The Fung Shui Nevus

Presented by: Micah Ashkenazi
Root Town, Ohio

The patient is a 19 year-old American-born, Chinese college student living in Ohio.  Her mother brings her in for an office visit regarding a nevus..  The 2 mm in diameter lesion has been present near the bulb of the nose for years with no worrisome changes.

Diagnosis:  Acquired melanocytic nevus.  Possibly a blue nevus.

Discussion:  I reassured the patient's mother that this is a benign lesion and can be safely observed.  The mother only speaks Cantonese.  She and her daughter have a longish conversation in Chinese.  The daughter tells me that her mother believes that moles on this part of the nose have bad fung shui.  In that case, I acquiesced and agreed to remove the mole which can be done with a 3 mm punch.  A shave may leave some residual pigment and that would be unacceptable to them.

The patient and her mother take fung shui seriously and want the lesion removed.  This will be scheduled at a propitious time as decided by their astrologer in Chinatown.

Clearly, this is a cultural issue, not a medical one.  Failure to consider that might have led to a disconnect between the patient, her family and the physician. How many other similar scenarios have I missed over the years?

Post 3 mm punch bx

Follow-up at Six Months

Reference:
PubMed is strangely silent on Feng Shui; however there are many references on Google.

Face Reading Feng Shui in Chinese Five Arts.  It says, " If there is a mole on the nose, it will be bad luck between 40 to 50 years old."

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

Active Nevus

17 yo boy seen for another problem.  Atypical nevus noted on left shoulder.

O/E:  Type III-IV skin. 5 mm papule with slight play of color clinically.  Pt. unaware of lesion.

Dermoscopic images shows pigment dots of varying sizes.

Dx:  Actively growing nevus.  Easy to excise with a 6 mm punch.  Best to do this of just observe?  Patient will be leaving for college in another city in a few months.

Nevi of Interest

In this post, we will present photos of interesting pigmented tumors.  Please feel free to send us interesting photos with brief captions.

7/25/2015
1) 15 y.o. girl with a 6 mm diameter congenital nevus on upper back.  Looks benign to me but has an interesting play of color.

2) 10 y.o. girl with a planaria shaped nevus on the right 4th toe.  Pigment globules likely represent growth.

3) 14 yo girl last seen 10 years ago.  Congenital nevus noted on l. upper back then, 9 mm diameter.  7.28.15 the lesion is 20 mm diameter. It has find terminal hairs.  There are two (?) satellite lesions near to it, the largest being 7 mm diameter.  The new lesion has a peculiar pattern dermatoscopically.  Still, I think it is benign.  I gave them a follow-up for 6 months.

Dermatoscopic Dilemmas

The dermatoscope is a source of endless wonder.  Here are two cases seen in the past week.

1. Congenital Nevus of Special Site

This 5 month old bi-racial (Black/Caucasian) foster infant was noted to have a slowly enlarging pigmented lesion in his left crural fold since around one month of age.

photo taken by Dr. Yoon Cohen

Question/Comment: Would anyone do anything other than follow this child?  Is the gray veil significant? The symmetrically distributed brown clods are to my mind markers for a benign growing nevus (cobblestone pattern).  There is no pertinent literature about growth in small congenital nevi.  Melanoma, in this age group and ethnicity, is exceedingly rare.

2. Unusual Subungual Hematoma

A 72 yo woman noted nail pigmentation that appeared shortly after knee replacement surgery.  I do not know if she had been anticoagulated after surgery, but the information would help.  The subungual color under the cuticle may be an example of a "pseudo-Hutchinson sign."

1 month follow-up

Note:  The one month follow-up shows distal progression of pigmented area confirming the clinical impression of subungual hematoma.

Question/Comment: The fact that this appeared shortly after surgery strongly suggests trauma rather than neoplasia.  If the patient was anticoagulated during surgery, that would be one more helpful historical fact.  The pattern of the long band could be called the "tadpole sign" -- I wonder if it is specific for subungual hematoma.

References:
1. Precursors to melanoma and their mimics: nevi of special sites.

Elder DE. Precursors to melanoma and their mimics: nevi of special sites. Mod Pathol. 2006 Feb;19 Suppl 2:S4-20.  Free Full Text.

2. Dermnet.nz.org has good sections on dermtoscopy: Introduction to Dermatoscopy   Dermatoscopic Features 

3. Overview of Nail Dermatoscopy

Changing Nevus

Presented by:
Dr. Salvatore Donatello
Dermatologica e Venereologia. Catania, Sicilia


Abstract:  44 year old man with changing naevus

HPI:  The patient was seen in July of 2012 for a general cutaneous exam. He has Type IV skin. A naevus was noted on his right shoulder.  Dermatoscopic exam was felt to be not particularly worrisome but he was asked to return to have the lesion rechecked in six months.  He returned 18 months later.  The patient thought it had been present for many years and had not noted change.

O/E: July 2012:  5 mm in diameter dark brown papule  on right shoulder.  At the time, I thought the dermatoscopic exam looked normal.  It did look like an active lesions

January 2014:  The lesion is still 5 mm in diameter.  However, the brown clods noted on dermatoscopy in 2012 have disappeared and the lesion now looks uniformly dark gray.

Clinical photos:

Clinical Photo 31.1.14

Dermatoscopic Photo 31.1.14

Plan:  The lesion was excised with 3 mm margins on 31.1.14

Follow-up:  The biopsy report showed that this is an intradermal melanocytic without any atypical features. The brown clods in the first biopsy most likely are a sign of an active growing lesion.

Discussion:  Neither lesion on its own was very worrisome.  However, fortunately we have dermatoscopic images from July 2012 and January 2014.  The brown clods have disappeared and the lesion looks uniformly gray. Although the patient was asked to return in six months he did not do so.  We have no way of knowing if the change would have been noted then.
The pathology will tell us the story.  Is this an evolving naevus or a melanoma.  The practice of medicine can be humbling. There are few articles on evolving naevi in the literature.  This case will teach us something.

We will add an update after the biopsy is signed out. I have sent the specimen to a dermatologist in Napoli with a special interest in pigmented lesions.