Microscopic Findings. Histologically, a moderate
elongation of the rete ridges is seen.5 The melanocytes
may be increased in number in the basal cell layer.4,5
Increased pigment is seen in the melanocytes as well as
in keratinocytes4 and melanin granules may be ob
served in the upper layers of the epidermis, including
the stratum corneum. In the upper dermis, melano
phages alone' or in association with a mild mononu
clear infiltrate can be seen.5 According to some au
thors, these lesions may be the precursors of junctional
nevi because nests of nevus cells can sometimes be
seen at the tips of the rete ridges.5,6 In our opinion,
such le sions should be termed nevus incipiens and not
lentigo.
Electron-Microscopic Findings. The keratinocytes
of the basal cell layer contain melanin granules concen-
 International Journal of Dermatology
Vol. 35, No. 4, April 1996

13654632, 1996, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-4362.1996.tb02994.x by University Of Ulsan, Wiley Online Library on [27/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Table 1. Classification of Lentigines
Lentigines With Associated
Lentigines Without Associated Anomalies Ultra-violet Induced Lentigines Anomalies/Syndromes
Juvenile lentigo/lentigo simplex Solar lentigines/senile lentigines/senile freckle LEOPARD
Freckles/ephelides Reticulate black solar lentigo'' Moynahan''
Generalized lentigines/lentiginosis profusa Lentigo benigna '' Peutz-Jeghers
PUVA-induced Syndromes associated with myxomas
Unilateral/segmentalt Tanning bed LAMB

Mucosal/genital NAME

Labial CARNEY

Genital Langier-Hunziker
Atypical Penile'' Neurofibromatosis
Acral Leschke's''
Xeroderma pigmentosa
Bannayan-Riley-Ruvalcaba
Tay's
Centrofacial neurodysgraphic
*Subtype of the above.
t May also be associated with systemic disorders.

trated in the supranuclear area.7 The keratinocytes usu processes than the melanocytes of adjacent normal
ally appear normal, whereas the melanocytes may have
skin.5,9 Solar elastosis is not apparent.13
an indented nucleus and a dense cytoplasm.7 Giant
melanin granules (macromelanosomes) may be seen in
Lentigines Profusa (Generalized Lentigines)
the melanocytes, keratinocytes, and macrophages.5
Clinical Picture. Numerous lentigines can be a cuta
Freckles (Ephelides)
neous sign of a systemic disorder, but occasionally may
appear in the absence of any associated abnormalities or
Clinical Picture. Clinically, freckles appear as light
triggering factors.2 Lentiginosis profusa that persisted for
brown macules on sun-exposed areas of the face, back
up to 20 years following an attack of measles was docu
of the hands, and forearms in individuals who have
mented by Darier in 1902; a similar phenomenon was
light, especially red hair and light skin;1,4,s but, they
observed by Gaucher and Milian in 1897 in a patient fol
can also be seen in people with blonde or brown hair,
lowing an episode of typhoid fever.14 The exact incidence
dark hair, and dark skin. The freckles in such people
of lentiginosis profusa following infection or exanthem is
are smaller and fewer.9 Freckles usually appear in the
not known, but appears to be a rare phenomenon. The
summer months but may persist throughout life.8 Ex
clinical appearance of the individual lesions of lentigi
amination of the skin with Wood's light may uncover
nosis profusa is similar to freckles, but the distribution is
freckles that are not evident in ordinary light.10 The
widespread. The lesions appear as small pigmented mac
distribution of the lesions is symmetric and they may
ules that are present at birth or arise during childhood or
be sparse or dense.9 The color varies from pale yellow
early adulthood.15 The lesions may be numerous and
to brown and even black, and tends to deepen after
widespread, involving the trunk, extremities, palms, geni
sun exposure. The borders are well defined and irregu lar
talia, and mucosa! surfaces such as conjunctiva, but the
and the diameter may be up to 5 mm.4,8 Freckles can
buccal mucosa and soles may be spared.15 The size of the
be induced by a single exposure to UVB in patients with
macules vary from 1 mm to 2 cm and the color is from
natural freckles.11
dark brown to black. The texture of the skin remains
Microscopic Findings. Histologically, rete ridges
normal and lesions are not palpable.15 The differential
are not elongated but there is an increase in the
pigment content in the basal cell layer; however, an diagnosis should include LEOPARD, LAMB, and NAME syn
increase in the number of melanocytes is not dromes which have other associated systemic features.
observed.4,5,u The density of dopa-reactive Microscopic Findings. The histologic picture is
melanocytes in split-epidermal sheets has been similar to that of a lentigo simplex; there is slight to
reported to be decreased in comparison to adjacent moderate elongation of the rete ridges and an increase
uninvolved skin or skin from the same site of different in the number of melanocytes as well as melanin in the
individuals.5,9 The melanocytes may be strongly dopa- melanocytes and kera tinocytes. Macromelanosomes
positive, larger, and have more dendritic may be present.2·15

