STUDENT PROJECT

(LENTIGO)

SGD B5:
Anak Agung Ayu Kania /1702511198
Elisabeth Yunilan /1702511091
I Gusti Ayu Aruna Krisnadewani /1702511124
I Kadek Wahyu Putra Dyatmika /1702511126
Jonathan Yoshua Patuan /1702511098
Maria Preicilia Pragra /1702511089
Nicholas Brian /1702511201
Putu Ivan Sandyputra Santosa Oka /1702511083
Rovie Hikari Parastan /1702511152
Jude Arvind Raj K Gerald Anthony /1702511241
Kerthana Sunderasagar /1702511223

FACULTY OF MEDICINE
UDAYANA UNIVERSITY
2019
 FOREWORD

We thank God for the completion of this paper. This student project of the skin and
hearing system disorder about lentigo is meant for academic purpose only. We
would also like to thank:
1. Dr. dr. I Putu Eka Widyadharma, M.Sc, Sp.S(K) as our small group facilitator
and dr. Ni Made Dwi Puspawati, Sp.KK, FINSDV as our evaluator,
2. dr. Nyoman Suryawati, M.Kes, Sp.KK, FINSDV, FAADV as the block
coordinator for “Skin and Hearing System and Disorders”
For guiding us in making this paper. We are grateful for your critics and advice to
make this paper better. We hope that this paper would be of use to those in the
medical field, and to those whose interest is in dermatology; especially about
lentigo.

Denpasar, 11 November 2019

Author

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 TABLE OF CONTENTS

FOREWORD ........................................................................................................... I
TABLE OF CONTENTS ........................................................................................ II
CHAPTER I .............................................................................................................1
1.1 Background ..................................................................................................1
CHAPTER II ............................................................................................................2
2.1 Definition .....................................................................................................2
2.2 Types and Clinical Manifestation.................................................................2
2.2.1 Lentigo Simplex ...................................................................................2
2.2.2 Solar Lentigo ........................................................................................4
2.2.3 PUVA Lentigines .................................................................................5
2.2.4 Ink Spot Lentigo ...................................................................................7
2.2.5 Leopard Syndrome ...............................................................................8
2.3 Differential Diagnosis ..................................................................................9
2.3.1 Ephelides ..............................................................................................9
2.3.2 Lentigo Maligna .................................................................................10
2.3.3 Lentigo Maligna Melanoma ...............................................................10
2.4 Treatment ...................................................................................................11
2.5 Prognosis ....................................................................................................11
CHAPTER III.........................................................................................................13
3.1 Summary ....................................................................................................13
BIBLIOGRAPHY ..................................................................................................14

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 CHAPTER I
INTRODUCTION

1.1 Background

There are many types of skin disease along with its lesion accompanying it. One
of them is an epidermal melanocytic lesion called lentigo. The melanocytes
occurring at the dermoepidermal junction (DEJ) are dendritic cells that supply
melanin to the skin. These cells contain pigment granules (melanosomes). A
lentigo is characterized by pigmented macule surrounded by normal skin. On
histologic finding there are an increase in melanocytes. There are multiple
varietis of lentigo, clinically and etiologically.

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 CHAPTER II
CONTENT

2.1 Definition

A lentigo is a small, sharply circumscribed, pigmented macule surrounded by

normal-appearing skin. Histologic findings may include hyperplasia of the
epidermis and increased pigmentation of the basal layer. A variable number of
melanocytes are present; these melanocytes may be increased in number, but
they do not form nests. Lentigines may evolve slowly over years, or they may
be eruptive and appear rather suddenly. Pigmentation may be homogeneous or
variegated, with a color ranging from brown to black.1

2.2 Types and Clinical Manifestation

2.2.1 Lentigo Simplex

Lentigo simplex is a pigmented lesion that is not due to sun exposure.

