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Indian Journal of Dermatology
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Table of Contents 
CASE REPORT
Year : 2014  |  Volume : 59  |  Issue : 2  |  Page : 193-194
Squamous cell carcinoma in a patient with vitiligo of photo-covered skin


1 Department of Dermatology, Vivekananda Institute of Medical Sciences, Kolkata, India
2 Department of Dermatology, Anandloke Hospital and Neurosciences Centre, Siliguri, Darjeeling, West Bengal, India

Date of Web Publication21-Feb-2014

Correspondence Address:
Amit Kumar Agarwal
G2, Block A, Vandana Apartment, New Milanpally, Siliguri, Darjeeling, West Bengal - 734 005
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.127685

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   Abstract 

Ultraviolet radiation is an important risk factor for the development of skin cancers. Melanin is known to protect the skin against harmful effects of ultraviolet radiation. Hence, vitiligo patients are at higher risk of developing such malignancies. But few reports of occurrence of skin cancers in vitiligo lesions suggest that their occurrence in vitiligo is rare. There are reports of development of Squamous cell carcinoma (SCC) in vitiligo lesions, following long-term Psoralen and Ultraviolet-A (PUVA) therapy. But there are no reports of occurrence of SCC in a vitiligo patch located in photo-covered area. We describe a patient with SCC in a vitiligo patch present in photo-covered skin.


Keywords: Squamous cell carcinoma, ultraviolet radiation, vitiligo


How to cite this article:
Gangopadhyay A, Das JK, Agarwal AK. Squamous cell carcinoma in a patient with vitiligo of photo-covered skin. Indian J Dermatol 2014;59:193-4

How to cite this URL:
Gangopadhyay A, Das JK, Agarwal AK. Squamous cell carcinoma in a patient with vitiligo of photo-covered skin. Indian J Dermatol [serial online] 2014 [cited 2017 Sep 22];59:193-4. Available from: http://www.e-ijd.org/text.asp?2014/59/2/193/127685

What was known?
1. UVR is the most important risk factor for development of SCC. 2. Melanin is known to protect the skin against harmful effects of UVR. 3. SCC is known to develop in photo-exposed Vitiligo patch.



   Introduction Top


Ultraviolet radiation (UVR) is now recognized as the most important risk factor for the development of Squamous cell carcinoma (SCC). [1] Patients with vitiligo often have no protective pigment in the depigmented skin. Moreover, with severe oxidative stress due to accumulation of millimolar epidermal hydrogen peroxide, it would be expected that these patients develop a higher risk for early photo-damage and SCC. [2],[3] But, sporadic case reports of occurrence of SCC in vitiligo lesions [4],[5] suggest that development of SCC in vitiligo is rare. There have been increased reports of development of SCC in vitiligo lesions, following long-term PUVA therapy. [6] But there are no reports of occurrence of SCC in a vitiligo patch located in photo-covered area. We describe a patient with SCC in a vitiligo patch present in photo-covered skin.


   Case Report Top


A 65-year-old woman with Fitzpatrick type V skin presented with an asymptomatic keratotic papule in the right knee. She had a single focal vitiligo patch in the right knee for 10 years. There was no family history of vitiligo. As the patch was in a covered area, she did not take any specific treatment for it. She had no history of excessive sun exposure, x-irradiation, or chronic arsenic exposure. The keratotic papule was first noticed 6 months before presentation to us. It grew insidiously to attain the current size in 6 months. Physical examination revealed a round keratotic papule of 1.5 cm in diameter [Figure 1], with irregular surface and firm to hard consistency. The papule was non-tender with no sign of ulceration. The lesion was not fixed to the underlying tissue. There was no significant regional lymphadenopathy. Routine blood investigations, X-ray of chest and right knee were normal. A provisional diagnosis of SCC was made with seborrheic keratosis and keratoacanthoma as differential diagnosis. Excisional biopsy with 5 mm margin on all sides was performed. Histopathological examination of the specimen revealed hyperplastic epidermis with well-differentiated horny pearls in the dermis [Figure 2]a and b. The diagnosis of SCC was made and the patient was referred to an oncologist, who suggested no further treatment. Follow-up examination done 6 months after the biopsy revealed that the area had healed uneventfully, with no signs of recurrences or new lesions.
Figure 1: Keratotic papule in a vitiligo patch, present in the right knee