230
 Lentigo
Rahman and Bhawan

13654632, 1996, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-4362.1996.tb02994.x by University Of Ulsan, Wiley Online Library on [27/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Table 2. Clinical Features of Lentigines without Associated Systemic Anomalies
Variant Age Site Size Color Margins
Simplex Childhood
Any area 1-5 mm Brown-black Jagged/smooth
Freckles Childhood Sun-exposed Pale brown
1-5111111 Jagged
Generalized Birth to adult
Face, trunk, extremities 1111111-2 cm Brown-black Jagged/smooth
buttock/genitalia
Unilateral Early
Unilateral/segmental Variable Shades of Jagged
childhood Labial
Lips/oral mucosa Few mm brown Brown- Jagged
Adult black Tan to
Labia minora/majora, vulva Up to a few 15 111111 Jagged
Genital Women Penile glans corona/shaft Atypical penile lesions brown
Men up to 1 cm
Acral Childhood to adult Palms, soles 1-5111111 Brown Regular

Unilateral/Segmental Lentigines
multiple. Although the most common site is the lower
lip, lesions can also occur on the gingiva, buccal mu cosa,
Clinical Picture. Pigmented macules have been de palate, muco-buccal folds, and tongue.27 The age
scribed that are limited to one side of the body8 or of onset ranges from 25 to 71 years. A predominance of
arranged in a segmental, zosterifonn pattern.1•2•16 They women was observed by some authors;25•27 however, in
can be seen in people with dark hair and dark skin in another study men predominated.26 Differential diagno
the absence of exposure to the sun.8 The zosteriform sis can include the Laugier-Hunziker and the Peutz
pattern does not necessarily have a systemic manifesta Jeghers syndromes. Lack of involvement of other sites
tion;1•2 however, an association with diseases such as and associated systemic features should help in differen
sickle cell anemia,17 ipsilateral rigid cavus foot,18 men tiating labial melanotic macule from these syndromes.
tal deficiency,19 familial goiter,20 blue nevi,21 and Microscopic Findings. Histologically, hyperpara
plaque-type of blue nevus22 have been recorded. They keratosis and epithelial hyperplasia may be seen. There
have also been regarded as 'formes frustes' of neurofi is an increase in the pigment content of the basal
bromatosis.3•19 Lesions may be seen at birth or during layer.25-27 An increase in the number of dendritic
early childhood. In unilateral/segmental lentigines, cir melanocytes has been observed.27 Melanophages, acti
cumscribed dark macules appear on normal back vated fibroblasts, and scattered telangiectasias may
ground skin.8 This is important because it distinguishes also be seen.25•27
this entity from segmental nevus (nevus spilus), where
the background skin is hyperpigmented.1•2 The mac Genital Lentigines
ules may concentrate in the midline of the body form
ing a distinct border8 that is also seen in zosteriform Clinical Picture. Genital lentigines are seen in both
speckled lentiginous nevus. sexes. In men, the most common sites are the glans
Microscopic Findings. There is elongation of the penis, corona, corona sulcus, and the penile shaft. The
rete ridges with an increased number of melanocytes lesions have irregular borders and vary in color from
and melanin in the basal layer with melanophages in tan to brown to dark b_rown and skip areas are seen.
the upper dermis.17,19-21,23,24 The diameter of the individual lesions may be up to
Electron-Microscopic Findings. The melanocytes are
slightly increased in number and appear to contain
melanosomes at various stages of development. Large Table 3. Histologic Features of Lentigines
number of clumped melanosomes and membrane bound without Systemic Disorders
melanosome complexes are seen in the sur rounding
Le11tigo
basal keratinocytes, but not more than in the Finding Simplex Freckles Generalized Unilateral Mucosa/
uninvolved skin.17 EH + + + ± +
RR + + + + ±
Mucosal/Genital Lentigines: MEL + ± + ± +
Labial Melanotic Macule (Solitary Labial Lentigo)
PIG + + + + +
MP + + + +
Clinical Picture.Melanotic macules may be seen on
CI +
the lower lips in healthy adults without any systemic
SE
disorder.25 The term 'solitary labial lentigo' is used by
some,25 whereas others prefer the term 'labial melanotic EH = epidermal hyperplasia; RR = rete ridge elongation; MEL =
increased number of melanocytes; PIG = epidermal pigmentation;
macule'26,27 because these pigmented macules can be MP= melanophages; CI= cellular infiltrate; and SE= solar elastosis.
 International Journal of Dermatology
Vol. 35, No. 4, April 1996
15 mm. They tend to increase in size and number and
darken in color with psoralen-ultraviolet A (PUVA)
therapy.28,29 Penile lentigines should be differentiated
from the atypical penile lentigines which are usually
larger than 1 cm in size.28,30,31 They may have irregular
borders with a variegated pigment pattern28,31 as well
as areas of depigmentation.29 Clinically, the atypical
penile lesions have to be differentiated from melanoma.31
