Vascular Diameter as Clue for the Diagnosis of Clinically and/or Dermoscopically Equivocal Pigmented and Non-Pigmented Basal Cell Carcinomas and Nodular Melanomas.

Background and objectives: Dermoscopy is a useful tool for the early and non-invasive diagnosis of skin malignancies. Besides many progresses, heavily pigmented and amelanotic skin tumors remain still a challenge. We aimed to investigate by dermoscopy if distinctive morphologic characteristics of vessels may help the diagnosis of equivocal nodular lesions. Materials and Methods: A collage of 16 challenging clinical and dermoscopic images of 8 amelanotic and 8 heavily pigmented nodular melanomas and basal cell carcinomas was sent via e-mail to 8 expert dermoscopists. Results: Dermoscopy improved diagnostic accuracy in 40 cases. Vessels were considered the best clue in 71 cases. Focusing on the diameter of vessels improved diagnosis in 5 cases. Conclusions: vascular diameter in addition to morphology and arrangement may be a useful dermoscopic clue for the differential diagnosis of clinically equivocal nodular malignant tumors.

Effect of allergens and irritants on levels of natural moisturizing factor and corneocyte morphology.

BACKGROUND: The irritant sodium lauryl sulfate (SLS) is known to cause a decrease in the stratum corneum level of natural moisturizing factor (NMF), which in itself is associated with changes in corneocyte surface topography. OBJECTIVE: To explore this phenomenon in allergic contact dermatitis. METHODS: Patch testing was performed on patients with previously positive patch test reactions to potassium dichromate (Cr), nickel sulfate (Ni), methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI), or p-phenylenediamine. Moreover, a control (pet.) patch and an irritant (SLS) patch were applied. After 3 days, the stratum corneum from tested sites was collected, and NMF levels and corneocyte morphology, expressed as the amount of circular nanosize objects, quantified according to the Dermal Texture Index (DTI), were determined. RESULTS: Among allergens, only MCI/MI reduced NMF levels significantly, as did SLS. Furthermore, only MCI/MI caused remarkable changes at the microscopic level; the corneocytes were hexagonal-shaped with pronounced cell borders and a smoother surface. The DTI was increased after SLS exposure but not after allergen exposure. CONCLUSIONS: MCI/MI significantly decreased NMF levels, similarly to SLS. The altered corneocyte morphology suggests that skin barrier damage plays a role in the pathogenesis of MCI/MI contact allergy. The DTI seems to differentiate reactions to SLS from those to the allergens tested, as SLS was the only agent that caused a DTI increase.

Current knowledge on biomarkers for contact sensitization and allergic contact dermatitis.

Contact sensitization is common and affects up to 20% of the general population. The clinical manifestation of contact sensitization is allergic contact dermatitis. This is a clinical expression that is sometimes difficult to distinguish from other types of dermatitis, for example irritant and atopic dermatitis. Several studies have examined the pathogenesis and severity of allergic contact dermatitis by measuring the absence or presence of various biomarkers. In this review, we provide a non-systematic overview of biomarkers that have been studied in allergic contact dermatitis. These include genetic variations and mutations, inflammatory mediators, alarmins, proteases, immunoproteomics, lipids, natural moisturizing factors, tight junctions, and antimicrobial peptides. We conclude that, despite the enormous amount of data, convincing specific biomarkers for allergic contact dermatitis are yet to be described.

Mycosis fungoides with large cell transformation (CD30+) and B-cell chronic lymphocytic leukemia.

