Simple cases
Case 60
15-year-old girl with multiple small brown spots comes in with her mother
History
How long have these spots been present?
For a few years; I keep getting more.
Because of the age of the patient, a solar or senile lentigo can be excluded, although it clinically is very similar to this lesion.
Are they darker in the summer than the winter?
No, they have about the same color all year long.
Very good! This answer eliminates ephelides (freckles) which typically become darker with exposure to UV irradiation.
Do you have similar spots (question for mother)?
Yes, primarily on my face and hands.
Careful! This answer can be misleading, as the mother may have solar lentigines.
Is there a family history of malignant skin diseases?
Yes, that is one reason why we are concerned. Her grandmother had a malignant melanoma on the leg. Is there a family history of malignant skin diseases?
A routine part of the dermatologic history, but it is not relevant here.
Did you have lots of sunburns as a small child?
Yes, our family sails a lot and we all frequently got sunburned.
A good question for differential diagnostic considerations, but these lesions are not caused by UV irradiation.
Do you take birth control pills?
No.
This question would be good if the patient had larger brown lesions on cheeks or forehead, suggesting melasma (chloasma) which is commonly triggered by hormones and UV irradiation.
Lesion
Choose the right efflorescences:
Atrophy leads to a slight depression in the skin because of loss of dermis or subcutaneous fat; it is often paler than the adjacent normal skin.
Lichenification is an area of skin thickening with exaggerated skin markings. It is always pruritic.
A macule is a small flat lesion, identified only by a change in color; it is not palpable.
Diagnosis
Choose the right diagnosis:
Lentigo simplex may be present at birth, but typically increase in number during childhood or puberty. They are not limited to sun-exposed areas.
Café-au-lait macules are much larger, usually more tan; hence their name of coffee with milk.
Vitiligo is a localized area of depigmentation. because of loss of epidermal melanocytes. Rarely patients with widespread vitiligo will have a few spots of remaining normal skin which appears darker, but that is not the case here.
A melanocytic nevus is palpable; it is usually a flat papule, not a macule.
Therapy
Choose the right therapy(ies):
Can be used if cosmetically disturbing. Be careful about hypopigmentation.
Correct; no treatment is needed.
Excision leaves a scar which is likely to be more disturbing than the small brown macule.
Correct; if you choose to treat, this is the best method.