In women, these lentigines occur any where on the
genital mucosa.28 They may appear as individual mac
ules or as a mottled, pigmented patch with skip areas,
the diameter can be up to S to 15 mm or larger. They
may also appear in episiotomy scars and after child
birth. Associated diabetes mellitus has been noted.28
Microscopic Findings. In genital lentigines the most
consistently recorded features in both sexes are epithelial
hyperplasia (usually with elongated rete ridges), basal
cell hyperpigmentation, slight melanocytic hyperplasia,
and the presence of melanophages in the connective tis
sue stroma. No cytologic atypia of the melanocytes is
seen.28,29 In contrast to the penile lesion, vulvar lentigines
lack the prominent melanocytic dendrites.28 Occasional
ly, a lymphoid infiltrate, stromal fibroplasia, and vascu
lar dilatation may be seen.28 Histologically, there is ep
ithelial hyperpigmentation with slight increase in the
number of normal appearing melanocytes in penile lenti
go, whereas in the atypical penile lentigo the melanocytes
may be normal,31 atypical,30 or dendritic with a large
number of melanophages in the upper dermis.30,31
Electron-Microscopic Findings. Atypical nuclear
features include an increase in size, hyperchromasia,
and indentation; markedly dendritic melanocytes have
also been reported in penile lentigo.29 These findings
suggest a defect in melanosome transfer; however,
these findings are difficult to interpret in view of lack
of appropriate controls.
Acral Lentigines
Clinical Picture. In blacks, the paler skin of the
palms and soles may show a variety of pigmentary
changes, including mottled pigmentation, lentigines,
nevi, and melanomas.32 Acral lentigines are pigmented
macules, 1 to 5 mm in size, well circumscribed32 and
are seen on the palms and soles. They are more com
mon and more numerous in blacks and dark-skinned
people, but may also be seen in whites. They may be
seen in children as well as adults.33 Some authors have
claimed the evolution of malignant melanoma in acral
lentigines after 40 years,32 however, these reported
findings lack confirmation or regular follow-up and
may be regarded as accidental occurrences.
Microscopic Findings. Acral lentigines are histo
logically similar to lentigo simplex.32 The lesion shows
elongation of rete ridges and diff se melanocytic hy
perplasia in the basal layer. The melanocytes are elon
gated and show pigmented, well-developed dendrites.32
231
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ULTRA VIOLET (UV)-INDUCED LENTIGINES
The clinical and histologic features of various types of
UV-induced lentigines are summarized in Tables 4 and 5.
Solar Lentigines (Senile Lentigo, Senile Freckle,
Liver Spots)
Clinical Picture. Solar lentigines occur as multiple
pigmented macular lesions on sun-exposed areas, and
are commonly seen in middle-aged and elderly peo
ple.4,12 The age of onset is between the second and
the
ninth decade.34 The sites of predilection are the face,
arms, dorsa of the hands,35 and upper trunk.36 Solar
lentigines increase slowly in number and individual le
sions may increase in size.12 Ninety percent of the
whites over 70 years are likely to have solar lentigines
on the dorsa of the hands. Solar lentigines appear as
flat macules; the color varies from tan to brown with
some variation.5,36 The margins may be smooth or ir
regular,36but are not as sharply defined as those of the
junctional nevus.4 The size varies between 1 mm and 1
cm, but can also be greater than 1 cm. The lesions may
coalesce to form larger plaques.12,36 They have a flat or
slightly depressed surface which may be cleaved by fine
wrinkles. Orifices of the eccrine gland and the pilary
canal may be seen on the surface.35
Microscopic Findings. The epidermis is slightly
acanthotic and the granular layer is preserved.12 The
rete ridges are elongated and may be either club
shaped36 or tortuous. Bud-like extensions can be seen
between the rete ridges.12 The rete ridges may also ap
pear crowded, show branching, and may fuse at the
base.35 The epidermis between the rete ridges may be at
rophic.5 There is a marked increase in pigmentation of
the basal cells in the proliferating rete ridges.12 The
melanocytes may be normal4 or increased in num
ber.2,12,35,36 In 1983, Rhodes et al. did a quantitative
study of dopa-incubated, paraffin-embedded sections of
solar lentigines from the backs of patients between the
ages of 24 to 71 years. They observed an increased num
ber of melanocytes, concentrated along the club-shaped
epidermal rete ridges with a density of 25 ± 7% as com
pared to adjacent normal skin (14 ± 3%). No signific nt
difference was seen between the mean diameter of the
dopa-reactive melanocytes in solar lentigines as com
pared to the adjacent normal skin. Cellular atypia is not
seen.37 The dermis contains elastotic material with
telangiectasias.4,34 There may be a mild dermal fibrosis