Mycosis fugnoides (MF) is an indolent cutaneous T-cell lymphoma (CTLC) and is the most common of all cutaneous lymphomas. An increased risk for developing a second primary malignancy in patients with CTCL has been described in several studies, with a range from 1.04 to 2.4 (1-4). Caucasian males are at higher risk for MF development. MF is often diagnosed at ages between 55 and 67 years, and second malignancy usually occurs 5 or 6 years after the diagnosis of MF was established (5). The most common second primary malignancies include non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), lung carcinoma, bladder carcinoma, and melanoma. Even though a higher incidence rate of all NHL was described in patients with MF (15/1000) in comparison with the general population (0.32/1000), there are still only a few cases of B-cell NHL following MF described in the literature (6,7). We describe a rare case of a patient with MF and simultaneous large cell transformation (LCT) and a small B-cell lymphocytic lymphoma/chronic lymphocytic leukemia (B-CLL). In 2017, an 82-year-old man previously treated for MF presented with two fast growing tumorous lesions with ulceration on the right tight (Figure 1). A biopsy was performed, and a diagnosis of MF with LCT was established (Figure 2). During hospitalization, mild leukocytosis (12.2 x109 L-1), lymphocytosis (64%, total count of 7.81 x109 L-1), and anemia were found. Bone marrow biopsy was not performed due to low pain threshold. Bone marrow aspirate showed 70% of atypical lymphocytes and few "smudged" cells. Immunophenotyping by flow cytometry detected 49% monoclonal kappa+ B-cells with phenotypic features typical for B-CLL (CD5+, CD23+, kappa +). Of overall bone marrow cells, the ratio of monoclonal kappa + B-cells with the B-CLL phenotype was 21%. Immunophenotyping of peripheral blood showed up to 50% monoclonal kappa+ B-cells with phenotypic features typical for B-CLL (CD5+, CD23+, kappa +). Of overall peripheral blood cells, the ratio of monoclonal kappa+ B-cells with the B-CLL phenotype was 28%. Multi-sliced computed tomography was within normal ranges. A flow cytometry showed lymphocytes with phenotypic findings for CD20+ B-CLL. A diagnosis of MF with LCT (CD30+) clinical grade IIB (T3, N0, M0) and B-CLL was established. The patient was treated with fractionated superficial irradiation that resulted in applanation and regression of the tumorous lesions. No hematologic treatment was indicated other than regular follow-up. On dermatologic follow up for 2 years, the patient was stable, with no active skin lesions and no progression of MF. The patient was subsequently lost to follow-up. This is a rare case of MF with LCT and B-CLL occurring simultaneously. Large cell transformation in patients with MF can occur in 20-55% of advanced MF, as in our case, and this something physicians must be aware of, so repeated biopsies are advised (8). We also should keep in mind that patients with MF are at higher risk of developing a second malignancy. Of those second malignancies, a coexistence of lymphoproliferative disorders in two lineages, T-cell and B-cell, such as CTCL and B-CLL, is very uncommon, and only a few cases have been published (6,7,10). In most of these cases, CTCL preceded B-CLL, and with the only established explanation being increased risk of second malignancy in patients with CTCL (3,5,10). Other explanatory hypotheses include neoplastic stem cells, a genetic predisposition to malignancy, the use of immunosuppressive agents for the treatment for a first neoplasm, viral agents, and modulation of the B-cell system by monoclonal T-cell proliferation (1,5,6,9,10). Regular follow-up is mandatory for all patients with CTCL as well as MF, in order to identify the disease progression but for the timely detection of second malignancies.

Immunohistochemical Analysis of Adhesion Molecules E-Selectin, Intercellular Adhesion Molecule-1, and Vascular Cell Adhesion Molecule-1 in Inflammatory Lesions of Atopic Dermatitis.

E-selectin, ICAM-1 (intercellular adhesion molecule-1), and VCAM-1 (vascular cell adhesion molecule-1) play a role in atopic dermatitis (AD). This study aimed to evaluate their expression in skin biopsy specimens of patients diagnosed with AD using an optimized computer program. A descriptive analysis and comparison of digitally measured surface area and cell number were performed. The number of E-selectin-positive cells did not vary between the groups. In patients with AD, decreases of 1.2-fold for ICAM-1- and 1.3-fold for VCAM-1- positive cells were observed. The E-selectin-positive epidermal surface area increased (p < 0.001), while ICAM1 and VCAM1 decreased 2.5-fold and 2-fold, respectively, compared to controls. In the AD-affected skin, the E-selectin-positive endothelial area was 3.5-fold larger (p < 0.001), and the ICAM1-positive area was almost 4-fold larger (p < 0.001). E-selectin and ICAM-1 were expressed in the control dermis moderately and weakly, respectively. A strong E-selectin signal was detected in the AD-affected skin macrophages and a strong ICAM-1 signal in the dermal vessel endothelium. In the endothelial cells of AD-affected skin, no VCAM-1 signal could be found. E-selectin, ICAM-1, and VCAM-1 expression show significant disease-specific changes between AD-affected and control skin. The combination of digital analysis and a pathologist's evaluation may present a valuable follow-up of AD activity parameters.

