presented by

David Elpern MD (1) Williamstown, MA, USA


Jag Bhawan MD (2) Boston, MA, USA

on April 26, 2004

(1) Dermatologist, The Skin Clinic, Williamstown, Massachusetts, USA

(2) Professor of Dermatology and Pathology, Boston University School of Medicine, Boston, MA, USA

M.K., 20-year-old man

The patient is a 20 year old student who grew up Eastern Europe but emigrated to Florida at age 12. He presented for an unrelated problem and was noted to have a tumor on his forehead present since birth. His physicians had not commented on this.

Physical Examination

On the right forehead, there is a linear, flesh-colored tumor with a pebbly surface. It is 4 cm long and at its widest 1.5 cm in width.


Laboratory Data



Fig 1 Papillomatous epidermal hyperplasia, with basket weave hyperkeratosis and hypertrophic sebaceous glands. (4x)

Fig 2 Higher magnification shows a sebaceous gland opening into the epidermis. (10x)

Diagnosis Nevus Sebaceous
Reason Presented
Should treatment be recommended?
Questions 1) Should this be excised and when?
2) Even if malignant potential is low, as this lesion grows it may become more obvious. Is this reason enough for removal?
3) Should this be removed by traditional cold steel or are there laser modalities that would be effective?
  1. Cribier B, Scrivener Y, Grosshans E. Tumors arising in nevus sebaceus: A study of 596 cases J Am Acad Dermatol. 2000 Feb;42(2 Pt 1):263-8. ( To view abstract)
  2. Santibanez-Gallerani A, Marshall D, Duarte AM, Melnick SJ, Thaller S. Should nevus sebaceus of Jadassohn in children be excised? A study of 757 cases, and literature review. J Craniofac Surg. 2003 Sep;14(5):658-60. ( To view abstract)

Comments from Faculty and Members

Benjamin Barankin MD, Department of Dermatology, University of Alberta, Edmonton, Canada on Apr 26, 2004

This is a good case of nevus sebaceus of the forehead and brings up the question for the need for prophylactic excision. Cribier et al. showed a very low malignancy risk for NS that were left alone, but they didn't follow them out to an old age (mean age 39).
While a medical student, I reviewed the NS collection over 6 years at our centre, and out of 30 patients, 1 had syringo. papilliferum, 1 had a trichoblastoma, and 2 had BCCs for a 6.7% incidence of BCCs.
In any case, the NS here is in a cosmetically significant area, and excision would be difficult to do; the question is whether this needs to be removed for medical reasons. Since the nature of tumors in NS are of the more benign variety, in this case one could wait and follow the patient for changes in the lesion. Otherwise, although I have no experience with it, CO2 laser might be beneficial here. An interesting therapeutic dilemma!

Jairo Messa MD, Manizales, Columbia on Apr 26

Syringocystoadenoma papilliferum...the more common associated in my experience.

Stephen Glinick MD, Providence, Rhode Island, USA on Apr 27

I have seen 3 or 4 patients over the past 22 years with BCE arising in a Nevus Sebaceous. The lesions were managed easily at that time without complication. I agree that it is a low percentage event so these lesions can be followed clinically. In this case I would approach it from a cosmetic perspective and let the patient decide about removal. I don't believe that CO2 laser will adequately remove it so I would favor scalpel excision to deep fat if any manipulation is contemplated. Serial staged excsions could be done to minimize the scarring.

One additional point. The Linear Epidermal Nevus Syndrome has been described with Nevus Sebaceous, even with small lesions, therefore the patient should be evaluated from this standpoint as well.

Khaled El-hoshy, MD, Troy, Michigan on Apr 27 Depending on patient's desire for removal, CO2 laser ablation is a good option. Prophylactic excision for fear of malignancy is a thing of the past, I believe.

Abir Saraswat MD, Lucknow, India on Apr 28 Cold steel excision, staged if required should be done if the patient requests it for cosmetic reasons. Malignant potential is certainly not high enough to justify prophylactic excision. I have done CO2 laser ablation in one patient; scarring was significant. I believe that the ultimate cosmetic result will be better with cold steel excision.

Reference: Saraswat A, Dogra S, Bhansali A, Kumar B. Phacomatosis pigmentokeratotica associated with hypophosphatemic vitamin D- resistant rickets: improvement in phosphate homeostasis after partial laser ablation. British Journal of Dermatology 2003; 148: 1074-6.