and mjld to moderate inflammatory infiltrate with a few
melanophages.2,5,36 Some authors believe that solar
lentigo is the same as a large-cell acanthoma, because
the histologic features are similar, the only difference
being that, in large-cell acanthoma, the keratinocytes are
larger in the lower half of the rete ridges.34 Others dis
agree pointing out that large-cell acanthomas are clini
cally more keratotic38 and paler in color than solar
232
 Lentigo
Rahman and Bhawan
Table 4. Clinical Features of UV-Induced Lentigines
Variants Age Site
Solar 2nd to 9th decade Sun-exposed
PUVA
Any Buttock/groin, chest, genitalia
Tanning-bed
Adults''· Acral, anterior legs, arms, chest
'' = cases reported only in adults.
lentigines and they differ histologically by the absence of
the club-shaped proliferation of the rete ridges. These
two lesions also have a different nuclear DNA content as
measured by computerized microscopic image analysis.
The DNA index was found to be 1 in solar lentigo (simi
lar to the normal diploid lymphocyte control) and nor mal
adjacent epidermis, whereas large-cell acanthomas
measured between 1.28 and 1.5.39
Electron-Microscopic Findings. The melanocytes
are increased in number and occur as single cells or as
small aggregates above the dermoepidermal junction.
The keratinocytes are laden with melanosomal com
plexes and the size of these may vary, but they are
larger than those of the surrounding keratinocytes. In
the upper layers of the epidermis, numerous melano
somes are seen, dispersed and not as complexes, indi
cating that not only is there an increase in melanin syn
thesis, but also a probable delay in the lysosomal
destruction of the melanosomes. 5 In 1980, using a
scanning microscope on epidermal sheets, Montagna et
al. 35 observed that the underside of a lentigo had
crowded epidermal rete ridges and columns fusing to
form a plate, pock-marked by craters, the resultant
patterns resembled chain-links from which columns
descended downward. Light oval bodies measuring 10
to 15 p with dendritic processes were seen at the tips
of the rete ridges. These bodies were lighter in color in
the lentiginous areas as compared to the surrounding
noninvolved epidermis, where they appear like plates.
These bodies represent melanocytes.35
Reticulated Black Solar (Ink Spot) Lentigo
Clinical Picture. Black reticulated solar lentigo is a
variant of the solar lentigo. They are seen on the sun-ex
posed areas of the body and appear as very dark brown
to black macules. They have an irregular outline and
may have a reticulate pattern giving a wiry or beaded
Table 5. Histologic Features of UV-Induced Lentigines
Type EH RR MEL
Solar + ++ + +
PUVA ± ± + I few atypical
Tanning bed ++
EH= epidermal hyperplasia; RR= rete ridge elongation; MEL= increased number of melanocytes; PIG= epidermal pigmentation; MP= melanophages;
CI= cellular infiltrate; SE= sol.ar elastosis; ND = not documented.
233
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Size Color Margins
1-5111111 Tan-brown black Jagged
Pin head to 3 cm Shades of brown Jagged
2-5111111 Brown-black Jagged
appearance as in an 'ink spot.' They are seen in associa
tion with numerous solar lentigines in individuals of
Celtic origin and fair skin. Usually one black reticulate
lentigo is seen amongst a sea of solar lentigines.40
Microscopic Findings. There is hyperplasia and
mild elongation of the epidermal rete ridges without
any budding or tortuous appearance. There is marked
hyperpigmentation of the basal layer with skip areas
involving rete ridges. Additionally, there may be a
min imal increase in the number of melanocytes as
com pared to the normal adjacent skin. Mild solar
elastosis in the upper dermis is observed in addition to
a mild perivascular lymphocytic infiltrate. Dopa-
incubated, paraffin-embedded sections show prominent
and thick er dendritic melanocytic processes compared
to adja cent normal skin.40
Electron-Microscopic Findings. The keratinocytes
of the involved area show an increased number of
melanosomes within complexes as compared to the
normal uninvolved skin. The melanosomal complexes
contain 2 to 8 melanosomes as compared to 2 to 5 in
the normal pale skin. The number of melanocytes ap
pear to be unchanged.40
PUVA-Induced Lentigines
Clinical Picture. Individuals undergoing prolonged
PUVA-therapy for psoriasis may develop prominent, dis
crete brown macules that have been termed freckles,41
stellate hyperpigmented freckles,42 or star-like hyper
pigmented lentigines.43 These are commonly seen on
the upper part of the back and chest,42 buttocks, groin,
glans penis, and penile shaft with sparing of the palms,
soles, axillae and gluteal cleft.37 The color varies be
tween light and dark brown.37•42 The size of the lesion
varies between 3 and 8 mm,37 but, the stellate lesions
may measure up to 3 cm in diameter.42 Although these
lentigines may persist for 3 to 6 months after therapy
PIG MP CI SE
few mild ++
++ + ± variable
+ ND

