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Café au lait macules (CALMs) are flat, pigmented brown spots on the skin. They may not necessarily be present right at birth but usually first occur in infancy and early childhood.

When do we worry?

Having one or two café au lait is not uncommon. However, having 6 or more (>0.5 cm in children or >1.5 cm in adults) may herald an underlying genetic condition known as Neurofibromatosis (NF) Type 1. Up to 50 % of patients with NF 1 do not have a family history. There are also a number of other syndromes that may also be associated with CALMs.

How do we treat?

If the patient does not have any other signs to suggest an underlying syndrome, and cosmesis is of concern, we can consider laser treatment to lighten the CALMs. Response is variable and there is always a potential for the CALMs to recur or darken with laser treatment.

Reference

1. Artzi O et al. Picosecond 532 nm neodymium-doped yttrium aluminium garnet laser – a novel and promising modality for the treatment of café au lait macules. Lasers Med Sci 2018;33:693-697.

An epidermal nevus is an overgrowth of the epidermal layer of skin. Half of them can be present at birth and the other half may develop during childhood. It tends to follow the lines of Blashko.

When do we worry?

It can be part of a syndrome if associated with neurological, skeletal and eye abnormalities.

How do we treat?

If cosmesis is of concern, we can cauterise or laser these lesions.

Congenital melanocytic nevi (CMN) are moles that are present at birth or become visible during the first year of life.

They enlarge with the child and are classified as small, medium, large or giant based on their projected final adult size.

When do we worry?

Location

-Over the lower back/ buttock/ garment location as there is higher association with neurocutaneous melanosis
-This in turn leads to neurodevelopmental disorders and risk of leptomeningeal melanoma

Size

-Large/Giant CMN have higher risk of melanoma

Satellite nevi

-Large CMN and more than 20 satellites had a 5.1 fold increased risk of neurocutaneous melanosis compared with large CMN with 20 or fewer satellites. 1

How do we treat?

If cosmesis is a concern, treatments with carbon dioxide laser or surgery can be performed. More than anything, sun protection and being familiar with the ABCDE (asymmetry, border irregularity, colour variegation, diameter greater than 0.6 cm, evolution) rule for melanoma skin surveillance is of paramount importance. However, of even greater importance, is to regularly feel the mole for any nodules/lumps. In addition, in children, a modified ABCD (amelanotic, bleeding, bump, colour uniformity, de novo, any diameter) has been introduced to be used together with the conventional ABCDE (asymmetry, irregular borders, varying colours, diameter of more than 6mm and evolving in size, shape or colour) as paediatric melanoma can present differently from adults.2

References

1. Marghoob AA et al. Number of Satellite Nevi as a correlate for neurocutaneous melanocytosis in patients with large congenital melanocytic nevi. Arch Dermatol. 2004;140:171-175.
2. Cordoro KM et al. Paediatric melanoma: Results of a large cohort study and proposal for modified ABCD detection criteria for children. J Am Acad Dermatol. 2013;68:913-925.

Nevus of Ota, otherwise termed as Oculodermal melanosis, is an uncommon brown, bluish grey pigmented birthmark which has a higher predilection for Asians. It usually occurs on one side of the face

It affects females more than males. Up to two thirds present at birth or shortly thereafter, with the remaining third presenting at puberty.

When do we worry?

Location

-If the eyes are affected, melanocytosis may rarely lead to glaucoma

Cutaneous malignant change (4.6%) 1-3

-Presence of subcutaneous nodules as opposed to following the ABCDE rule (asymmetry, border irregularity, color variegation, diameter > 6mm, evolution) to survey for melanoma
-Malignant change can rarely occur within the brain

How do we treat?

If cosmesis is of concern, laser treatment can be performed. Lasers performed in children at a mean age of 3 years old, required fewer treatment sessions and had greater response rates with lower complications compared with adults.4,5 Picosecond lasers have also helped revolutionise the treatment of this condition, with lesser number of treatments, shorter treatment intervals and lesser risk of post inflammatory hyperpigmentation.6 Treatment at an early age before school going age helps with clinical and psychological outcome. Although, recurrence can occur a few years later.

References

1. Patel BC et al. Cutaneous malignant melanoma and oculodermal melanocytosis (nevus of ota): report of a case and review of the literature. J Am Acad Dermatol. 1998;38:862-865.
2. Shaffer D et al. Malignant melanoma in a Hispanic male with nevus of Ota. Dermatology. 1992;185:146-150.
3. Baroody M et al. Extensive locoregional malignant melanoma transformation in a patient with oculodermal melanocytosis. Plast Recontr Surg. 2004;113:317-322.
4. Belkin D et al. Sucessful and safe use of Q-switched lasers in the treatment of Ota in children with phototypes IV – VI. Lasers Surg Med. 2018;15:1:56-60.
5. Zong WK, Tong L. A retrospective study on laser treatment in Nevus of Ota in Chinese Children – A seven year follow up. J Cosmet Laser Therapy. 2014;16:4:156-160.
6. Loh TY, Wu DC. Novel application of the 730 and 785 nm Picosecond Titanium Sapphire Lasers for the treatment of Nevus of Ota. Lasers in Surg and Med. 2021