The Association Between the Severity of Psoriasis and Obesity Based on the Analysis of Visceral Fat Index and Serum Levels of Tumor Necrosis Factor-α, Interleukin-6, and Resistin.

Aim of this study was to investigate the relationship between the severity of psoriasis and obesity based on the analysis of the visceral fat index and serum levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and resistin. The study included 50 patients with psoriasis and 30 subjects in the control group. The measured parameters were height, weight, waist circumference, visceral fat index, and serum levels of TNF-α, IL-6, and resistin. The severity of the disease was evaluated using the psoriasis area and severity index (PASI). Visceral fat index was measured using the method of bioelectrical impedance analysis. Serum levels of TNF-α, IL-6, and resistin were correlated with visceral fat index, and the relationship of all these parameters with psoriasis severity was also analyzed. Patients with psoriasis have a significantly higher body mass index, waist circumference, and visceral fat index compared with the control group. Elevated serum levels of TNF-α, IL-6, and resistin, as well as a correlation with psoriasis severity and visceral fat index was also found in the patient group. Visceral fat index was a better indicator of the relationship between psoriasis severity and obesity than waist circumference and body mass index. We concluded that serum levels of TNF-α, IL-6, and resistin could be useful in assessing psoriasis activity and optimizing therapeutic strategies. It is suggested that visceral fat index should be evaluated in all patients with psoriasis, especially before the decision on systemic therapy.

Pyogenic Granuloma of the Proximal Part of a Nail Unit in a Child.

Dear Editor, We present a case of proximal pyogenic granuloma in 4-year-old child. The patient presented to our Department due to a fast-growing lesion on the proximal part of the nail unit. The lesion had appeared over several weeks, and it was extremely painful for the child. On the day of the 1st visit, the lesion was not bleeding but was very painful during examination and photo-documentation. Clinically, it presented as an exogenous tumoral lesion of the proximal 1/3 of the nail, partially exulcerated with one part exhibiting coagulated hemorrhage and with uneven coloration (Figure 1). The lesion was not sharply demarcated. Dermoscopically, the majority of the lesion presented an unspecific dermoscopic structure, orange background color, and matched the criteria for a vascular lesion: few unspecific vessels and hemorrhage. The "sticky fiber" sign was also present (Figure 2). Since the lesion was fast-growing and due to the unspecific dermoscopic appearance, the child was referred to a pediatric surgeon and a complete excisional biopsy of the lesion was performed. The dermoscopy of pyogenic granuloma has been already described (1). The histology report confirmed pyogenic granuloma. Pyogenic granulomas of the nail unit are not a common finding, but our case confirms that even this location can be site of this type of benign lesion. It more commonly found in the periungual region and can be expected due to adverse effects of different kinds of systemic therapies. However, due to differential diagnosis that includes different types of tumors occurring at the nail unit, most importantly amelanotic melanoma and SCC, it is suggested to excise or take a biopsy of this type of lesion to be able to exclude aggressive tumor types, which are very rare but not impossible the in pediatric population (2). In cases of unquestionable diagnosis, several local treatments are available. Since the lesion presented a destructive nature in our case, we decided to perform excisional biopsy followed by histology, which in our case was both a diagnostic and therapeutic procedure.

Dermoscopic Features of Twin Melanomas of the Lower Leg: A Case Report.

Multiple primary malignancies, including melanoma, usually present singly over time rather than simultaneously. Hovewer, approximatelly one third of the patients develop multiple primary melanomas. We present a case of a 57-year-old woman, with two grossly suspicious, unevenly pigmented lesions on her left lower leg measuring up to 8 and 11 mm. Dermoscopy of both lesions showed similar findings with complete asimmetry of colour and structure. More than four colours including milky red and accumulation of pigment at 1 o'clock were observed in the smaller lesion. Dermoscopy of the largest lesion showed more than 3 colours, milky-red areas, and a slight blue-white veil. Histopathology of both lesions revealed melanoma. Although uncommon, multiple primary melanomas do appear. Careful dermoscopical evaluation of all lesions is mandatory in order to not miss such cases.

Contact Sensitivity in Patients with Atopic Dermatitis.