International Journal of Dermatology
Vol. 35, No. 4, April 1996
has been discontinued, the stellate lesions have been
known to persist for more than 2 years.42
Microscopic Findings. Hyperkeratosis and thinning
of the epidermis between the rete ridges have been ob
served.44 The rete ridges are elongated,37 and increased
pigmentation of the basal and malpighian layers has
been observed.42,44 The number of melanocytes may be
normal42 or increased.37•44 The melanocytes appear to
be concentrated along the elongated rete ridges.37 Few
atypical melanocytes may be seen.37,44 Some pigmentary
incontinence has been observed in the upper dermis.41
Dopa-stained split preparations show an increased den
sity of melanocytes,34•44 but the actual number of
melanocytes is difficult to quantify because of different
microscopic planes of the elongated rete ridges.37
Melanocytes also appear more strongly dopa-positive
and dendritic.41,44 Quantitative studies reveal that the
melanocyte density for PUVA macules and solar
lentigines is not significantly different, but it is increased
in com parison to the normal adjacent skin. The average
diame ter of the melanocytes is greater in the PUYA
lentigines (8
± 0.7 µm) as compared to solar lentigines (6 ± 0.5 µm)
and normal adjacent skin (7 ± 0.4 µm).37
Tanning-Bed Lentigines
Clinical Picture. Prolonged or excessive use of a tan
ning (sun)-bed may be followed by the appearance of
lentigines.45,46 These lesions are similar to the !'UVA-in
duced lentigines, except that UVA is used without pso ralens
and the site for the tanning bed lentigines is re
portedly to be primarily acral despite whole body
exposure. These tanning-bed lentigines are frequently
seen on the anterior aspects of the legs45·46 and arms,
but can also be seen on the neck and anterior chest.46
The lesions may appear either abruptly after intense
tanning45 or after prolonged regular use of up to 1
year.46 The tanning-bed lentigines vary between 2 and
5 mm in size, may be unevenly pigmented, and are
dark brown to black in color with irregular bor
ders.44·46 Some of these lesions may coalesce.46
Microscopic Findings. Tanning-bed lentigines
probably represent a clinical variant of PUVA-induced
lentigines, because they are histologically similar. The
basal and the malpighian layers appear deeply pigment
ed. Melanocytes are increased in number in the basal
layer with a few melanocytes migrating upward into
the epidermis. Mild atypia of the melanocytes has been
described. They may have large angular and hyperchro
matic nuclei. A mild perivascular infiltrate may be pre
sent.45
Electron-Microscopic Findings. The basal cells and
the keratinocytes of the stratum spinosum appear heavily
pigmented and laden with large compound melano somes.
Some of these cells contain up to 50 single mela nosomes.
The melanosomal complexes may push or in dent the
nucleus of the keratinocytes and obscure the
234 in the LEOPARD syndrome shows an increase in the pig
13654632, 1996, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-4362.1996.tb02994.x by University Of Ulsan, Wiley Online Library on [27/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
tonofilaments and cytoplasm.45 The basal melanocytes
contain a moderate number of stage IV melanosomes
and a few stage III melanosomes. There are also melano
somal complexes in the melanocytes, a finding previously
described in solar and !'UVA-induced lentigines.45 The
melanocytes may be binuclear and the mitochondria and
endoplasmic reticulum are reduced, however, the den
drites are abundant and contain melanosomes. Collagen
fibers are disrupted in the papillary dermis and some
degenerated elastic fibers may be seen.45
LENTIGINES ASSOCIATED WITH SYSTEMIC ANOMALIES
Lentigines may be part of many syndromes with a
wide variation of associated abnormalities. The follow
ing syndromes are included:
Multiple Lentigines (LEOPARD) Syndrome
Clinical Picture. The LEOPARDsyndrome is
comprised of Lentigines, Electrocardiographic
conduction defects, Ocular hypertelorism, Pulmonary
stenosis, Abnormal genitalia, Retardation of growth,
and Deafness. It is due to an autosomal dominant gene
with variable expressivi ty.2 Lentigines are present at
birth and increase in num ber until puberty. Lentigines
are numerous on the neck and upper trunk, but can also
be widespread, including on genitalia, palms, soles,
and scalp. The lentigines may
be limited to one side of the body.47 Commonly associ
ated abnormalities are cardiac defects in the form of
pulmonary and subaortic stenosis and similar conduc
tion defects; obstructive cardiomyopathy may be a
cause of early death. Mandibular prognathism may be
seen in addition to the skeletal abnormalities listed
above.2•48
Deafness is usually the sensorineural type and the geni
tal abnormalities include gonadal hypoplasia, hypospa
dias, and delayed puberty.2·49 Generalized lendgines
have also been described with electrocardiographic
changes in families without any other associated abnor
malities.50 Fixation nystagmus has been observed in a
pedigree with generalized lentigines.51
Variants of the LEOPARD syndrome have been de:
scribed, a syndrome referred to as the Moynahan syn
drome includes a large number of lentigines in a some
what symmetric distribution, psychosomatic infantilism,
and genital hypoplasia.52 The distribution of the lentig
ines is widespread with some sparing of the face. The
intensity of the pigment is variable.52 The genital ab
normalities are in the form of hypospadias, short pe
nile length, and undescended or atrophic testes. In the
girl or woman, the genital abnormalities include de
layed puberty, ovarian hypoplasia, or absent ovaries.
The psychic infantilism may be limited to general be
havior and the intelligence may seem normal.52
Microscopic Findings. The histology of the lentigo
ment content of the epidermis with an increase in the

