Oral Melanotic Macule - A Case Report - sygdoms

Oral Melanotic Macule - A Case Report
ISSN 0970-4388
PAIS S a , HEGDE S K b , BHAT S S C
ABSTRACT
A melanotic macule is a benign pigmented lesion of oral cavity
characterised by increase in melanin pigmentation. Presented here is
a case report of 12 year old girl with black pigmented area on right
buccal mucosa. An exciscon biopsy was done which confirmed the
diognosis by as melanotic macule.
Key Words
Differential diagnosis, Etiology, Histopathology,
Management, Melanotic mecule.
INTRODUCTION
The term melanotic macule has been used to describe a
benign pigmented lesion of the oral cavity, characterized by
an increase in melanin pigmentation along the basal cell layer
of the epithelium and the lamina propria. The melanotic
macule is typically a well circumscribed flat area of
pigmentation that may be brown, black, blue or grey in colour.
Most of the lesions are less than 1 cm in diameter, although
in occasional cases they may be larger in size. The solitary
oral melanotic macule is seen in middle aged adults.
Females are more affected than males. The oral melanotic
macule is usually located on the vermilion border of the lips
and termed as the labial melanotic macule. Intraorally, it may
be found on the gingiva, buccal mucosa or the palate and is
termed as the oral melanotic macule. 1,2,3 Treatment usually
consists of surgical excision, and a biopsy to rule out the
possibility of an early malignant melanoma. Periodic
evaluation may be necessary to assess any clinical
changes. 4 There is a paucity of literature concerning this
lesion in children.
CASE REPORT
A12 year old girl reported to the Department of Pedodontics,
Yenepoya Dental College Mangalore with the chief complaint
of black pigmented area on the right buccal mucosa, that
kept on increasing in size since one year (Fig. 1).
The family history did not reveal any such occurrences. Intra
a. Assistant Professor, b. Associate Professor, c. Professor and
Head Department of Pediatric Dentistry, Yenepoya Dental College,
Mangalore.
oral examination revealed a well circumscribed bluish black
area of pigmentation which was firm in consistency, elliptical
in shape and measuring about 1.0x0.5x0.1 cms. It was not
associated with pain or any other signs of inflammation.
Excision biopsy was done and the specimen was sent
(Fig.2) for histologic examination. Biopsy report showed a
mild degree of parakeratosis in the stratified squamous
epithelium (Fig. 3). Melanin pigment could be identified in
both the basal cell layer and the lamina propria. Although it
was difficult to evaluate the amount of found to be more in the
basal cell layer. Proliferation of capillaries and fibroblasts was
also observed.
The patient was recalled after one week and after six months.
There were no signs of recurrence.
DISCUSSION
There is very little information in literature about the brown or
black melanotic lesions of the oral mucosa, that are not a
manifestation of racial pigmentation and are not associated
with other syndromes. These melanotic macules have been
variously termed as ephelis, melanosis, lentigo, solitary labial
lentigo, labial melanotic macule and oral melanotic macules. 3
Buchner and Hansen analyzed 105 cases of oral melanotic
macule and found that in most of the patients, melanotic
macule was a solitary lesion and the most likely location was
the vermilion border, followed by the gingiva.
George et al, conducted a review of 353 cases of oral
melanotic macule 4 . They concluded that mean age of
occurrence of oral melanotic macule is 43.1 years with
significant predilection for female. Oral melanotic macule was
located on lower lip. The most oral melanotic macules were
Brown in colour and the mean size of the lesion was about
6.8 mm.
Regarding etiology, melanotic macules may result from racial
pigmentation, endocrine disturbance, antimalarial therapy,
Peutz-Jeghers syndrome, trauma, hemochromatosis, or
chronic pulmonary disease, or they may be idiopathic.
Majority of these require clinicopathologic correlation for
definitive diagnosis. In these instances, the diagnosis should
reflect the etiology (for example, melanin pigmentation
secondary to trauma). For those lesions without an
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Oral Melanotic Macule
identifiable etiologic factor, the term oral melanotic macule
has been suggested 2 .
In the literature, the oral melanotic macule has been given
various inappropriate and erroneous names, such as
ephelis 5,6 and lentigo 7,8 . Ephelis (freckle) is a circumscribed
brown macule over skin that has been exposed to sunlight.
Histologically, ephelis shows increased melanin
pigmentation in the basal-cell layer without an increase in the
number of melanocytes 3 .
