CASE
A 63-year-old female patient with skin of color (Fitzpatrick skin type IV) and prior medical history of a cerebrovascular event, hypertension, hypercholesterolemia, and anxiety/depression presented to the dermatology office for "dark spots" on her trunk. She had no personal or family history of skin cancer. The patient reported having scalp hair loss that began approximately 10 years prior with associated areas of depigmentation noticed by her hairdresser. She had not started treatment for any skin or hair problems and had no prior autoimmune diagnoses.
The lesions on her trunk relating to her chief complaint were consistent with seborrheic keratoses and solar lentigines. Her full body skin exam was otherwise significant for exclamation point hairs on the scalp consistent with alopecia areata, as well as depigmentation of the left frontoparietal scalp and right dorsal foot and ankle, consisting of <5% body surface area. At the edge of the depigmented patch on her dorsal foot, she had a <4 mm dark brown macule shown below (Figure 1). She reported wearing closed-toed shoes that covered the dorsal surfaces of her feet on a daily basis.
The macule of interest had an irregular rim on the lateral border with strikingly dark pigmentation, concerning for a melanocytic neoplasm. Shave biopsy of the macule was performed. Histopathologic examination showed poorly-formed proliferation of melanocytes at the dermo-epidermal junction and melanocyte atypia with pagetoid migration consistent with an early, evolving melanoma in situ (Figure 2).
The lesions on her trunk relating to her chief complaint were consistent with seborrheic keratoses and solar lentigines. Her full body skin exam was otherwise significant for exclamation point hairs on the scalp consistent with alopecia areata, as well as depigmentation of the left frontoparietal scalp and right dorsal foot and ankle, consisting of <5% body surface area. At the edge of the depigmented patch on her dorsal foot, she had a <4 mm dark brown macule shown below (Figure 1). She reported wearing closed-toed shoes that covered the dorsal surfaces of her feet on a daily basis.
The macule of interest had an irregular rim on the lateral border with strikingly dark pigmentation, concerning for a melanocytic neoplasm. Shave biopsy of the macule was performed. Histopathologic examination showed poorly-formed proliferation of melanocytes at the dermo-epidermal junction and melanocyte atypia with pagetoid migration consistent with an early, evolving melanoma in situ (Figure 2).
The patient subsequently underwent Mohs staged excision with clear margins. Concurrent with her excision, she was diagnosed with hypothyroidism by her primary doctor and started on levothyroxine. In the ensuing two years, the patient noted progressive depigmentation involving the bilateral lower extremities extending to the groin, back, upper extremities, and bilateral scalp and ears to comprise ~45% BSA.
DISCUSSION
The association between vitiligo and melanoma has been a subject of clinical and scientific interest. Vitiligo is a chronic disease characterized by depigmented patches on the skin due to the autoimmune destruction of melanocytes. Vitiligo is
