NR 602 Vascular and Pigmented Nevi Soap Note

NR 602 Vascular and Pigmented Nevi Soap Note

NR 602 Vascular and Pigmented Nevi Soap Note

Port wine stains (Nevus flammeus), Salmon Patches, Café au lait Spots, & Hemangioma

NR 602 Vascular and Pigmented Nevi Soap Note

Nevi are a common finding in children. The two most common types are vascular nevi (vascular malformations and hemangiomas) and pigmented nevi (e.g., mongolian spots, café au lait spots, acquired melanocytic nevi, atypical nevi, and lentigines).

Vascular nevi are caused by a structural abnormality (malformations) or by an overgrowth of blood vessels (hemangiomas) and are flat, raised, or cavernous. Flat lesions or vascular malformations include salmon patches (also called macular stains), an innocent malformation that is a light red macule appearing on the nape of the neck, upper eyelids, and glabella. Approximately 60% to 70% of newborns have a salmon patch on the back of the neck. Port-wine stains occur in 0.2% to 0.3% of newborns (Cohen, 2013). At 1?year old, 10% to 12% of Caucasian infants have a hemangioma—females three times more likely than males. There is also an increased incidence of hemangioma in premature neonates. Vascular malformations are always present at birth and do not resolve spontaneously. Precursor lesions of hemangiomas are present at birth 50% of the time. They undergo rapid growth (proliferative stage), stability (plateau phase), and regression (involution phase); 90% are completely resolved in children 9 to 10 years old (Paller and Mancini, 2011).

Pigmented nevi are caused by an overgrowth of pigment cells. Pigmented nevi most commonly seen are mongolian spots (found in up to 90% of African Americans, 62% to 86% of Asians, 70% of Hispanics, and less than 10% of Caucasians), café au lait spots (found in up to 33% of normal children and in 50% of patients with McCune-Albright syndrome), and acquired melanocytic nevi, the most common tumor of childhood. Atypical nevi, also called dysplastic nevi, are potential precursors for malignant melanoma. Dysplastic nevi are uncommon under 18 years old but have a higher incidence in melanoma-prone families (Paller and Mancini, 2011).

NR 602 Vascular and Pigmented Nevi Soap Note

Clinical Findings

History

• Presence from birth, or age first noted
• Progression of lesion
• Familial tendencies for similar nevi, especially for history of melanoma

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Physical Examination

Findings include the following (Box 37-8):

• Vascular malformations or flat vascular nevi are present at birth and grow commensurate with the child’s growth.
• Hemangiomas are classified as superficial, deep (cavernous), or mixed. They may or may not be present at birth, but they usually emerge by 2 to 3 weeks of life. They may manifest initially as a pale macule, a telangiectatic lesion, or a bright red nodular papule. After appearing, hemangiomas go through a proliferative phase during which they grow rapidly and form nodular compressible masses, ranging in size from a few millimeters to several centimeters. Occasionally they may cover an entire limb, resulting in asymmetric limb growth. Rapidly growing lesions may ulcerate. The final phase of involution occurs slowly (10% per year) but spontaneously (30% by 3 years old, 50% by 5 years old, 70% by 7 years old, and 90% by 9 to 10 years old). Average involution begins between 12 and 24 months old, heralded by gray areas in the lesion followed by flattening from the center outward. Most hemangiomas appear as normal skin after involution, but others may have residual changes, such as telangiectasias, atrophy, fibrofatty residue, and scarring (Paller and Mancini, 2011).
• Pigmented nevi may be present at birth or acquired during childhood.
• Atypical nevi are larger than acquired nevi; have ir­regular, poorly defined borders; and have variable pigmentation.

**Common Vascular and Pigmented Lesions ***

1. Vascular malformations or flat vascular nevi
2. Salmon patch or nevus flammeus: Light pink macule of varying size and configuration. Commonly seen on the glabella, back of neck, forehead, or upper eyelids.
3. B.Port-wine stain: Purple-red macules that occur unilaterally and tend to be large. Usually occur on face, occiput, or neck, although they may be on extremities.
4. Hemangiomas
5. Superficial (strawberry) hemangiomas are found in the upper dermis of the skin and account for the majority of hemangiomas.
6. Deep cavernous hemangiomas are found in the subcutaneous and hypodermal layers of the skin; although similar to superficial hemangiomas, there is a blue tinge to their appearance. With pressure, there is blanching and a feeling of a soft, compressible tumor. Variable in size, they can occur in places other than skin.
7. Mixed hemangiomas have attributes of both superficial and deep hemangiomas.

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III. Pigmented nevi

1. Mongolian spots: Blue or slate-gray, irregular, variably sized macules. Common in the presacral or lumbosacral area of dark-skinned infants; also on the upper back, shoulders, and extremities. The majority of the pigment fades as the child gets older and the skin darkens. Solitary or multiple, often covering a large area.
2. Café au lait spots: Tan to light brown macules found anywhere on the skin; oval or irregular shape; increase in number with age.
3. Acquired melanocytic nevi are benign, light brown to dark brown to black, flat, or slightly raised, occurring anywhere on the body, especially on sun-exposed areas above the waist.
4. Junctional nevi represent the initial stage, with tiny, hairless, light brown to black macules.
5. Compound nevi—a few junctional nevi progress to more elevated, warty, or smooth lesions with hair.
6. Dermal nevi are the adult form, dome shaped with coarse hair.
7. Atypical nevi usually appear at puberty, have irregular borders, variegated pigmentation, are larger than normal nevi (6 to 15?mm); usually found on trunk, feet, scalp, and buttocks.
8. Halo nevi appear in late childhood with an area of depigmentation around a pigmented nevus, usually on trunk (seeFig. 37-34).
9. Acanthosis nigricans is velvety brown rows of hyperpigmentation in irregular folds of skin, usually the neck and axilla; tags may also be present.
10. Lentigines are small brown to black macules 1 to 2?mm in size appearing anywhere on the body in school-age children.
11. Freckles: 1 to 5?mm light brown, pigmented macules in sun-exposed areas.

NR 602 Vascular and Pigmented Nevi Soap Note

Verruca vulgaris

Common warts (verruca vulgaris) are usually elevated flesh-colored single papules with scaly, irregular surfaces and occasionally black pinpoints, which are thrombosed blood vessels. They are usually asymptomatic and multiple and are found anywhere on the body, although most commonly on the hands, nails, and feet. They may be dome shaped, filiform, or exophytic (Fig. 37-19). Filiform warts project from the skin on a narrow stalk and are usually seen on the face, lips, nose, eyelids, or neck. Periungual warts are common, occurring around the cuticles of the fingers or toes.