Becker Melanosis


Article Author:
Feroze Kaliyadan


Article Editor:
Karalikkattil Ashique


Editors In Chief:
Ahmad Al Aboud
Jayakar Thomas
Pramod Nigam


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
1/9/2019 9:57:19 AM

Introduction

Becker melanosis (Becker's Nevus) [BM] is a form of acquired hyperpigmentation. S. William Becker first described the condition in 1949, in two reported cases, as "concurrent melanosis and hypertrichosis in the distribution of nevus unius lateris."[1]

Etiology

The exact etiology is not clear. BM is considered to be a benign, late-onset type of epidermal nevus. Associated features like peri pubertal development, male preponderance, hypertrichosis, and acneiform lesions suggest a role for androgens. An increase in the number of androgen receptors has been reported.[2]

Epidemiology

Males are more commonly affected (male to female ratio of about 5:1). BM has an estimated prevalence of 0.5% among males. The lesion usually presents during puberty, but rarely cases of BM presenting at birth or early childhood have been reported. Familial occurrence of BM has been reported. Some studies have shown a higher incidence among people with darker skin.[3][4]

Pathophysiology

Androgen sensitivity and stimulation have been suggested as one of the main factors involved in the pathogenesis of Becker nevus. The onset of the lesions during adolescence, male preponderance, associated features like hypertrichosis and acneiform lesions, have all been linked to the role of androgens in the pathophysiology. Some studies have reported an increased amount of androgen receptors in the lesional skin. Post-zygotic mutations in beta-actin have been reported in association with both Becker nevus and Becker nevus syndrome.[5][6]

History and Physical

BM presents as a well-defined, unilateral, hyperpigmented tan or brown patch which increases in size, gradually often developing into a geographic pattern. Some studies have reported the right side of the body to be more commonly affected. The most common sites involved are the shoulder, scapular area, and the upper arms. Rarely, BM may present with bilateral lesions and on atypical sites like the lower limbs. Significant hair growth over the lesions is usually seen some time after the hyperpigmentation is established and may take months to years to develop. Acneiform lesions may develop over the affected area. BM may be associated with other findings related to ectodermal abnormalities known as Becker nevus syndrome. Reported associations include smooth muscle hamartomas, hypoplasia of the breast, pectoral muscle and fat, limb hypertrophy, adrenal gland hyperplasia, and accessory scrotum. A rare association with melanoma has been reported. Once developed, the natural course is for the lesions to persist indefinitely. The hypertrichosis typically develops after the hyperpigmentation and the hairs become progressively coarse with time. Some recent studies have suggested that hypertrichosis may not be associated with a majority of the case of BM. [7][3][8][9][10]

Evaluation

The diagnosis is mainly clinical. A skin biopsy shows mild acanthosis and hyperkeratosis. Increased melanin is seen in the basal layer although the number of melanocytes tends to be normal. Dermal melanophages can be seen. Other features reported in histopathology include elongation of the rete ridges, smooth muscle, and sebaceous gland hyperplasia. The hyperproliferation of keratinocytes, melanocytes, arrector pili muscle and dermal nerve fibers have been reported in recent studies. Some immunohistochemical studies have shown increased expression of some markers like epidermal Ki-67, melan-A, and keratin 15 in the lesional and perilesional skin as compared to normal skin. Dermal nerve fiber length and expression of smooth muscle actin have also been reported to be higher in the lesional skin of Becker melanosis.[11][10][12]