235
 Lentigo
Rahman and Bhawan
number of melanocytes. This increased number of
melanocytes is primarily in the lower epidermis and to a
lesser extent in the upper epidermis; they are distributed
singly or in the form of micro-nests.2 The melanocytes
are filled with melanosomes.2 Macro-melanosomes have
been observed in keratinocytes as well as in melano
cytes.47 The histologic appearance of the pigmented
macules in the Moynahan syndrome is similar to that of
the lentigines in the LEOPARD syndrome.
Electron-Microscopic Findings. Ellipsoid melano
somes are the most commonly seen in the melanocytes
and keratinocytes with a size varying between 0.2 and
0.6 µm. The melanosomes are mostly single, but com
plexes may also be seen. Macro-melanosomes are seen
in both keratinocytes and melanocytes. They are spheri
cal and measure up to 2 µm in diameter and may or
may not have a membrane. Vesicles (30 to 40 µm in di
ameter) can be seen and are characterized by three
zones: a central core of dense amorphous material,
translucent vesicles, and a thin outer layer having vesi
cles within a clear matrix. In addition, complex melanin
granules and spherical granular melanosomes have been
observed in keratinocytes and melanocytes.47
Peutz Jeghers Syndrome
Clinical Picture. This is an autosomal dominant dis
order with a high degree of penetrance, characterized
by gastrointestinal polyps and pigmented macules
commonly seen on the oral mucosa, lips, face, palms,
soles, and dorsa of the hands.3 The pigmented macules
are present at birth or appear in early childhood and
the oral mucosa is always involved.
The pigmented lesions are usually round to oval in
shape but can form irregular patches. The color varies
from brown to black. The size varies between 1 and 5
mm. They may be distributed on the gums, hard
palate, lips, palms, and soles. Rarely the nails may be
pigmented. The macules may disappear over time, but
the oral pigmentation does not.1-3 The associated
polyps are found throughout the intestine, more
often in the jejunum and ileum and less frequently
in the
colon, rectum, stomach, and duodenum. The polyps
are benign hamartomas and result in recurrent abdom
inal pain and perirectal bleeding. The risk of an adeno
carcinoma is slight.2 Associated features include club
bing of the fingers and ovarian tumors, especially
granulosa theca cell tumors.1•2
Microscopic Findings. The histopathologic ap
pearance of the lentigines show marked hyperpigmen
tation of the basal cell layer, especially of lentigines on
the lips; however, there may be no increase in the num
ber of melanocytes. 5 In the pigmented areas, the
melanosomes are seen within the keratinocytes rather
than within melanocytes. Pigmented macules on the
fingers show many melanosomes within the dendrites
of the melanocytes and a few in the keratinocytes.L,5
236
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SYNDROMES ASSOCIATED WITH LENTIGINES AND MYXOMAS
A number of syndromes are associated with lentigines
and with cardiac and mucocutaneous myxomas.48
These include the LAMB, NAME, and Carney's syn
dromes. They probably are variants of one syndrome
that encompasses a variety of systemic anomalies.
LAMB Syndrome
Clinical Picture. A combination of Lentigines, Atrial
Myxomas, Mucocutaneous myxomas, and Blue nevi
constitute the LAMB syndrome.53 The lentigines are up
to 10 111111 in diameter, brown in color, and favor the
face, lips, sclerae, and vulva.53 The mucocutaneous
myxomas appear as papules or dermal nodules and can
appear at various sites of the body, including the oral
mucosa, tongue, genitalia, breast, and shoulders.53 Car
diac myxomas usually occur in the form of atrial myxo
mas. They are rarely seen in childhood. They may man
ifest as intermittent valvular obstructions and embolic
episodes. Benign thyroid nodules may be associated.
Microscopic Findings. Elongated epidermal rete
ridges are seen associated with marked
hyperpigmenta tion of the basal cell layer. The
melanocytes may have large dendritic processes and
melanophages may be
seen in the upper dermis.53
Electron-Microscopic Findings. An increased con
centration of stage IV melanosomes, either singly or in
complexes, may be seen in the melanocytes.53
NAME Syndrome
Clinical Picture. This syndrome may be a variant of
the LAMB syndrome which is composed of Nevi, Atrial
myxoma, Myxoid neurofibroma, and Ephelides.s4,ss
The pigmentary lesions are in the form of multiple flat
macules beginning at bii;th and showing an accentua
tion in the summer. The sites involved are neck, trunk,
and thighs with the color varying from pale brown to
dark brown. Pigmented macules may be seen on the
palms and soles.55
Microscopic Findings. There is increased pigmen
tation of the basal and spinous layers of the epidermis.
Whether hyperplasia of the epidermal rete ridges exists
is debated in the reported cases.54,55
Carney's Syndrome
Clinical Picture. This syndrome comprises cardiac,
cutaneous, and mammary myxomatous masses; lentig
ines and blue nevi; endocrine disorders and testicular
tumors.56,57 The involvement of organs is often multi
centric and bilateral and usually occurs in young pa
tients.57 The cardiac myxomas may be single or multi
ple and may result in fibrosis or calcification. Cuta
neous myxomas are seen commonly on the eyelids;
 13654632, 1996, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-4362.1996.tb02994.x by University Of Ulsan, Wiley Online Library on [27/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
International Journal of Dermatology
Vol. 35, No. 4, April 1996

