Pigmented Lesions

Pigmented Lesions
A is for Asymmetry
One half is different from the other
B is for Border Irregularity
Notched, uneven or blurred borders
C is for Color
Uneven color; brown, tan, black
D is for diameter
> 6mm
from Meleti et al. 2008
Melanin-associated pigmented lesions
of the oral cavity
• Racial pigmentation
– Dark-skinned individuals
– Diffuse bilateral
• Fungiform papillae distinct
– Gingiva, buccal mucosa, lips, palate tongue
– Innocuous
– No treatment needed except for aesthetic purposes
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Oral Melanotic Macule
• Relatively common lesion
• Increased melanin in the basal cell layer and
superficial connective tissue without melanocytic
activity
• Vermilion border of lower lip, anterior maxillary
gingiva, buccal mucosa in blacks
• Intraoral larger than labial
• 2F:M
• 5th decade
Lentigines
• Solar (actinic) lentigo
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Middle-aged and older patients
UV light
Face
Between 0.5-1.0 cm
No changes after exposure to UV light
Melanocytic hyperplasia
Sharply circumscribed
Single or multiple
No malignant transformation potential
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Solar lentigo
Lentigo Simplex
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Melanocytic hyperplasia
Any skin surface including skin not exposed to sunlight
Color intensity does not relate to sun exposure
? Precursor to melanocytic nevi
Small, uniform, tan to brown or black
Solitary or multiple
– Multiple are seen with rare syndromes
• Lentiginosis profusa, Peutz-Jeghers, LEOPARD, xeroderma
pigmentosum, etc
• Some lesions regress
• No malignant transformation potential
Multiple Lentigines
Multiple Lentigines
Multiple Lentigines
Peutz-Jeghers syndrome
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Ephelis – Ephelides
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Fair-haired individuals
Genetic predilection
Melanocortin-1-receptor gene
1st decade; become less prominent in adults
More pronounced after sun exposure
Small, uniform color, not as dark as lentigo
simplex
My kind of girl
Smoker’s melanosis
• Heavy smokers
– Also in children of heavy smokers (Japan)
• Melanin plays a role in the detoxification of
nicotine and benzopyrene
• Anterior facial gingiva, floor of mouth, buccal
mucosa, lips, hard palate
• Females; synergistic effect of hormones
• Smoking cessation may lead to resolution
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Melasma
• Symmetric diffuse hyperpigmentation of sunexposed skin
• Usually in pregnancy – very rare in men
• Estrogen and progesterone play a role
• Face
Oral Melanoacanthoma
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Benign, uncommon, acquired
Almost exclusively in blacks
Buccal mucosa
Fast increase in size
Frequent spontaneous resolution
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Oral Melanocytic Nevi
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Nevus cell
~ 500 cases reported
Palate,
Aquired, rarely congenital
MacularÆ Juctional
PapularÆ Compound or intramucosal
Occasionally decrease in pigmentation
Blue nevus
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Congenital Nevus
Melanoma
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From benign melanocytic lesion or de novo
3rd most common skin cancer; most deaths
Acute sun damage
2-8x increased risk if a relative has melanoma
Fair complexion and light hair
Tendency to sunburn
Outdoor recreational activities
Four types
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Superficial spreading
Nodular
Lentigo maligna
Acral lentigenous
Oral Melanoma
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One every 2,000,000
< 1% of all melanomas
More frequent in other countries, i.e. Japan
More aggressive than cutaneous
1/3 of patients has macule in the area
Often nodular
Early lesions flat
Hard palate and maxillary alveolus
Poor prognosis: 45% 5-year; 28% 10-year
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Localized Exogenous Pigmentations
• So-called amalgam tattoo
– Silver, mercury, tin
– Amalgam restoration including retrofill
– Flossing
• Dentifrices containing charcoal, pencil graphite
• Intentional tattooing
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Drug-related Discolorations
• Stimulation of melanin overproduction
• Deposition of drug metabolites
– Chelation with iron
• Most frequently diffuse hyperpigmentation
• Interaction with estrogen - progesterone
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Drug-related Discolorations
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Minocycline
Amiodarone
Bleomycin
Busulfan
Chloroquine, hydrochloroquine, quinidine, quinacrine (antimalarial
medications)
Zidovudine (AIDS)
Ketoconazole (AIDS)
Clofazimine (AIDS)
Chrorpromazine (tranquilizer)
Cyclophosphamide
Doxorubicin
Minocycline - Tetracycline
Oral contraceptives
Phenothiazines
Minocycline
Chloroquine
Differential Diagnosis
• Adisson’s disease
• Smoker melanosis
• Reactive (post-inflammatory) hyperpigmention
– Trauma
– Lichen planus, pemphigoid etc.
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Pigmentations due to Systemic
Metallic Intoxication
• Lead: Gingival lead line
• Silver: Argyria
• Bismuth: Bismuth line
from Meleti et al. 2008
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