Lentigo simplex can occur in all areas of the body, including areas not
exposed to sunlight. Some lentigo is associated with several inherited
syndromes, but lentigo simplex can also occur as a single lesion. Single
lesions often appear on the lips or gums. Lesions can be caused by
several forms of ultraviolet light therapy. If this is the case, the lesions
can be seen as identical to those caused by sun exposure.2

Lentigo simplex can occur on the surface of the skin, conjunctiva, and
mucocutaneous. The development of lentigo can be started from the age
of adolescence and appears on both sun-exposed and sun-protected sites.
The mechanism underlying lentigo simplex formation is still unclear.
Increased melanocyte density indicates that melanocyte homeostasis is
impaired in lentigo simplex. In addition, the presence of macro-globular
melanin in melanocytes indicates that melanization is not regulated and
can contribute to lentigine formation. The presence of lentigine in
relation to various hereditary syndromes underscores the possibility

2
that the development of lentigo can be influenced by a variety of
different genetic and developmental factors.1,3

Lentigo simplex consists of limited macules, measuring 1 to 5 mm, with

light brown to uniform black pigments. If there is partial or general
lentiginosis, the specific pattern and clinical course of the lesion may
indicate specific hereditary syndrome. Lentigines can develop in
unilateral, agminated (partial or segmental lentigine), or general
distribution (abundant ocular lentigines) and can occur as isolated
phenomena or related to a number of inherited disorders, including
LEOPARD (lentigine, electrocardiographic conduction abnormalities,
ocular ocular abnormalities, hypelelorism) ocular, pulmonary valve
stenosis, genital abnormalities, growth retardation, and sensorineural
deafness), Carney's syndrome, Peutz-Jeghers syndrome, Laugier-
Hunziker's syndrome (mucocutaneous lenticular idiopathic
pigmentation), and centrofacial lentiginosis.1

In LEOPARD syndrome, lentigene is not found at the age of 1 year;

then hundreds of lentigines can occur during childhood, including the
genitalia, conjunctiva, oral cavity, palms, and soles. In Peutz-Jeghers
syndrome, lentigine is commonly found on the buccal mucosa, lips,
perioral skin, and ventral surfaces of the hands and feet. Although skin
lesions can fade at puberty, oral lentigine usually lasts into adulthood.
In centrofacial lentiginosis, lentigine is typically distributed in
horizontal bands across the face. In Laugier-Hunziker's syndrome,
lentigines mainly occur on the lips, hard and soft palate, fingers, nail
and palm matrix, and rarely at other sites, including the conjunctiva and
genitalia. In LAMB syndrome (lentigine, atrial myxoma,
mucocutaneous myxoma and blue nevi), lentigine mainly occurs on the
face, torso, and genitalia such as tan to black macules (Figure 2.1).4

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 Figure 2.1 Lentigo Simplex

2.2.2 Solar Lentigo

Solar Lentigo or called liver spot is a benign lesion induced by sun

which mostly appears on sun exposed areas like face, arms, dorsal of
the hands and upper part of the trunk. Solar lentigo are associated with
long term exposure to ultraviolet radiations, leading to local
proliferation of melanocytes and accumulation of melanin within the
keratinocytes (skin cells) which are more abundant in fair-skinned
whites than in dark-skinned individuals because the greater amount of
natural pigment that gives some degree of photoprotection (Figure
2.2).5 These lesions are commonly appears in individuals aged 30-50
years, but now they are seen in younger individuals because of their
increased exposure to sun-tanning and the use of artificial sources of
UV light.6

Figure 2.2 Solar Lentigo

The clinical features are small pigmented macules smaller than 5 mm

in diameter but may merge to form larger spots and surrounded by
normal-appearing skin, well circumscribed patch, with a surface either