other sites include nipple, scalp, face, ears, neck, are of various sizes. They may be solitary or grouped.59
trunk, limbs, and perineum. Oral lesions may be
seen.56 En
docrine involvement include adrenocortical disease
leading to Cushing's syndrome, pituitary adenomas
with acromegaly and gigantism, and calcifying pig
mented neuroectodermal tumors.56•57Testicular tumors
include Sertoli cell tumors, Leydig cell tumors, and
adrenocortical rest tumors. Features of mammary in
volvement include gynecomastia, generalized enlarge
ment of the breast, and myxoinatous alteration of the
stroma. Two types of pigmented lesions are seen. They
may appear as blue nevi or lentigines. Lentigines mea
sure 0.2 to 2 mm in diameter, are brown to dark
brown to black in color, round, with irregularly
shaped or jagged margins. The distribution is wide
spread, primarily on the face, eyelids, ears, vermilion
borders of the lips, trunk, conjunctiva or sclera, vulva,
extremities, and back of the hands. Other sites include
the scalp, finger tips, the anal verge, and glans penis.
The lesions may coalesce to form brown patches.56
Microscopic Findings. Histologically, the lentig ines
show hyperpigmentation of the basal layer and
melanocytic hyperplasia with or without elongation of
the rete ridges.56

Laugier-Hunziker Syndrome

Clinical Picture. This is a rare disorder seen in the

3rd to 5th decade in both sexes. The lesions appear as
pigmented macules that are seen primarily on the
lower lip, hard palate, and sometimes on the tips of the
fingers.58 Other locations include the labial commis
sure, gums, floor of the mouth, tongue, neck, thorax,
abdomen, soles, and nails.59 The lentigines may be nu
merous. They may be confluent and rarely show a lin
ear pattern. The color varies from grey to brown to
blue black. The borders are well defined with a smooth
surface. Pigmentation of the nail may be seen as a lin
ear band.58,59 This syndrome differs from the Peutz
Jeghers' syndrome by the absence of hamartomas and
intestinal polyps.10 The Laugier-Hunziker syndrome
has to be differentiated from the labial melanotic mac
ule, which is usually solitary and affects younger pa
tients.58 Azidothymidine, which is frequently used in
the treatment of AIDS patients, may cause pigmentation
of oral mucosa and nails. The clinical and the drug
his
tory would help differentiate it from the Laugier-Hun
ziker syndrome.60
Microscopic Findings. There may be slight epider mal
hyperplasia and increased melanin pigment is seen
in the basal keratinocytes. Melanophages may be pre
sent in the upper dermis.58
Electron-Microscopic Findings. A large number of
melanosomes are observed in the cytoplasm of the
basal layer cells. The melanosomes appear mature and
237
Axillary Freckling in Neurofibromatosis

Clinical Picture. Freckling is seen in the different

parts of the body,61 including axilla, neck, trunk,
and
sometimes on the upper extremities in 20% of cases
of neurofibromatosis.10 This freckling may be present
at birth or appear in the early years of life and is
consid ered pathognomonic for neurofibromatosis;
however, these have also been observed in patients
without neu rofibromatosis.10 The lesions are
macules of varying shades of brown 1 to 5 mm in
size, and the borders are sharply defined.10
An association of cafe-au-lait spots and freckling
of neurofibromatosis with an endocrine syndrome
termed Leschke's syndrome has been briefly
described in asso ciation with myxedema.3 No further
clinical and histo logic details are available.
Microscopic Findings. These pigmented macules
are histologically similar to cafe-au-lait spots. The pig
mented freckles do not show an increase in epidermal
thickness. There may be a slight increase in the pig
ment content, but the number of melanocytes is nor
mal. The adnexal epithelium may be spared. There
may be melanophages in the upper dennis.10

Xeroderma Pigmentosa

Clinical Picture. During childhood, pigmented le

sions appear that resemble freckles or lentigines. Later
the skin findings become more classical and there is
at rophy of the skin, mottled pigmentation, and
telangiec
tasia, giving the appearance of radiodermatitis.2•61Sub
sequently, ulceration and skin cancers appear on the
sun-exposed skin.
Microscopic Picture. The histologic picture is not
specific. Hyperkeratosis with epidermal atrophy and
with elongation of a few rete ridges may be seen:
There is an increase in the pigment content of the
basal cell layer with a variable number of
melanocytes. Chronic
inflammatory cells may be seen in the upper dermis.5 A
haphazard arrangement of the epidermal nuclei, atypi
cal downward budding of the epidermis, and solar
elastosis may be seen.5
Electron-Microscopic Findings. The hyperpig
mented areas may show an increase in the number of
melanosomes; giant melanosomes may be seen in the
keratinocytes and melanocytes. 5

