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Melanocytic nevi changes during pregnancy: What to do?

2024; Elsevier BV; Linguagem: Inglês

10.1002/ijgo.15843

1879-3479

Matteo Bevilacqua, Giorgia Salvia, Marco Romanelli, Giovanni Bagnoni, Giulia Ciccarese, Francesco Drago, Agata Janowska, Cristian Fidanzi,

Nonmelanoma Skin Cancer Studies

Women experience multiple skin changes during pregnancy, which are primarily physiological.1 These modifications predominantly involve alterations in skin pigmentation, characterized by a tendency towards hyperpigmentation.1 Increased levels of beta and alpha-melanocyte-stimulating hormones, estrogen, progesterone, and b-endorphin contribute to this phenomenon.2 It has been shown that nevi exhibit sensitivity to estrogens, with the prevailing estrogen receptor in normal nevi, dysplastic nevi, and malignant melanomas being the estrogen receptor beta (Erβ).2 Previous studies have documented various instances of clinical and dermatoscopic modifications in pre-existing nevi during pregnancy.3 However, the exact relationship between pregnancy, nevi changes and the occurrence of melanomas is not yet fully understood. This underscores the critical role of gynecologists in discerning when modifications in melanocytic lesions hold significance and determining the appropriate timing for a dermatology consultation. We present the case of a 31-year-old woman who consistently attended annual nevi check-ups with videodermoscopy at our clinic. The patient had a skin phototype 2 with an overall nevi count <30. Personal and family history were negative for melanoma and other non-melanoma skin cancer. She did not take any drugs and no comorbidities were present, but she reported a few sunburns during childhood. In March 2022 3 months after delivery, during a follow-up visit, the clinical and dermatoscopic images of a paraumbilical flat pigmented lesion were collected and stored in the standardized digital system of our clinic; the lesion was symmetric, with slightly irregular borders and a diameter of 3.3 mm (Figure 1a); the dermatoscopic pattern revealed a thick reticular network with small globules on a homogenous hyperpigmented background (Figure 1b). The patient reported a progressive increase in size and pigmentation of the lesion especially during pregnancy. When comparing it to the clinical and dermatoscopic images taken in April 2021 gestational age 8+3 (Figure 1c), significant changes were observed. Remarkably, the nevus had visibly increased in size (more than 1 mm), and its pigmentation had intensified. Furthermore, regular streaks had developed around the periphery of the nevus. Due to the substantial changes observed over a brief period, and the suspicion that it might be a malignant neoplasia, a biopsy of the lesion was performed. Histologic examination determined the melanocytic lesion to be benign and defined it as a compound melanocytic nevus. Changes in nevi during pregnancy have been extensively reported in the literature.1 Melanoma is thought to be the most common malignancy during pregnancy.4 The incidence of pregnancy-associated melanoma is 45.7 per 100 000 maternities.5, 6 Several hypotheses exist concerning the potential impact of pregnancy on the development of melanoma, even though there is no solid evidence that pregnancy is a risk factor for this skin cancer. It has been suggested that the mechanisms associated with immune tolerance between the mother and the fetus may facilitate increased cancer tumorigenesis during pregnancy.7 Furthermore, sex hormones are linked to increased melanocytes and melanin production even though their impact on melanoma progression remains unclear.2 It is hypothesized that the expression of estrogen receptor beta (ERβ) might be correlated with melanoma pathogenesis.2 Obstetric and Gynecology (OB-GYN) specialists are the first medical professionals who are most likely to deal firsthand with nevi changes in pregnant women. Among the changes reported during pregnancy, the most frequent is an increase in the size of nevi. A statistically significant difference in the diameter of nevi between the first and the third trimester of pregnancy was described, theorizing a correlation with skin expansion during pregnancy.3 Nevi changes can occur any time during pregnancy but because of the sustained high hormone levels over time, they tend be more relevant during the second and third trimesters.1 Additional variations in color and alteration of dermatoscopic patterns have been reported in the literature.3 In our case, the nevus changes over time were objectively appreciated by videodermoscopy showing an increase in diameter and pigmentation associated with dark globules of various shapes and thickening of the network. This clinical case provides evidence of the notable modifications that nevi can undergo during pregnancy. The extent of the observed changes raised concerns about the potential development of cutaneous melanoma, prompting the decision to conduct an excisional biopsy. However, the significance of dermatoscopic changes remains not fully understood. Even though the nevus had modified remarkably, the histology report still revealed a benign lesion. Despite the increased incidence of melanoma during pregnancy, our case suggests that not every pigmented lesion undergoing changes during pregnancy is malignant.4 The main aim of this report is to emphasize the importance for gynecologists to closely monitor changes in nevi during pregnancy. While a moderate increase in size is expected, modifications in pigmentation and dermatoscopic patterns may necessitate a consultation with a dermatologist. The ABCDE rule may be applied by an OB-GYN specialist to detect suspicious lesions.8 The ABCDE rule was originally introduced by dermatologists to help primary care physicians recognize important macroscopic changes in skin lesions.8 Each letter represents a pivotal parameter to be assessed specifically "Asymmetry," "Border" irregularities, "Color" changes, "Diameter" ≥6 mm, and "Evolution" over time.8 While this case underscores the caution against automatically interpreting changes in these lesions as indicative of malignancy, it remains crucial to promptly conduct a biopsy when there is a shift in dermatoscopic characteristics of a pigmented lesion during pregnancy to not miss a melanoma diagnosis. Matteo Bevilacqua, Giorgia Salvia, Marco Romanelli, Giovanni Bagnoni, Francesco Drago, Giulia Ciccarese, Agata Janowska and Cristian Fidanzi: Made substantial contributions to the conception and design of the work, were responsible for the acquisition, analysis, and interpretation of data, contributed to the draft of the work, took part in the final revision and approved the submitted version. They agree to be personally accountable for their own contributions and all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. None. The authors confirm there are no conflicts of interest. The authors confirm that the data supporting the findings of this study are available from the corresponding author on request.