4
 flat or depressed and usually brown colored but may range from yellow-
tan to black. It can be oval, round or irregular in shaped. Solar lentigines
slowly increase in size and number and often gets more darker (dark
brown or brownish black).6 In histology finding, solar lentigines have
elongated rete ridges which may appear flattened and a higher rate of
pigmented basaloid cells proliferation which form buds and strands.
The number of melanocytes are increased compared with unaffected
skin from the same subject. Solar lentigo is often diagnosed based on
its clinical appearance, but on some occasion it can be difficult to
differentiate with melanoma. Examination with dermatoscopy can be
used to clarify the diagnosis and skin biopsy may be performed for
histological examination if there is still diagnostic doubt. 7

2.2.3 PUVA Lentigines

PUVA Lentigines are a equivalent word to a number of alternative

names like Lentigines because of PUVA medical care, Psoralen and
Ultraviolet. A Lentigine and PUVA medical care inflicting lentigines.
PUVA lentigines referred to melanotic macules that are the dark spots
which will be discovered on the skin, mucous secretion membranes of
the mouth, the crotch, and within the nails. Melanotic macules are
benign and there is no malignant transformation to a skin cancer that
has been recorded. A patch typically does not involve any modification
within the thickness and texture of the realm of affected skin. PUVA-
Lentigines may be a type of variant of melanotic macules and
discovered in patients World Health Organization are being treated with
PUVA medical care, typically for a protracted period. Medical care for
PUVA may be a type of photochemotherapy that been used for treating
diseases like skin problem, eczema, and alternative medical conditions.
In most cases, PUVA-Lentigines are usually well and does not gift any
vital signs and symptoms. No complications are generally related to
these lesions. In a very majority, termination of the PUVA treatment
might facilitate mitigate the condition. Talking concerning the

5
prognosis of PUVA-Lentigines is superb once Associate in nursing
acceptable treatment is given to the patient.
PUVA-Lentigines are caused by PUVA therapy; PUVA may be a
variety of photochemotherapy that uses the drug psoralen and
ultraviolet exposure. during this ultraviolet (UV) light-weight medical
care, the affected skin (due to varied alternative medical conditions) is
exposed to ultraviolet radiation a light-weight following skin
sensitization victimization the drug psoralen, that is taken orally or
applied on the body as a topical skin cream. Because of this, the skin
cells (the keratinocytes that kind the epidermis) ar burnt or broken from
prolonged exposure to the ultraviolet A radiation part following
psoralen bodily process or application.
The clinical signs and manifestations of PUVA-Lentigines incorporates
the condition may be viewed as a visible modification within the skin
within the body regions that are handled utilizing PUVA therapy; it
tends to be named as a proof of the body to the treatment. The lentigines
or macules kind stained, flat, and uneven patches on the skin space,the
color of the macules is also uniform or non-uniform; the colour is also
in shades brown or typically black, the macules ar typically multiple
having Associate in Nursing irregular borders,signs and symptoms of
the underlying condition is also gift.
The diagnosis of PUVA-Lentigines may involve the following
procedures such as:

1. The diagnosis is usually made by a complete physical examination

and evaluation of medical history

2. Dermoscopy: Dermoscopy is a diagnostic tool where a

dermatologist examines the skin using a special magnified lens

3. Wood’s lamp examination: In this procedure, the healthcare

provider examines the skin using ultraviolet light. It is performed to
examine the change in skin pigmentation

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 4. Skin biopsy: A skin biopsy is performed and sent to a laboratory for
a pathological examination, who examines the biopsy under a
microscope. After putting together clinical findings, special studies
on tissues (if needed) and with microscope findings, the pathologist
arrives at a definitive diagnosis. A skin biopsy is performed to rule
out other similar conditions

The complications of PUVA-Lentigines ar a really long skin patches

which will cause emotional stress and cosmetic issues in some
people,the appearance of the pigmented spots might induce a worry of
carcinoma referred to as skin cancer and additionally the complications
that arise from the underlying skin condition.The treatment of PUVA-
Lentigines ar use of other measures to treat the underlying skin
condition; discontinuing photochemotherapy victimisation PUVA (may
be for a definite amount as assessed by the health care provider), the
health care supplier might value more highly to often observe the benign
lesions; once a identification is established. In cases like such, no
treatment is mostly given to patients, a surgical excision and total
removal of the skin lesions, to cope up with aesthetic problems is also
performed,treatment of the underlying associated skin disease.8,9