Bannayan-Riley-Ruvalcaba Syndrome

This syndrome is characterized by macrocephaly, pig

mented spotting of the penis, and associated intestinal
polyposis. This syndrome has also been called Sotos
syn
drome, Ruvalcaba-Myhre-Smith syndrome, and Ban
nayan syndrome. 62-64 Inheritance is autosomal
domi
nant with a predominance in men. The syndrome is
associated with an unusual growth pattern at birth that 238
 Lentigo
Rahman and Bhawan
later becomes normal, and with hypotorua, craniofacial
defects, ocular hypertelorism, intestinal hamartomatous
polyps, and mesodennal hamartomatous masses, usual ly
lipomas, hemangiomas, and lymphangiomas.62,65 Pig
mented macules occur on the penile shaft and rarely
cafe-au-lait spots are seen on the trunk.66 The micro
scopic features have not been described.
Tay's Syndrome
This rare syndrome is inherited as an autosomal reces
sive trait and is comprised of multiple lentigines, vitili
go, premature dental canities, cafe-au-lait spots, dimin
ished growth, mental retardation, and skeletal defects,
cirrhosis of the liver and hypersplenism.67 Develop
mental defects include delayed milestones, low weight,
trident hands, and stubby toes. An abnormal facies
with a triangular face, pointed nose, prominent eyes,
small mouth, and peg-shaped incisors is seen. Other
defects include hyperglobulinemia and hyperamino
aciduria. Portal hypertension and a conduction hearing
defect may also be present.67 No additional cases or
histologic features have been reported.
Centrofacial Neurodysgraphic Lentigines
Many families were described by Tourine in 1941 and
1958 in which some of the members had lentigines dis
tributed in a horizontal pattern across the face, appear
ing during the first year of life and increasing in num
ber until the age of 8 to 10 years. The lentigines
appeared in a butterfly distribution on the nose and
cheeks. Mucosa! surfaces were not involved.2,68 Associ
ated defects included joining of the eyebrows, high
arched palate, absent upper median incisors, dental
malposition, winged scapulae, sacral hypertrichosis,
spina bifida, and scoliosis. Mental retardation was fre
quent and seizures and epilepsy were seen in some pa
tients. Associated neuropsychiatric disorders included
oligophrenia, emotional instability, and behavior dis
turbances.68 Histopathologic changes are not known.
DIFFERENTIAL DIAGNOSIS
Lentigines are common and may have to be differenti
ated from melanoma and other pigmented lesions that
look similar clinically and may even be histologically
similar with only very subtle differences. Lentigines
should be differentiated from the following:
Junctional Nevi (Eruptive)
Junctional melanocytic nevi are macular pigmented le
sions that at times may be confused with lentigines.
They may be single or multiple. The single lesions of
junctional nevus appear primarily in early adulthood.
239
13654632, 1996, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-4362.1996.tb02994.x by University Of Ulsan, Wiley Online Library on [27/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Multiple lesions are rare; they can be eruptive69 and
have to be differentiated from lentigines. The color
varies from light brown to dark brown and black. They
can occur anywhere on the body.4 Microscopically,
there is elongation of the rete ridges as seen in lentigo;
the presence of nests or theques of nevus cells at the tip
of the rete ridges distinguishes the nevi from lentigines.4
Seborrheic Keratosis (Flat Pigmented)
These are benign epithelial lesions that usually develop
in individuals over 30 years. They appear frequently
on the face and trunk, usually as papules or plaques
and have a stuck-on appearance.10 The macular forms
may be confused with lentigines. The size varies from
a few millimeters to many centimeters and the color
varies in different shades of brown.1 A closer view of
the lesion may show a slightly raised surface and skin
markings.1 Microscopically, there is hyperplasia of the
epidermis and adnexal epithelium. There is delicate,
laminated orthokeratosis on the surface and within the
lesions appearing as pseudocysts. The granular layer is
not prominent and there may be an increased amount
of melanin within the keratinocytes. The melanocytes
may be small and restricted to the basal layer only;10
however, an increased concentration of mdanocytes
can be seen in pigmented lesions that are referred to as
melanoacanthomas. The melanocytes in these lesions
are scattered throughout the tumor.5
Pigmented Actinic Keratosis
These are seen primarily on sun-exposed skin such as
the face and dorsa of the hands. The size varies from a
few millimeters to a few centimeters. The pigmented
variant may be difficult to distinguish from lentigines
or lentigo maligna. The microscopic picture shows ker
atinocytic atypia which is the hallmark of actinic ker
atosis.1,5 Melanophages -may be seen in the
superficial dermis. Solar degeneration of the upper
dermal colla
gen is usually also seen.5
Acknowledgment: Dr. Jean Bolognia reviewed the manuscript.
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Black and White Piedra

White piedra is an uncommon superficial fungal infection of hairs caused by Tri

chosporon cutaneum (T. beigelli), and is characterized by formation of nodules
on the hair shafts. It has been described in both tropical and temperate climates
with reports from South America, Europe, Asia and, rarely, the United States,
Australia and Finland. To the best of our knowledge, no cases of white piedra in
India have been reported in the international literature. Piedra (which is the Span
ish word for stone), manifests as small hard nodules on hairs and is of two types:
white piedra caused by Trichosporon cutaneum (T. beigelli), is less frequent than
black peidra which is caused by Piedraria hortai. The white to tan nodules of
white piedra are barely visible and result in a gritty sensation when palpated.
Sources of the fungus include soil, lake and river water, animal excreta, sewage
and domestic animals. High humidity and abundant rain-fall, straight hairs and
use of hair oils may be predisposing factors. Also, individuals who swim or wash
their hair in stagnant water may develop the disease. The fungus can involve the
hairs of scalp, beard, eyebrows, eyelashes, groin and perigenital area.
T. cutaneum is an imperfect or asexual fungus belonging to the Cryptococ
caceae family with certain features of true yeasts. It may result in intrapilar inva
sion causing hair loss and can rarely disseminate in immunocompromised
patients. Clinically it may be confused with trichomycosis axillaris,
pediculosis, hair casts monilethrix and trichorrhexis nodosa. The differentiation
can be made by KOH 'or saline mounts and culture. From Ghorpade A,
Ramanan C. White
piedra. J Eur Acad Dermatol Venereol 1994; 3:169, 171-172.
241
13654632, 1996, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-4362.1996.tb02994.x by University Of Ulsan, Wiley Online Library on [27/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

about the accuracy of the copy. Users should refer to the original published version
This document is a scanned copy of a printed document. No warranty is given

of the material.