| 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.
References
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
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