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An adolescent male with pearly pink papule on scalp
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A 14-year-old male presents to pediatric dermatology for evaluation of a new bump on his scalp. The patient’s mother notes this has been present for a few months and may be slightly growing. The patient denies any pain or pruritus; the lesion does not have a history of bleeding or purulent drainage. He has not had any prior treatment for this lesion. Nine years ago, the patient had chemotherapy and radiation treatment involving the occipital scalp for disseminated medulloblastoma, which has been in remission ever since. There is no personal or family history of melanoma or non-melanoma skin cancer. He has no history of jaw cysts or dental problems.
Shehla Admani
Andrew C. Krakowski
On exam, he is found to have a 2-mm pink pearly papule with telangiectasia on his left parietal scalp. The rest of his cutaneous exam is unremarkable. There is no lymphadenopathy. There is no evidence of palmar or plantar pits or frontal bossing.
Can you spot the rash?
A. Nevus sebaceous
B. Basal cell carcinoma
C. Molluscum contagiosum
D. Congenital nevus
E. Metastatic medulloblastoma
F. Pilar cyst
Diagnosis: Basal Cell Carcinoma
Given the patient’s previous medulloblastoma, immunosuppression and radiation exposure, cutaneous malignancy was highest on our differential, including basal cell carcinoma (BCC) and metastatic medulloblastoma. Morphologically, the lesion in question resembled a classic BCC: a pink pearly papule with telangiectasia.
Less than 2% of all bumps excised from children are found to be a malignant. Although BCCs are the most common form of cancer in the general population, they are rare in children younger than 15 years and usually associated with a predisposing genetic condition such as basal cell nevus syndrome (with its characteristic palmar and plantar pits, frontal bossing and jaw cysts) and xeroderma pigmentosum. In patients without a genetic predisposition, ultraviolet radiation and ionizing radiation, which our young patient had, are risk factors for the development of BCCs.
In the United States, an estimated 14,000 children younger than 20 years are diagnosed annually with a first primary cancer, the majority of which require chemotherapy and/or radiation. Location of the lesion can serve as a telltale sign because the anatomic location of the BCC can be aligned with the location of the primary cancer and prior radiation therapy, as in this patient’s case.
Although the suspicion for other cutaneous malignancies should remain high in this special population, these patients also can develop the same conditions seen in other adolescents. For example, nevus sebaceous, although present from birth, begins to increase in size and can become more prominent during adolescence. These lesions are typically yellow in appearance and often become warty at puberty.
Pearly pink papule on left parietal scalp (left figure). Close-up of basal cell carcinoma demonstrating pearly pink papule with "rolled" borders and telangiectasia (right figure).
Source: Admani S
Molluscum contagiosum lesions present as pearly papules; however, one would suspect more than one single lesion, and these lesions are often — but not always — umbilicated. Side-lighting a molluscum lesion with an otoscope also will frequently reveal a central core, which can help make the diagnosis.
Congenital nevi on the scalp may typically be pinker in appearance than elsewhere on the body; dermoscopy also may be very helpful in elucidating the presence of a pigment network.
Finally, cysts may be seen on the scalp with a characteristic history of increasing in size, but the morphological description of this patient’s lesion is not characteristic of a cyst. More importantly, in a patient with a history of previous neoplasm, immunosuppression and radiation therapy to the involved area, watchful waiting may not be the best option.
The increased index of suspicion in our patient led to a shave biopsy, which showed a BCC. A subsequent re-excision with 2-mm to 3-mm margins cleared the area. The patient now continues to be in full remission from his primary malignancy and has not developed any further cutaneous lesions. He returns every 6 months for follow-up skin exams.
References:
Sasson M. Curr Opin Pediatr. 1996;8:372-377.
Turner CD. J Pediatr Hematol Oncol. 2001;23:247-249.
USCSW Group. United States Cancer Statistics: 1999-2007 Incidence and Mortality Web-based Report. Atlanta, Ga.: Department of Health and Human Services, CDC and National Cancer Institute; 2010.
Watt TC. J Natl Cancer Inst. 2012;104:1240-1250.
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