Atopic dermatitis (AD) is a common chronic and relapsing, non-contagious inflammatory skin disorder, characterized by skin barrier impairment and baseline immune irregularities. The literature on the relationship between AD and cutaneous delayed-type hypersensitivity is inconclusive. There is an ongoing debate whether contact sensibility (CS) is found more or less often among patients with AD. Aim of the study was to evaluate the incidence of contact sensitivity (positive patch test reactions) in patients with and without AD. We patch tested a total of 2143 patients (563 men and 1580 women). There were 226 patients with history of AD; 61 (27%) men and 165 (73%) women. The patient group without AD consisted of 1917 patients, 502 (26%) male and 1415 (74%) female patients, who were referred to our Department with clinical suspicion of allergic contact dermatitis (ACD). A patch test was performed with the baseline series, and readings were performed on days D2, D3, and D7. Among patients with AD, 109 (48.2%) had a positive patch test reaction to at least one allergen, whereas 1094 (57.1%) patients with no history of AD had a positive patch test reaction. The most common positive allergens in patients with AD were nickel (II) sulfate (13.3%), thimerosal (12.4%), cobalt (II) chloride (11.5%), methylisothiazolinone (MI) (8.4%), fragrance mix I (6.6%), potassium dichromate (5.3%), methyldibromo glutaronitrile (4.0%), and carba mix (4.0%). The results of our study agree with previous findings that there is no significant difference in prevalence of CS between the atopic and nonatopic populations.

Nonallergic hypersensitivity to nonsteroidal antiinflammatory drugs, angiotensin-converting enzyme inhibitors, radiocontrast media, local anesthetics, volume substitutes and medications used in general anesthesia.

Urticaria and angioedema are common allergic manifestations and medications are one of common triggering factors. The most severe immediate drug reaction is anaphylaxis. Apart from the well established IgE-mediated immediate type hypersensitivity reactions, the pathogenesis of drug-induced urticaria, angioedema and anaphylaxis often remains obscure. In this article, emphasis is put on nonallergic reactions to the most commonly used drug groups of nonsteroidal antiinflammatory drugs, angiotensin-converting enzyme inhibitors, radiocontrast media, volume expanders and drugs used in general anesthesia. Urticaria is the second most common drug eruption after maculopapular exanthema. The mechanisms of acute urticarial reactions are multiple, mostly IgE mediated, but some drugs can induce immune complex reactions and activate complement cascade, while others can induce direct activation of mast cells and degranulation or activation of complement by non-immune mechanisms. With different types of medications different pathomechanisms are involved. Non-steroid anti-inflammatory drugs are thought to cause reaction due to cyclooxygenase-1 inhibition and overproduction of leukotrienes, blamed for cutaneous and respiratory symptoms. Angiotensin-converting enzyme inhibitors can cause fatal angioedema, which is partially explained with bradykinin excess and impairment of aminopeptidase P and dipeptidyl peptidase IV that are involved in the metabolism of substance P and bradykinin. It remains unknown what additional mechanisms are involved. Radiocontrast media and local anesthetics mostly cause nonallergic hypersensitivity reaction, but in rare cases true allergic reaction can occur. Dextran is known to cause IgG mediated, immune complex anaphylaxis and it is recommended to use human serum albumin as the safest colloid.

Treatment of chronic urticaria.

Urticaria is a disorder characterized by rapid onset of localized swelling of the skin or mucosa, called wheals or urtica. According to frequency and duration, urticaria can be divided into acute and chronic type. Chronic urticaria is any type of urticaria occurring every day or twice per week, lasting longer than 6 weeks. Chronic urticaria is a common disorder and estimated prevalence is 1% of the population. Also, it is not rare in childhood. The pathogenesis of chronic urticaria has not yet been completely understood. Chronic urticaria is a heterogeneous group of disorders, and according to the etiology and cause, several groups of chronic urticaria are distinguished, i.e. autoimmune, pseudoallergic, infection-related, physical urticaria, vasculitis urticaria and idiopathic urticaria. Treatment and management of chronic urticaria can be non-pharmacological and pharmacological, and sometimes it is not possible to control the disease with antihistamines only, which are considered to be the mainstay of treatment. In severe cases of chronic urticaria, especially if autoimmunity has been proven, several authors describe different modules of immunomodulation: cyclosporine, cyclophosphamide, mycophenolate-mofetil, omalizumab, plasmapheresis, systemic corticosteroids, and immunoglobulin therapy. This article primarily addresses the treatment of chronic idiopathic and autoimmune urticaria.

