Photo: Angela Roma

What are the 4 abnormal skin colors?

Certain skin colors may represent serious disease, including pallor (pale), cyanosis (blue), jaundice or icterus (yellow), gray, and hyperpigmentation (brown). Table 8-1 summarizes these abnormal states, including the underlying physiological features and associated causes of the color.

sciencedirect.com - Skin Color - an overview | ScienceDirect Topics

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Skin color is determined mainly by the amount and distribution of melanin, a pigmented polymer produced by melanocytes. Hyperpigmentation is almost always the result of either production of too much melanin or abnormal distribution of pigment, although heavy metals or drug metabolites can change skin color.

A.

Dermal melanosis/melanocytosis refers to a group of pigmentary skin conditions in which an increased number of melanocytes are producing melanin within the deeper levels of the dermis. The skin overlying these pigmented cells appears slate-blue to bluish-black. Mongolian spots are bluish macules presenting at or near birth that occur in 95% of black and 10% of white newborns. Of these lesions, 75% occur over the sacrum. They may be single or multiple and may be as large as 10 cm. They generally disappear by 5 years of age. Nevus of Ota is a form of dermal melanocytosis involving the distribution of the fifth cranial nerve. It is more common in Asians and also occurs in blacks. It is present at birth in 60% of those affected. Skin color is blue-gray to blue-brown. The sclera of the eye may also be involved.

B.

Blue nevi are localized benign proliferations of melanocytes. They may be congenital or acquired. There are two types. Common blue nevi range in size from 2–10 mm. They present as small round to oval, smooth-surfaced, well-defined papules with a bluish-black pigmentation. Cellular blue nevi are less common and tend to be >1 cm. They are also bluish-black and may be mistaken for nodular melanoma. Rarely, cellular blue nevi can undergo malignant transformation.

C.

When pigment derived from melanocytes is concentrated in the epidermis, the resulting skin color may range from tan to brown or even black. Freckles are an example of localized areas of increased pigment production caused by a normal concentration of melanocytes. They appear as small (2–5 mm) tan to brown macules on sun-exposed areas of skin and arise by age 2–4 years. They can be clinically differentiated from lentigos (“liver spots”) or nevi by the fact that they darken with sun exposure in the summer and fade in the winter. Café-au-lait spots present at birth as well-marginated tan macules. Six or more lesions >1.5 cm in diameter are diagnostic of neurofibromatosis (NF). In these patients, take a history for any personal or family history of NF. In patients suspected of having NF, do a slit-lamp examination of their eyes to look for Lisch nodules, which are pathognomonic for NF and are present in all cases by age 5. Lentigos are well-demarcated tan to brown macules that may occur on any part of the skin, but particularly on sun-exposed areas of the face and dorsum of the hands. Unlike freckles, they do not fade over time. They are caused by an increased number of melanocytes with increased pigment production at the dermal-epidermal (DE) junction. Most lentigos are <5 mm. When lentigos are >5 mm and have irregular borders, perform a biopsy to determine whether the lesion is a lentigo maligna (LM). LMs are a form of melanoma in situ that can progress to invasive melanoma if not treated in time. If an LM is suspected, perform an incisional biopsy.

D.

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Congenital nevi are present from birth and range from 2 mm to >20 cm in diameter. They are typically deeply pigmented brown to black papules or plaques that may have verrucous surfaces and associated thick dark hairs. Giant congenital nevi (GCN) may involve an entire extremity or even large sections of the torso, scalp, or face. The risk of melanoma occurring in a GCN is estimated to be 5%. Although small and medium congenital nevi are associated with melanoma, the incidence of malignant transformation is far less than with GCNs; however, they should be followed with photographs and biopsied or excised if changes are seen.

E.

Common acquired nevi (moles) appear during the first three decades of life and begin to regress after age 65. The average person has 40 nevi. Acquired nevi are divided into three categories depending on the localization of their melanocytes. In junctional nevi the melanocytes are present at the DE junction. These lesions are smooth-bordered macules <5 mm with uniform color ranging from light to dark brown or even black. Compound nevi are raised well-demarcated symmetric papules or thin plaques. They range from light to dark brown; some have a stippled appearance. Melanocytes are present at the DE junction and within the dermis. Dermal nevi present as flesh-colored or pink papules. All melanocytes are found within dermis. Compound nevi may progress to dermal nevi as the melanocytes lose their ability to produce pigment and melanocytes are lost from the DE junction.

F.

A number of acquired pigmented lesions can mimic nevi. The most common of these are seborrheic keratoses (SKs) and dermatofibromas. SKs usually occur after age 35 and are well-defined, verrucous, usually hyperpigmented papules or plaques without surrounding pigment incontinence. They may become irritated by clothing or trauma, in which case they may show signs of inflammation or pruritus and require removal by cryotherapy, curettage, or shave excision. Occasionally, SKs may be misdiagnosed as melanomas because of their dark color, and at times, melanomas may masquerade as SKs. When there is any doubt, a biopsy is indicated. Dermatofibromas are smooth, brown or pink papules that often pucker in the center when compressed from the edges (the “dimple sign” of Fitzpatrick). Although their cause is unclear, they may arise after minor trauma such as an insect bite or razor cut. Becker's nevus is a uniformly tan to brown plaque that occurs primarily on the upper trunk and shoulders. It is more common in males than in females. These lesions usually present in adolescents and may be confused with large congenital nevi as they mature and acquire coarse dark hairs. They are a form of connective tissue nevus and present no malignant potential.

G.

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Dysplastic or atypical nevi are acquired nevi that are >5 mm in diameter and have irregular or variegate pigmentation (blues, browns, black, red, or white) with poorly defined or irregular borders. Some of these lesions may be precursors for melanomas. Patients with atypical nevi who have two or more first-degree relatives with dysplastic nevi and a history of melanoma have nearly a 100% chance of developing melanomas. Follow these patients carefully for any signs of change in their nevi. These changes can best be assessed when baseline high-quality photographs have been taken so that the current findings can be compared with previous images.

H.

Melanomas are skin cancers arising from the malignant transformation of melanocytes. As discussed, they may arise from precursor lesions such as atypical nevi, congenital nevi, and LM. They may also arise de novo from melanocytes within the skin. Suspect melanoma if a pigmented lesion displays any combination of asymmetry, border irregularity, variegate colors, or a diameter >5 mm. Other worrisome signs are pruritus, ulceration, bleeding, or change in color or size of the lesion.

I.

Melasma is a form of hyperpigmentation characterized by mottled tan to brown macules coalescing into irregular patches on the face. The forehead, cheeks, and upper lip are often involved. Melasma is common in pregnancy, and the condition may also be triggered by oral contraceptive use. It may be idiopathic or familial and can also be seen in men. Postinflammatory hyperpigmentation is another form of localized macular hyperpigmentation that occurs after cutaneous trauma or inflammatory dermatoses. It is more common and may be more severe in darker-skinned individuals.

J.

sciencedirect.com - Skin Color - an overview | ScienceDirect Topics

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