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Repigmentation of Scalp Hair: A Feature of Early Melanoma

Published:September 25, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.09.005
      To the Editor:
      Lentigo maligna is a variant of melanoma in situ that develops on chronically sun-damaged skin, often presenting as a slowly growing pigmented macule or patch with irregular borders. A discontinuous appearance with ill-defined boundaries may be seen.
      • Iznardo H
      • Garcia-Melendo C
      • Yélamos O.
      Lentigo maligna: clinical presentation and appropriate management.
      We report a case of scalp hair repigmentation as a feature of lentigo maligna.

      Case Synopsis

      An 85-year-old man with a history of chronic lymphocytic leukemia and chronic myeloid leukemia on ibrutinib presented for evaluation of his right parietal scalp. His history included prior melanoma in situ and nonmelanoma skin cancer. The patient reported hair darkening on the right scalp for several months. He denied an underlying skin lesion.
      Examination of the scalp revealed grey-white hair throughout except for a 0.5-cm ill-defined light brown macule with an overlying 4.5 × 3.0 cm patch of brown hair in the right parietal area (Figure 1). Shave biopsy was performed with a resulting diagnosis of melanoma in situ, lentigo maligna type. A wide local excision of the lesion and scar via the “square” method was performed. The square method is a staged excision technique that resembles Mohs micrographic surgery but uses permanent sections for margin control.
      • Johnson TM
      • Headington JT
      • Baker SR
      • Lowe L.
      Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma: the “square” procedure.
      • Patel AN
      • Perkins W
      • Leach IH
      • Varma S.
      Johnson square procedure for lentigo maligna and lentigo maligna melanoma.
      • Moyer JS
      • Rudy S
      • Boonstra PS
      • et al.
      Efficacy of staged excision with permanent section margin control for cutaneous head and neck melanoma.
      Stage 1 excision revealed melanoma in situ with follicular involvement (Figure 2) extending to peripheral margins. Two additional rounds of excision were needed to achieve clearance.
      Figure 1
      Figure 1An 0.5-cm ill-defined light brown macule with an overlying 4.5 × 3.0 cm patch of brown hair on the right parietal scalp.
      Figure 2
      Figure 2Histologic evaluation of the initial wide local excision specimen revealed a broad junctional lentiginous and nested proliferation of cytologically atypical melanocytes exhibiting confluent growth, pagetoid spread, and extension down hair follicles, consistent with melanoma in situ, lentigo maligna type.

      Case Discussion

      Lentigo maligna is a type of melanoma in situ with distinctive epidemiology, risk factors, and clinical features that can progress to invasive melanoma. Lentigo maligna most commonly presents in the 8th-9th decades of life. Repigmentation of previously white or gray hair should rise suspicion for lentigo maligna on the scalp because it has been reported as a rare early sign of melanocytic neoplasia.
      • Gotland N
      • Svenning MIE
      • Lang CL
      • Venzo A.
      Atypical presentation of lentigo maligna melanoma.
      ,
      • Chan C
      • Magro CM
      • Pham AK
      • et al.
      Spontaneous hair repigmentation in an 80-year-old man: a case of melanoma-associated hair repigmentation and review of the literature.
      Lentigo maligna may often have subclinical spread, which can result in incomplete excision in 50% of cases as well as recurrence rates of 8%-20% if a standard wide local excision with 0.5-cm margins is used.
      • McKenna JK
      • Florell SR
      • Goldman GD
      • Bowen GM.
      Lentigo maligna/lentigo maligna melanoma.
      At anatomic sites where cosmesis is important, such as the head and neck where lentigo maligna is commonly seen, a staged surgical excision is of benefit, with improved recurrence rates of 0%-5%.
      • Patel AN
      • Perkins W
      • Leach IH
      • Varma S.
      Johnson square procedure for lentigo maligna and lentigo maligna melanoma.
      ,
      • Moyer JS
      • Rudy S
      • Boonstra PS
      • et al.
      Efficacy of staged excision with permanent section margin control for cutaneous head and neck melanoma.

      References

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        • Garcia-Melendo C
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        Lentigo maligna: clinical presentation and appropriate management.
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        • Johnson TM
        • Headington JT
        • Baker SR
        • Lowe L.
        Usefulness of the staged excision for lentigo maligna and lentigo maligna melanoma: the “square” procedure.
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        • Perkins W
        • Leach IH
        • Varma S.
        Johnson square procedure for lentigo maligna and lentigo maligna melanoma.
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        • Rudy S
        • Boonstra PS
        • et al.
        Efficacy of staged excision with permanent section margin control for cutaneous head and neck melanoma.
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        • Venzo A.
        Atypical presentation of lentigo maligna melanoma.
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        Spontaneous hair repigmentation in an 80-year-old man: a case of melanoma-associated hair repigmentation and review of the literature.
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