Treatment / Management

The hyperpigmentation of Becker melanosis usually remains stable; although, there are reports of the pigmentation fading spontaneously in some cases. Treatment is mainly indicated for cosmetic reasons, especially the rapid transformation of the lesion during adolescence. The hyperpigmentation and the hypertrichosis respond to lasers. Different types of lasers have been found to be effective in BM like the Q-switched Ruby laser, Q-switched Nd YAG, long-pulsed Alexandrite and various types of fractional ablative lasers. The most commonly used lasers are the q-switched ruby and the Q-switched Nd YAG lasers. However, both are associated with a high rate of recurrence. Hypertrichotic lesions have been reported to respond to combinations of fractional lasers (like the 1550 nm non-ablative laser) with hair removal lasers. Multiple sessions are required for optimum results. Electrolysis has also been reported to be effective in treating the hypertrichosis associated with Becker melanosis.  Sun protection is advised as sun exposure might make the lesions appear darker. Acneiform lesions have been found to respond to topical retinoids. In patients with associated breast hypoplasia, a novel yet effective treatment is breast lipofilling which is fat grafting to treat the cosmetic defect related to ipsilateral breast hypoplasia, which can be associated with Becker melanosis.Cosmetic camouflage can be useful in addressing the psychosocial issues and quality of life in patients who have lesions in relatively exposed areas[13][14][15]

Pearls and Other Issues

Although the typical presentation is in the form of a single, unilateral, hyperpigmented or tan-colored macule over the shoulder or pectoral area, BM has been reported to manifest in various atypical presentations.

Associated abnormalities include unilateral hypoplasia of the breast which can vary in magnitude, affecting the whole breast area or the nipple/areola alone. Supernumerary nipples can also occur as an association with aplasia of the ipsilateral pectoralis major muscle, ipsilateral limb shortening, localized lipoatrophy, spina bifida, scoliosis, pectus carinatum, quadriparesis, osteoma cutis, congenital adrenal hyperplasia, and accessory scrotum. BM has been found to occur in association with phakomatosis pigmentovascularis and neurofibromatosis. BM occurring in association with nevus depigmentosus has been described as a possible example of twin spotting. A case report has mentioned the occurrence of basal cell carcinoma occurring on the site of BM in a sun-protected area. Hypohidrosis associated with BM has been reported. Pityriasis versicolor localized to the area of BM has been described.

Multiple and bilateral lesions have rarely been reported. A case of giant, bilateral Becker melanosis simulating the armor of a gladiator's arm has been described. The same patient also had marginal osteophytes over the cervical vertebrae. Becker melanosis associated with short stature, skeletal deformities, and mental retardation. Bilateral, congenital BM has been described. There are reports of Becker melanosisBM occurring in siblings. Atypical sites of involvement include the lower limbs. Many cases may present with later age of onset and absence of hypertrichosis.[16][17][18][19][8]

Enhancing Healthcare Team Outcomes

It is important to look for extra cutaneous involvement in all cases of suspected Becker's melanosis. Patients must know the possibility of increased hair growth over the lesions and that the treatment is essentially for cosmetic purposes only. Advanced surgical treatment will require a coordinated effort from dermatologists and plastic surgeons. Lasers are as of the main evidenced based management option for better cosmesis in Becker's melanosis. [15]


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Becker Melanosis - Questions

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Becker nevus is most commonly seen males in which locations?

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With which other skin finding is Becker nevus most associated?



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A 15 year old male patient presents with an asymptomatic hyperpigmented patch of about 15 cm over his right shoulder, extending to the right upper arm. The lesion was first notice two years ago and has been gradually increasing in size since then. A skin biopsy shows acanthosis, mild hyperkeratosis, increase pigmentation in the basal layer, and increased follicular units. Which of the following would be the best treatment option in this patient?



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A male patient presents with an asymptomatic hyperpigmented patch of about 15 centimeters over his right shoulder, extending to the right upper arm. The lesion was first noticed 2 years ago and has been gradually increasing in size. A skin biopsy shows acanthosis, mild hyperkeratosis, increase pigmentation in the basal layer, and increased follicular units. What condition may be associated with this diagnosis?

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A 15 year old male patient presents with an asymptomatic hyperpigmented patch of about 15 cm over his right shoulder, extending to the right upper arm. The lesion was first notice two years ago and has been gradually increasing in size since then. A skin biopsy shows acanthosis, mild hyperkeratosis, increase pigmentation in the basal layer and increased follicular units. Which of the following is true regarding this condition?



