Visual Diagnosis: Circumscribed Pigmentation Stippled with Punctate Macules and Papules in a 9-year-old Boy

Alexander K.C. Leung; Benjamin Barankin

doi:10.1542/pir.2017-0045

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Alexander K.C. Leung, MD*
Benjamin Barankin, MD^†

^*Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
^†Toronto Dermatology Centre, Toronto, Ontario, Canada

AUTHOR DISCLOSURE
Dr Leung has disclosed no financial relationships relevant to this article. Dr Barankin has disclosed that he receives honoraria for giving CME talks from AbbVie, Galderma, Leo Pharma, Janssen, Valeant, Pierre Fabre, La Roche-Posay, Novartis, Celgene, Eli Lilly, Amgen, Actelion, Cipher Pharma, Beiersdorf Canada, and Tribute Pharma. The commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A 9-year-old Chinese boy presents with an asymptomatic giant hyperpigmented patch on his back that has been present since birth. The parents were told that this is a café-au-lait patch and that by itself it is of no medical significance. They were advised to keep an eye on the future appearance of similar lesions, 6 or more of which measuring 0.5 cm or larger may signify neurofibromatosis, a neurocutaneous disorder. Speckled, dark, superimposed spots were seen in this patch at 2 years of age. Over the subsequent years, the dark spots have gradually increased in size and number. Some of dark spots have become elevated.

The child was born to a 28-year-old gravida 3 para 2 mother at 39 weeks' gestation after an uncomplicated pregnancy and a normal vaginal delivery. The parents are healthy and nonconsanguineous. There is no family history of similar lesions, dysplastic nevus, melanoma, or neurofibromatosis. His developmental milestones and past health are normal.

On examination there is a sharply demarcated, well-circumscribed, light tan elliptical patch on the lower back (Fig 1). Numerous speckled, dark macules and papules as well as 2 plaques are seen in the patch. The remaining …