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Presentation

Pigmentary and Neoplastic Skin Conditions in Asian Patients: Key Clinical Pearls and Differential Diagnoses

Description

The talk reviewed four Asian-patient dermatology cases and highlighted key diagnostic pearls. First, zosteriform lichen planus in a South Asian patient presented as violaceous, blaschkoid or zosteriform papules with perifollicular violaceous hue and scale on dermoscopy; in Asian patients, lichen planus may appear more violaceous or hyperpigmented, so scalp and mucosal exam are important and early, aggressive treatment helps limit postinflammatory hyperpigmentation. The speaker also discussed lichen planus pigmentosus, a common cause of violaceous-brown patches on the face, neck, upper back, and axillae in South Asians, noting that laser therapy can help but must be done cautiously with low fluence, minimal frosting or erythema, reassessment every 4–6 weeks, pretreatment, and stabilization first. Second, pigmented basal cell carcinoma is especially important in Asian patients because it is often the most common skin cancer and can mimic seborrheic keratosis or even melanoma; clues include blue-gray or brown-black globules, ovoid nests, leaf-like structures, pearly borders, bleeding, or microerosions, and early biopsy allows small lesions to be excised promptly. Third, a nonspecific nasal papule or plaque with bleeding, discharge, facial destruction, or ulceration should raise concern for extranodal NK/T-cell lymphoma, nasal type, which is more common in Asians; pathology often shows angiocentric tumor infiltrates and EBV testing is important, with urgent oncology referral needed. Finally, violaceous-brown dermal papules on the face, neck, or trunk with minimal epidermal change should suggest cutaneous plasmacytosis, which may be associated with systemic plasmacytosis, IgG4-related disease, or Castleman disease, so biopsy and workup including IgG4 and possibly IL-6 are recommended. Overall, the key message was to use Asian ancestry as a major clue in the differential for these pigmentary and neoplastic skin conditions.

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Conclusions

In Asian patients, lichen planus may present atypically as violaceous or hyperpigmented, zosteriform, or scalp-involving disease, so clinicians should examine mucosa and hair-bearing areas carefully and treat early to reduce postinflammatory hyperpigmentation.
Lichen planus pigmentosus in South Asian patients can be difficult to treat, and the presentation suggests that cautious use of low-fluence laser therapy with pretreatment stabilization may be helpful but usually requires multiple sessions.
Pigmented basal cell carcinoma is especially important to recognize in Asian patients because it is common, often pigmented, and may appear as a subtle crusted or nonspecific lesion that mimics seborrheic keratosis or melanoma.
When pigmented basal cell carcinoma is well defined, earlier biopsy and smaller excision margins may be sufficient, supporting the value of early detection for surgical management.
A rapidly progressive nasal mass in an Asian patient should raise strong concern for extranodal NK/T-cell lymphoma, nasal type, because delayed diagnosis can lead to destructive midline disease and poor outcomes.
Extranodal NK/T-cell lymphoma often shows EBV positivity, angiocentric histology, and requires urgent referral to oncology, although EBV-negative cases can still occur and may be more common in Asian patients.
Violaceous-brown dermal papules on the face, head, neck, or trunk in middle-aged East Asian patients should prompt consideration of cutaneous plasmacytosis.
Cutaneous plasmacytosis may be associated with systemic plasma cell disease, IgG4-related disease, or Castleman disease, so elevated IgG4 or IL-6 levels should trigger broader systemic evaluation and hematology referral.
Overall, the key message is that pigmentary and neoplastic skin conditions can look different in Asian patients, so recognition of ethnic- and site-specific clues can substantially improve diagnosis and outcomes.

Wang W. Oncol Lett. 2020;20(3):2665-2676
Wang W. Oncol Lett. 2020;20(3):2685-2676