BSN Reddy MD, Director Professor & Head,
Department of Dermatology & STD,
Maulana Azad Medical College & LNJPN Hospital, New Delhi, India
on Apr 28

Dr.Jag Bhawan and Dr. David Elpern have presented a really interesting case of nevus sebaceous with histopathological confirmation. The question of prophylactic excision on medical grounds does arise especially when the probability of malignant transformation is entertained. Recently, it has been reported that most of the basaloid neoplasms arising in these naevi are trichoblastomas and not BCCs (Cribier et al [1]; Jaqueti et al [2]). So far, in 35 years I have seen only one case of nevus sebaceous where the patient developed syringocystadenoma papilliferum lesions. Hence, it is logical to believe that the excision is not the immediate choice of treatment and the patient may be kept on observation. Cosmetically, the lesion is definitely a concern, although going by the history, the patient does not seem to have any apprehension. If he desires removal of the lesion, the basic question is whether to use cold steel or lasers? In my experience, the smaller lesions respond well to CO2 laser with good cosmetic outcomes, however a rare partial recurrence has been reported [3]. Considering the location (forehead) and size of the lesion, the final outcome of cold steel cosmetic surgery would be difficult to perceive. On the other hand, a staged CO2 laser ablation may do the trick. This may be followed by scalpel surgery and later on employing tissue expander techniques, to improve the overall outcome.

1. Cribier B, Scrivener Y, Grosshans E. Tumors arising in nevus sebaceus: A study of 596 cases. J Am Acad Dermatol 2000;42: 263-268.
2. Jaqueti G, Raquena L, Sanchez Yus E. Trichoblastoma is the most common neoplasm developed in nevus sebaceous of Jadassohn. A clinico-pathologic study of a series of 155 cases. Am J Dermatopathol 2000; 22: 108-118.
3. Ashinoff R. Linear nevus sebaceous of Jadassohn treated with the carbon dioxide laser. Pediatr Dermatol 1993;10: 189-191.

Jeffrey Dover MD, Adjunct Professor of Medicine (Dermatology) at Dartmouth Medical School, and Director, SkinCare Physicians of Chestnut Hill, Boston, MA, USA on May 1, 2004

This is a lovely example of Nevus Sebaceous of the forehead. There are 2 issues of concern. One is the malignant potential and the other is the cosmetic concern. As so well stated in the accompanying comments the risk of malignancy is very low, especially after puberty. The only reason to consider removal in this case is cosmetic. If the lesion doesn't bother the patient then it would surely be best to leave it alone. If, however, the patient is bothered by the appearance of the lesion removal must be considered.

I would not suggest an excision ,even a staged one, as the patient would be left with a relatively unsightly scar. Laser resurfacing with a combination of CO2 and Erbium:YAG lasers or a long pulsed Erbium:YAG laser would not be curative but it would have the effect of flattening the lesion and making it less noticeable.

I can think of 2 other options. One is ALA photodynamic therapy. There is only one case example, that I know of from the Massachusetts General Hospital and Drs. R. Rox Anderson and Christine Dierickxs. They effectively treated a patient with Nevus Sebaceous with this modality. The ALA concentrates in the sebaceous glands and the oxygen based dynamic process is a thinking doctors means of shrinking the nevus. The other technique is the use of one of the long pulsed infrared sources such as the Smooth Beam or Cool Touch lasers which are known to shrink sebaceous glands. We have one pending case and I have seen no reports of this but it makes sense.

Omid Zargari MD, Rasht, Iran on May 12

Thanks to Dr. Elpern and Dr. Bhawan for presenting this interesting case.
1. To treat or not to treat NS?
It appears that there is no rule on this subject. I think although the rate of malignant transformation is very low in NS, but it is a well-established complication. I clearly remember one case of true BCE (and not trichoblastma) arising on a SN. (She was one of my classmates in medical school).
2. To treat or not to treat this case?
If this lesion were located on the scalp, my answer would be yes. But in this patient with considering that it can easily be monitored and due to probable unacceptable cosmetic result after surgery, I think it is better to follow.

Laxmisha Chandrashekar MD, India on 30 July 2004

As the possibility of malignancy is very low I feel it can be left alone with a follow up every year