e. pigmented lesions...• hemangioma (childhood onset) reactive vascular proliferations pyogenic...
TRANSCRIPT
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DIFFERENTIAL DIAGNOSIS OF
PIGMENTED LESIONS
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Pigmented Lesions
• Blue • Black• Grey• Brown
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Pigments• Endogenous
– Hemoglobin,– Hemosiderin– Bilirubin– Melanin
• Exogenous– Amalgam– Graphite– Other Tattoos
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Color and Source
• Black, Gray– Melanin, Amalgam, Graphite
• Blue, Purple– Hemoglobin
• Brown– Hemosiderin, Melanin
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Oral-Facial Pigmentationsnormal Atrophy Inflammation
Vascular proliferation Basilar melanosis Melanin incontinence
Melanocyte proliferation Hemosiderin Extrinsic
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Classification of Pigmented Lesions
• Focal Macular• Focal Nodular• Multifocal/Diffuse Macular• Multifocal/Diffuse Nodular
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Focal Macular Pigmentations
• Brown– Ephelis, Melanotic Macule– Junctional Nevus– Melanoacanthoma– Ecchymosis
• Black, Gray– Tattoo (Amalgam, Graphite)
• Blue, Purple– Varix– Ecchymosis
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Oral Melanotic Macule
• Lips, Gingiva and Palate• Adults• Etiology? Trauma?• Basilar Melanosis• Melanin Incontinence• No Malignant Potential
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Oral Melanotic Macule
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Melanotic Macule Pigment Synthesis
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Melanoacanthoma
• Black Patients• Buccal Mucosa, Lips• Rapid Onset• Basilar Melanosis• Acanthosis• Dendritic
Melanocytes in spinous layer
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Melanoacanthoma
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Ecchymosis
• Traumatic Hemorrhage• PT (INR), PTT, Clotting Time• Coagulopathies
– Drug induced (Coumadin)– Heritable Factor Deficiencies– Liver Disease– Malabsorption Syndromes
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Ecchymosis from Trauma
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Tattoos• Amalgam
– Operative Dentistry– Apical Retrofill
• Graphite– Lead Pencil Injury
• Intentional Tattooing– Various Inks
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Amalgam Tattoo
• Clinical • Histology
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Graphite Tattoo
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Focal Nodular Pigmentations• Brown
– Compound, Intradermal Nevi– Ecchymosis (Hematoma)– Melanoma– Pigmented Neuroectodermal
Tumor of Infancy (Progonoma)• Black, Gray
– Tattoo– Melanoma
• Blue, Purple– Blue Nevus– Vascular Proliferation– Ecchymosis (Hematoma)
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Melanocytic Nevi
• Junctional>>>Compound– >>>Intradermal/mucosal
• Facial Skin• Palate, Gingiva• Adults• No Malignant Potential
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Junctional Nevus
• Childhood Onset• Destined to Progress to Intradermal• Proliferation of Melanocytes
– Within Basal Cell Layer– Junction with Connective Tissue
• Adults with Junctional Activity– Reassess for Atypical Melanocytic Hyperplasia
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Junctional Nevus
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Nevi
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Nevi• Intramucosal
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Blue Nevus
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Superficial Spreading Melanoma
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Nodular Melanoma
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Pigmented Neuroectodermal Tumor of Infancy (Progonoma)
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Vascular Proliferations• Varix (adult onset)
• Hemangioma (childhood onset)
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Reactive Vascular ProliferationsPyogenic Granuloma Peripheral Giant Cell Granuloma
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Diffuse/Multifocal Macular Lesions
• Black, Gray– Pigmented Lichen Planus– Superficial Spreading Melanoma– Multiple Tattoos
• Blue, Purple– Kaposi’s Sarcoma
• Brown– Ecchymosis– Peutz-Jehger syndrome– Basilar Melanosis
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Pigmented Lichen Planus
• A rare variant of LP in which white lesions are accompanied by grey/black pigmentation
• Basilar melanosis with melanin incontinence and a lichenoid infiltrate
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Pigmented LP
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Superficial Spreading Melanoma
• Lentigo Maligna Melanoma• Hutchinson’s Freckle• Variegated• Irregular Margins (coast of Maine)• Skin – neck, forehead, malar• Radial Growth along basement membrane• Good Prognosis: 1-2 cm. margins
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Superficial Spreading Melanoma
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Oral Melanomas
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Superficial Spreading Melanoma• Melanoma in situ,
Atypical Melanocytic hyperplasia
• Melanoma
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Kaposi’s Sarcoma
• Early lesions are macular• Hard and Soft Palate• HIV seropositive• CD4 Counts are below 300• Herpes Virus 8 • Progress to nodular phase
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Kaposi’s Sarcoma
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Ecchymosis
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Peutz Jegher Syndrome
• Intestinal polyposis, benign hyperplastic polyps without a proclivity for malignant change
• Autosomal Dominant• Perioral pigmentation• Intestinal polyps
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Peutz Jegher Syndrome
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Diffuse Lesions, Basilar Melanosis
• Racial Pigmentation• Cloasma, Malasma• Putz-Jehger Syndrome• Minocyline Palatal Melanosis• Smoker’s Melanosis• Addison’s Disease• Café-au-lait Pigmentation
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Racial Pigmentation
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Chloasma
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Putz-Jehger Syndrome
• Intestinal Polyposis• Hyperplastic Polyps• No malignant potential• Perioral Freckling• Focal pigmentations on the palms
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Putz-Jehger Syndrome
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Minocycline Induced Pigmentation
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Smoker’s Melanosis
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Addisonian Pigmentation• Adrenal Cortical Insufficiency
– Infections of the cortex– Idiopathic cortical atrophy
• Low corticosteroid output • ACTH is elevated due to negative
feedback loop perturbation• ACTH has melanocyte stimulating
activity akin to MSH • ACTH secreting tumors may also
induced mucocutaneous pigment
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Addison’s Disease
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Café au Lait
• Diffuse macular lesions• Multifocal• Neurofibromatosis
(vonRecklinghausen’s)– NF gene mutation
• McCune Albright Syndrome– G protein mutations
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Café au Lait Spot in Neurofibromatosis