Dermatologic medication in pregnancy.

In female body, a vast number of skin changes occur during pregnancy. Some of them are quite distressing to many women. Therefore, performing treatment for physiologic skin changes during pregnancy with antiinfective agents, glucocorticosteroids, topical immunomodulators, retinoids, minoxidil, etc., is discussed. Drug administration during pregnancy must be reasonable.

The incidence of basal cell carcinoma in Croatia: an epidemiological study.

The aim of the study was to investigate the basal cell carcinoma (BCC) incidence in Croatia in the 2003-2005 period. Data were collected from University Department of Dermatology and Venereology, Zagreb University Hospital Center and National Cancer Registry. The age-specific incidence rate and age-standardized incidence rate were calculated per 100,000 inhabitants according to the latest population census in Croatia from 2001. In the study period, there were 7,244 BCC cases (3,519 men and 3,725 women) in Croatia. The crude incidence rate for the Croatian population of 100,000 was 54.9 for men and 53.9 for women. The age-standardized incidence rate (adjusted for the world standard population) was 33.6 for men and 24.5 for women. The head and neck were almost exclusive localizations of BCC. The highest BCC incidence was recorded in Zadar County. The incidence of BCC was high in both littoral and inland counties of Croatia. Study results will serve as reference figures on studying the trend of BCC incidence in Croatia and Europe in the forthcoming years.

Occupational Airborne Contact Dermatitis Caused by Omeprazole.

Airborne contact dermatitis (ACD) is a frequent condition, and there has been increasing recognition of the occupational origin of airborne contact dermatitis. ACD caused by drugs is often occupation-related and occurs mainly in healthcare workers who use the drugs for therapeutic aims and employees of pharmaceutical industries involved in the production of the drugs (1). Omeprazole (OM) is a proton pump inhibitor from the benzimidazole group used for treatment of gastric acid-related disorders (2). A 52-years-old female chemist had been working in a pharmaceutical company for 20 years. When working in the laboratory, she wore protective latex-free gloves, a mask, and glasses. Skin lesions started 6 months after she had started working in an analytic laboratory with omeprazole and azithromycin. Whenever omeprazole was being manufactured, the patient presented with eczema with scaling on the eyelids, face, and neck, with the hands subsequently being affected as well. The patient's skin lesions cleared during holidays and sick leave and worsened when she was working in omeprazole production. Topical corticosteroids were applied, which resulted in temporally regression of skin symptoms. We performed patch tests with the baseline series (Chemotechnique Diagnostics, Vellinge, Sweden, and Imunoloski zavod, Zagreb, Croatia) to materials in the patient's workplace and a lymphocyte transformation test (LTT) to omeprazole. All tests were negative, except the patch test to OM which showed a positive reaction (+) to 0.1% OM in saline solution on day (D) 2 and D3 and positive reaction (+) to 0.5% OM in saline solution on D2 and ++ on D3 (Figure 1). Hausen et al. performed experimental animal studies in which they concluded that OM and other proton pump inhibitors constitute a high-sensitizing-potential group (3). However, when administrated, orally or parenterally, the frequency of contact sensitization was low (3). Although direct contact with the skin was not always present, distribution of the dust containing OM through the air and deposition on exposed areas may result in ACD. The first two occupational cases of ACD caused by OM among pharmaceutical workers were reported in 1986 (4). Since then, ACD caused by OM in an occupational setting has been reported occasionally (2,4-6). Other proton pump inhibitors such as lansoprazole and pantoprazole have less pronounced potential to cause ACD (7,8). Ghatan et al. conducted a study in 2014 in an occupational setting with 97 workers and reported 31 positive LTT tests and 28 positive patch tests; these results confirm a high risk of sensitization to OM from occupational exposure (6). Although direct contact with the skin is not always present, it is important to bear in mind that distribution of dust containing OM through the air and deposition on exposed areas may result in ACD.

Epidemiology of nonmelanoma and melanoma skin cancer in Zagreb, Croatia.