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Becker Melanosis - References

References

Clinical characteristics of Becker's nevus in children: report of 118 cases from Italy., Patrizi A,Medri M,Raone B,Bianchi F,Aprile S,Neri I,, Pediatric dermatology, 2012 Sep-Oct     [PubMed]
Atypical presentation of Becker's melanosis., Manoj J,Kaliyadan F,Hiran KR,, Indian dermatology online journal, 2011 Jan     [PubMed]
The use of lasers in Becker's naevus: An evidence based review., Momen SE,Mallipeddi R,Al-Niaimi F,, Journal of cosmetic and laser therapy : official publication of the European Society for Laser Dermatology, 2016 Jan 6     [PubMed]
Clinicopathological Features and Immunohistochemical Alterations of Keratinocyte Proliferation, Melanocyte Density, Smooth Muscle Hyperplasia and Nerve Fiber Distribution in Becker's Nevus., Sheng P,Cheng YL,Cai CC,Guo WJ,Zhou Y,Shi G,Fan YM,, Annals of dermatology, 2016 Dec     [PubMed]
Sebaceus and Becker's Nevus: Overview of Their Presentation, Pathogenesis, Associations, and Treatment., Patel P,Malik K,Khachemoune A,, American journal of clinical dermatology, 2015 Jun     [PubMed]
BECKER SW, Concurrent melanosis and hypertrichosis in distribution of nevus unius lateris. Archives of dermatology and syphilology. 1949 Aug;     [PubMed]
Danarti R,König A,Salhi A,Bittar M,Happle R, Becker's nevus syndrome revisited. Journal of the American Academy of Dermatology. 2004 Dec;     [PubMed]
Kim YJ,Han JH,Kang HY,Lee ES,Kim YC, Androgen receptor overexpression in Becker nevus: histopathologic and immunohistochemical analysis. Journal of cutaneous pathology. 2008 Dec;     [PubMed]
Cai ED,Sun BK,Chiang A,Rogers A,Bernet L,Cheng B,Teng J,Rieger KE,Sarin KY, Postzygotic Mutations in Beta-Actin Are Associated with Becker's Nevus and Becker's Nevus Syndrome. The Journal of investigative dermatology. 2017 Aug;     [PubMed]
Dasegowda SB,Basavaraj G,Nischal K,Swaroop M,Umashankar N,Swamy SS, Becker's Nevus Syndrome. Indian journal of dermatology. 2014 Jul;     [PubMed]
AlGhamdi KM,AlKhalifah AI,AlSheikh AM,AlSaif FM, Clinicopathologic profile of Becker's melanosis with atypical features. Journal of drugs in dermatology : JDD. 2009 Aug;     [PubMed]
Bhawan J,Chang WH, Becker's melanosis: an ultrastructural study. Dermatologica. 1979;     [PubMed]
Boiron G,Surlève-Bazeille JE,Maleville J, [Becker's melanosis. Study of seven cases by photonic and electron microscopy. Contribution to the histogenesis of the cytoid bodies (author's transl)]. Annales de dermatologie et de venereologie. 1980 Aug-Sep;     [PubMed]
Kansal NK, Lightening Becker's nevus: Role of topical therapies. Journal of the American Academy of Dermatology. 2018 Sep 6;     [PubMed]
Al-Saif F,Al-Mekhadab E,Al-Saif H, Efficacy and safety of short-pulse erbium: Yttrium aluminum garnet laser treatment of Becker's nevus in Saudi patients: A pilot study. International journal of health sciences. 2017 Jul-Sep;     [PubMed]
Bisht YS,Bhasin R,Manoj S,Sunita BS,Singhal E, Becker's nevus syndrome. Medical journal, Armed Forces India. 2015 Jul;     [PubMed]
Cohen PR, Poland's Syndrome: Are Postzygotic Mutations in β-Actin Associated with its Pathogenesis? American journal of clinical dermatology. 2018 Feb;     [PubMed]
Ghosh SK,Majumder B,Agarwal M, Becker's nevus syndrome: a report of a rare disease with unusual associations. International journal of dermatology. 2017 Apr;     [PubMed]
Glinick SE,Alper JC,Bogaars H,Brown JA, Becker's melanosis: associated abnormalities. Journal of the American Academy of Dermatology. 1983 Oct;     [PubMed]

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