2.2.4 Ink Spot Lentigo

Ink spot lentigo or reticulated black solar lentigo is a benign melanotic

macular lesion, appear in small dimension with diameter less than 6mm
and few in number compared with solar lentigo. Ink spot lentigo is
caused by the overexposed to UV light. It usually appears at sun-
exposed area and among several solar lentingens (Figure 2.3).

Figure 2.3 Dermoscopic View of Ink Spot Lentigo

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 The clinical and dermoscopic features of ink spot lentigo is very unique.
The dermoscopic features are characterized by a wiry or beaded and
have irregularly spider-like outline (Figure 2.4) . The histologic
findings of ink spot lentigo shows hyperplasia of epidermis with
hyperpigmentation of the basal layer which is associated with a
significant increase of melanocytes, and can also be found several
melanophages in the dermis. Ink spot lentigo may easily diagnosed by
the clinical and dermoscopical features. Histological findings can
confirm the diagnosis. It should regarded as a benign lesion and
distinctive entity.10

Figure 2.4 Clinical Appearance of Ink Spot Lentigo

2.2.5 Leopard Syndrome

Leopard syndrome is a rare condition caused by an autosomal dominant

which characterized by congenital anomalies of the skin, face, and heart.
Leopard is an acronym for the major clinical features of this condition.
Those features are multiple Lentigines, ECG conductiong
abnormalities, Ocular hypertelorism, Pulmonic stenosis, Abnormal
genitalia, Retardation of growth, and sensorineural Deafness.
Lentigines are hyperpigmented macules that vary in size, some can
reach several centimeters in diameter (café-au-lait spots). Ocular
hypertelorism is one of the facial dysmorphisms that can occur. In
addition to that, bilateral cryptorchidism are also present in some cases.
In diagnosing Leopard Syndrome, it’s not necessary to have all of the
hallmarks mentioned.12,13

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 Clinical diagnosis can be made when patient has multiple lentigines and
two features mentioned above. In some cases where lentigines aren’t
present, clinical diagnosis can be made when patient have three features
mentioned above with first-degree relatives with Leopard Syndrome.
The pathophysiology of this condition is still unknown, but in most
cases, mutation of the PTPN11 gene is detected. The treatment of
Leopard Syndrome is symptomatic.12,13

2.3 Differential Diagnosis

2.3.1 Ephelides
Ephelides is known as freckles, just like lentigines both are pigmentation
on the skin that affected by the sun. ephelides are genetically determined
but induces by sunlight, while lentigines are induced by sun exposure and
photodamage of the skin. ephelides and lentigines differ significantly in
development and morphology. Ephelides are usually small pigmented
spots generally 1-2mm, red to light brown coloured, appears at the age

of 2-3 year and will disappears with age. Ephelides usually found on the
face, neck, arms and chest, it become more pigmented in summer time,
compared with lentigines, ephideles are associated with skin type I or II
and blond or red hair color whilst lentigines are associated with darker
skin types. Ephelides are asymptomatic and no need to be treated. For
the morphology, ephelides has larger melanocytes than lentigines but
lentigines has more melanocytes, but for melanosome ephideles has more
number and larger size than lentigines (Figure 2.5).14

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 Figure 2.5 Facial Ephelides