Ephelides are not found on mucous membranes. Although
the histologic appearance of the melanotic macule of the oral
mucosa is similar to that of ephelis of the skin, it is not at all
related to exposure to sun and thus the term ephelis for the
intraoral lesion is a misnomer.
The term lentigo has also been suggested for oral melanotic
macules. But since melanotic macules of the oral mucosa do
not exhibit a significant increase in the number of
melanocytes, the term lentigo is not considered appropriate
for this type of lesion.
Weather et al 1 and Page et al 2 , recently introduced the terms
labial melanotic macule for lesions on the vermilion border
and oral melanotic macule for lesions within the oral cavity.
The term melanotic macule should be reserved for lesions in
which there is a clinicopathologic correlation between the
clinical feature of a discrete pigmented macule and the
histologic feature of hyperpigmentation of the basal-cell layer
and / or the lamina propria 3 .
The term focal melanosis should be used as a histologic
designation when hyperpigmentation of the basal-cell layer
and/or the lamina propria is associated with clinically
nonpigmented pathologic conditions 3 .
Regarding histopathology, the dark colour of the lesion is
due to increase in melanin pigment of the basal cell layer, not
from an increased number of melanocytes. Melanin may also
be found in the lamina propria. Further histologic criteria are
absence of elongated rete ridges and lack of prominent
melanocytic activity. If there is an elogation of rete ridges, a
heavily pigmented basal cell layer, and an increase in the
Fig: 1 Intra oral photograph showing Melanotic Macule in
the Right Buccal Mucosa
Fig: 2 Post- operative Intra oral photograph after the
excision of Oral Melanotic Macule.
Fig: 3 Histo-pathologic features suggestive of Oral
Melanotic Macule.
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Oral Melanotic Macule
number of normal-appearing basal layer melanocytes, a
junctional nevus has to be considered. If the melanocytes
show proliferation, atypia, and some irregularity in their
arrangement, the histopathologic diagnosis is atypical
melanocytic hyperplasia, which may correspond clinically to
early malignant melanoma (melanoma in situ) 9 .
In our case, we found melanin in both the basal cell layer and
the lamina propira. This agrees with the study conducted by
Buchner and Hansen 3 . Page et al 2 found that 30% of their
cases had melanin only in the basal cell layer and 3.8% only
in the lamina propria 2 .
The small size, slow growth rate, and flat clinical appearance
favour a benign diagnosis.
Oral melanotic macule has to be differentiated from certain
other similar conditions exhibiting hyperpigmentation. Racial
pigmentation is generally diffuse, is genetically acquired and
seen at birth. It is more common in Caucasians and has been
termed as oral melanosis.
The two most important causes of post inflammatory hyper
pigmentation are lichen planus and lupus erythematosis.
There are certain endocrinal hyper pigmentations. Addison's
disease causes a darkening of the oral mucosa which is
irregular, patchy and found on the gums.
Metal deposition can cause discolouration either from copper
as in Wilson's disease or from amalgam as in an amalgam
tattoo.
It could be associated with syndromes as in Peutz Jeghers
syndrome where freckles are seen not only in the oral cavity,
but also at the distal extremities, Leopard syndrome where
pigmentation is seen all over the body.
Antimalarial drugs like chloroquine can also cause muscosal
hyperpigmentation which also occurs on other body parts like
the shinns.
The treatment of oral melanotic macule is debatable 5 .
Although the lesion is completely benign 2 and shows no
tendency to recur or to become malignant, sometimes it is
difficult if to distinguish it cliniclly from other pigmented
lesions, such as nevus, malignant melanoma in situ, and
incipient malignant melanoma. Thus, complete excision of
oral melanotic macule is indicated and histologic
examination or at least be checked at frequent intervals for
any change in size, shape, or colour. This is especially
necessary for lesions of the palate - a location for which
oral malignant . melanoma has a strong predilection 10 .
Melanotic lesions having a duration of fewer than 5 years,
which have exhibited changes in size or colour or which
exhibit tumefaction, ulceration, or bleeding, should be
excised. Lesions with reliable history of more than 5 years
without change in character in which a known cause seems
evident (trauma, etc.), may be followed or excised, although
we prefer the latter.
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Reprint Requests to :
Dr. Sham Bhat
Head of the Department of paediatric Dentistry,
Yenepoya Dental College,
Kodialbail, Mangalore,
Karnataka,
INDIA.
J Indian Soc Pedo Prev Dent June (2004) 22 (2) 75
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