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Figure 2: (a) Hyperplastic epidermis with invasion of the dermis by irregular mass of tumor cells and horny pearl (H and E, ×40), (b) Well-differentiated SCC showing differentiated keratinocytes surrounding the horny pearl (H and E, ×100)

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   Discussion Top


Vitiligo is a common acquired disorder characterized by well-circumscribed depigmented macules devoid of melanocytes. Melanin pigment is known to protect the skin against harmful effects of UVR. Absence of melanin along with severe oxidative stress increases the risk of photodamage and development of SCC. [2],[3] However, reports of skin cancer in vitiligo patients are few. One probable explanation of low incidence of actinic damage and SCC in vitiligo is the protective function of up-regulated wild-type p53. [2],[3] It has been postulated that hyperkeratosis in vitiligo may offer as an efficient photoprotection as the normal stratum corneum in pigmented skin. [7] Also, photo-adaptation and the rate of repair of UVB-induced DNA damage in vitiliginous skin is equivalent to that in normal skin. [8] In our patient, SCC developed in a long-standing vitiligo patch present in an area which was protected from sunlight due to the draping of saree, the traditional dress of Indian women. The patient might have chronic exposure to sunlight, but she may deny that fact due to cultural reasons. With this report, we want to emphasize that even though the occurrence of SCC may be rare in vitiligo patches, there may be a subset of patients with vitiligo who are at risk of developing skin cancer. This population may increase in size with increased usage of phototherapy in the management of vitiligo.


   Acknowledgments Top


List all contributors who do not meet the criteria for authorship, such as a person who provided purely technical help, writing assistance, or a department head who provided only general support. Financial and material support should also be acknowledged.

 
   References Top

1.Mackie RM, Quinn AG. Non-melanoma skin cancer and other epidermal skin tumours. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 7 th ed. Oxford: Blackwell Science; 2004. p. 36.2-5.  Back to cited text no. 1
    
2.Schallreuter KU, Behrens-Williams S, Khaliq TP, Picksley SM, Peters EM, Marles LK, et al. Increased epidermal functioning wild-type p53 expression in vitiligo. Exp Dermatol 2003; 12:268-77.  Back to cited text no. 2
    
3.Schallreuter KU, Tobin DJ, Panske A. Decreased photodamage and low incidence of non-melanoma skin cancer in 136 sun-exposed Caucasian patients with vitiligo. Dermatology 2002; 204:194-201.  Back to cited text no. 3
    
4.Akimoto S, Suzuki Y, Ishikawa O. Multiple actinic keratoses and squamous cell carcinomas on the sun-exposed areas of widespread vitiligo. Br J Dermatol 2000;142:824-5.  Back to cited text no. 4
[PUBMED]    
5.Seo SL, Kim IH. Squamous cell carcinoma in a patient with generalized vitiligo. J Am Acad Dermatol 2001;45:S227-9.  Back to cited text no. 5
    
6.Buckley DA, Rogers S. Multiple keratoses and squamous carcinoma after PUVA treatment of vitiligo. Clin Exp Dermatol 1996;21:43-5.  Back to cited text no. 6
    
7.Gniadecka M, Wulf HC, Mortensen NN, Poulsen T. Photoprotection in vitiligo and normal skin. A quantitative assessment of the role of stratum corneum, viable epidermis and pigmentation. Acta Derm Venereol 1996;76:429-32.  Back to cited text no. 7
    
8.Hexsel CL, Mahmoud BH, Mitchell D, Rivard J, Owen M, Strickland FM, et al. A clinical trial and molecular study of photoadaptation in vitiligo. Br J Dermatol 2009;160:534-9.  Back to cited text no. 8
    

What is new?
SCC can very rarely develop in patient with Vitiligo of photo-covered skin.


    Figures

  [Figure 1], [Figure 2]



 

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    Abstract
   Introduction
   Case Report
   Discussion
   Acknowledgments
    References
    Article Figures

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