2.3.2 Lentigo Maligna

Lentigo maligna (LM) is a melanocytic neoplasm that happened on skin

because of sun exposed, usually occurs on the skin of the face and neck,
of middle-ages and elderly patients. Lentigo maligna is a type of
melanoma in situ or premelanoma.15,16 Clinical manifestation of LM
usually starts as a tan-brown macule or patch with varies pigmentation
brownish to dark black or even amelanotic features. It is a slow growing
macule with progresses in a prolonged radial growth phase before
vertical growth phase, usually asymptomatic pigmented. Risk factors
include history of nonmelanoma skin cancers, advanced age, lighter skin
types, history of sunburns, and genetic. In dermoscopy, the positive
predictive value was highest for a pattern of circles, the presence of a
gray color, asymmetric pigmented follicular opening, dark rhomboidal
structures, slate-gray globules, dots and streaks, annular-granular pattern,
and black blotches. Microscopic findings of LM include atypical
melanocytic hyperplasia at the dermoepidermal junction, confluence of
atypical melanocytes and angulated nuclei replacing the basal layer, and
nesting of atypical melanocytes with occasional pagetoid spread. 16

2.3.3 Lentigo Maligna Melanoma

Lentigo meligna melanoma (LMM) is a variant of skin cancer that occurs

on chronically sun exposed skin in elderly individuals. It presents as an
irregular brown macule or patch and usually asymptomatic, some cases
may produce pain, burning, itching, or bleeding. Histologically, it is
characterized by growth of predominantly solitary unit of melanocytes
that more invasive than LM with junctional nests become larger and more
spindled.17,18 Dermoscopic findings features based on degree of
infiltration of the follicular ostia, known as annular-granular structures
or blue-grey dots, the dots will coalesce to form short polygonal lines
around and in between adnexal openings. Further progression lead to

10
 darkening the polygonal lines into polyhedral shapes, this can become a
homogeneous dark brown to black blotch.18

2.4 Treatment

Medicamentosa18–21:

a. Non-invasive topical cream: tretinoin cream and hydroquinone cream, after

a few months of use it will slowly remove the freckles and lentigin color
appears brighter.

b. 2% mequinol (4-hydroxyanisole, 4HA) and 0.01% tretinoin 2x daily for 3

months. The therapy showed significant results in the form of lentigine color
lightening after 2 months of use.

Surgical18–21:

a. Cryosurgery: destroys excess pigment by providing coolant to the lentigo

area untul in become frozen,

b. Q-switched Nd: YAG laser,

c. Intense pulsed-light (IPL): remove the melanin-produsing cells

(melanocytes) without destroying or damagin the surface of the skin.

2.5 Prognosis

Lentigines are usually benign by nature, but in some cases where the lentigines
associates with systemic manifestations, the prognosis depends on the severity
of the systemic disease.1 In LEOPARD syndrome, most morbidity is caused by
cardiac disease with pulmonary valve stenosis as is most common cardiac defect.
Noncardiovascular systemic manifestation of LEOPARD syndrome also has
some sever consequences. If there is neurologic system involved, there might
be sensorineural hearing loss and mild mental retardation. 22

The prognosis for lentigo maligna and lentigo maligna melanoma is good, there
were no disease related deaths after excision in lentigo maligna and one in
lentigo maligna melanoma. However, on cases in which the tumor becomes

11
invasive the prognosis is the same for all melanomas after controlling for
Breslow depth, and can potentially has poor prognosis if the disease becomes
invasive and metastatic.18

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 CHAPTER III
SUMMARY

3.1 Summary

Lentigo is a small, sharply circumscribed, pigmented macule surrounded by

normal-appearing skin. There are several types of lentigo clinical
manifestations, some of them are lentigo simplex, solar lentigo, PUVA
lentigines, ink spot lentigo, and leopard syndrome. Differential diagnosis for
lentigo are ephelides, lentigo maligna, and lentigo maligna melanoma. Lentigo
can be treated by giving non-invasive topical cream such as tretinoin cream and
hydroquinone cream, cryosurgery, Intensed Pulsed-Light (IPL), and Nd-YAG
laser. Lentigines are usually benign and the prognosis is good, but in some cases
where the lentigines associates with systemic manifestations, the prognosis
depends on the severity of the systemic disease.

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