The purpose of this retrospective and hospital-based study was to evaluate the epidemiology of nonmelanoma and melanoma skin cancer at University Department of Dermatology and Venereology, Zagreb University Hospital Center and School of Medicine during the 2003-2006 period. The study yielded population based results on 2911 cases of skin tumors in 2402 patients out of 16938 biopsies performed at Laboratory of Dermatologic Histopathology, University Department of Dermatology and Venereology, Zagreb University Hospital Center nd School of Medicine during the study period. All newly diagnosed invasive and in situ skin cancers were recorded by use of the histopathology record forms. Basal cell carcinoma was most commonly identified in the histopathology material (n=2002), followed by squamous cell carcinoma (n=533), melanoma (n=46) and cutaneous lymphoma (n=35). Other, less common tumors were noted. The number of tumors, and differences in age, sex and localization were analyzed. During the study period, there was no increase in the total number of cases recorded: 4305, 4202, 4116 and 4315, respectively. Study results showed skin tumors to be mostly diagnosed in elderly population (median age, 71 years). There were no significant sex differences, with the exception of the adult age group in 2006. As expected, skin tumors were mostly found in sun-exposed areas with some specific localization of individual tumor types. Study results were consistent with recent literature data.

Atypical Nevi in a Patient After Toxic Epidermal Necrolysis.

Dear Editor, There are few literature data about nevi in patients with a history of toxic epidermal necrolysis (TEN) and little recommendations for follow-up and risks of melanoma (MM). Eruptive melanocytic nevi (EMN) is a rare phenomenon that has been associated with bullous disorders, immunosuppression, and immunodeficiency, but in some cases can occur without precipitating factors (1). The etiology is largely unknown, but there is evidence that immunosuppression might play a crucial role in nevogenesis, probably due to the inability of the immune system to inhibit melanocytic (MC) proliferation (2,3). We report the follow-up of a patient with a history of TEN who later developed atypical nevi. A 17-year-old man with a history of severe TEN two years earlier, most probably due to valproic acid and diclofenac, was referred to our Department due to atypical nevi. The patient presented with scars, scattered pigmentation (Fig. 1), and symblepharon as a consequence of TEN (Fig. 2). Most of his nevi developed in following two years after TEN. During the first visit in 2009, clinical and dermoscopic photodocumentation was performed. The patient presented with a moderate number of nevi (Fig. 3), dermoscopically subclassified as globular. One atypical MN was found on the back, with dermoscopic findings of reticular pattern and presence of suspected areas of regression (Fig. 4. a, b), and it was excised to rule out melanoma (Fig. 4, Fig. 5). The patient did not come to regular follow-up from 2009 to 2014, and presented in 2014 which was when comparative photo documentation was made. As this visit another, speckled type of newly-occurred nevus was excised. Both excised nevi were histopathologically characterized as dysplastic. Only a few references are available on nevi development after TEN. Anticonvulsives and NSAIDs, as in our case, are often involved in the etiopathogenesis of TEN (4,5). Survivors may experience a variety of long-term complications; authors reported that 19% of their patients developed new nevi after TEN (6,7). EMN develop several years after TEN as a suddenly arising large number of nevi that may resemble speckled lentiginous nevi (8). Histologically. EMN demonstrate a proliferation of MC at the dermo-epidermal junction and, if compound, in the papillary dermis, arranged mostly in nests. Junctional MC may appear slightly pleomorphic, but no significant cytological atypia or prominent pagetoid spread of MC was reported (9). EMN have been associated with a specific dermoscopic finding of a symmetrical peripheral rim of globules which represent pigmented junctional nests of MC in the periphery and are a specific feature of rapidly enlarging MC nevi (10,11). The pathogenesis of EMN is not known. The microenvironment of epidermal regeneration may have some effects on MC because MC hyperplasia develops after cutaneous trauma (observed in recurrent nevi). The cytokines and growth factors produced and secreted during epidermal regeneration might contribute to the proliferation of residual epidermal MC and subsequent nevus formation (12). Because most of the bullous disorders associated with EMN are transient, the authors believe that changes in local growth factors may also be temporary and MN remain stable without a propensity to malignant degeneration without further stimuli (13). This is corroborated by the fact that no reports of malignant change of EMN in patients with bullous disorders have been described. It is likely that the etiology and natural course of EMN differs between two main populations of patients, with EMN arising after bullous disorders being more likely to remain benign compared with those with ongoing immunosuppression, but this hypothesis has yet to be proven. The actual risk of MM in patients with EMN remains unknown. Since our patient did not have many nevi, he does not fit into the EMN category. Due to the atypical appearance of his nevi, long-term follow-up on 6-month basis is recommended.