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Bilateral, Symmetrical, Congenital Becker’s Nevus
Melanosis: A Rare Presentation and Review of the
Literature
Rahaf A. Abdulwahab , Tasneem A. Banjar , Emad A. Alharbi
1. Medicine and Surgery, Umm Al-Qura University, Makkah, SAU 2. Dermatology, King Abdulaziz Hospital, Makkah,
SAU
Corresponding author: Tasneem A. Banjar, tasneem.banjar@gmail.com
Abstract
Becker’s nevus, also known as Becker’s melanosis or Becker’s pigmentary hamartoma, is a concurrent
melanosis first described by S. William Becker. It is a type of acquired hyperpigmentation characterized by
well-defined, unilateral lesions with regular borders. It is associated with hypertrichosis and
hyperpigmented brownish patches with a mean diameter of 15 cm. The shoulder, scapular area, and upper
arms are the most commonly affected areas, but it can occur on any area of the body, including the forehead,
face, neck, lower trunk, extremities, and buttocks. The lesion usually appears around puberty, and males are
more likely to be affected than females.
A 27-year-old male of Arabic descent who was medically free presented to the dermatology clinic
complaining of bilateral, symmetrical, hyperpigmented patches on the upper back. The lesions started
almost at birth, gradually growing in size and darkening in color over time. On local skin examination, the
lesions were bilateral, symmetrical, hyperpigmented patches on the upper back. They were both
homogeneous and brown in color with irregular borders and blotchy hyperpigmented macules on both sides
of the upper back associated with sparse hair development. Histopathological examination revealed
epidermal hyperkeratosis, acanthosis, and focal regular elongation of rete ridges with clubbing. Increased
basal layer pigmentation was noticed. The dermis showed focal areas with pigment incontinence. Based on
the above clinicopathological findings, the patient was diagnosed with Becker’s melanosis. He was referred
to the laser clinic for further treatment.
Categories: Dermatology
Keywords: becker’s nevus, becker’s melanosis, becker’s nevus syndrome, rare case, congenital, case report, bilaterally
Introduction
Becker’s nevus (BN), also known as Becker’s melanosis or Becker’s pigmentary hamartoma, is a concurrent
melanosis first described by S. William Becker. It is a type of acquired hyperpigmentation characterized by
well-defined, unilateral lesions with irregular borders. It is associated with hypertrichosis and
hyperpigmented brownish patches with a mean size of 15 cm. Although it occurs mostly on the shoulders,
scapular area, and upper arms, it can also be found on any area of the body, including the forehead, face,
neck, lower trunk, extremities, and buttocks. It is rare when it appears as a bilateral lesion or in unusual
locations. Males are more prone to be affected than females, with a ratio of 5:1 and a prevalence of 0.5%.
The lesion generally appears around puberty; however, there have been a few reports of BN appearing at
birth or in early infancy. The majority of the cases are sporadic, whereas some are familial [1]. It is associated
with hypertrichosis that generally occurs after hyperpigmentation has been established. Furthermore, BN
occurs in combination with ipsilateral muscular and skeletal defects such as breast hypoplasia, scoliosis,
vertebral defects, and hypoplasia of the muscles in the upper trunk known as BN syndrome (BNS) [1,2]. It is
one of the epidermal nevus syndromes which is a broad phrase to describe epidermal nevi in association
with syndromic features and is quite rare. These connected syndromes share cutaneous, neurologic, skeletal,
and ophthalmologic features [2]. Only a few cases of multiple and bilateral BN have been described in the
literature [3]. Therefore, we present the case of a 27-year-old healthy male with congenital, atypical,
bilateral, symmetrical BN over the upper back.
Case Presentation
A 27-year-old healthy male of Arabic descent presented to the dermatology clinic complaining of bilateral,
symmetrical, hyperpigmented patches on the upper back. The lesions started almost at birth with a gradual
increase in size and darkening in color over years and were associated with the development of
hypertrichosis on the lesions. There were no relieving or aggravating factors and no associated pain, itching,
bleeding, or ulceration. A review of the systems and past medical, surgical, drug, and allergy history were all
unremarkable. There was no family history of any skin diseases or medical or congenital conditions. The
patient’s four siblings were normal, with no active or previous complaints or skin manifestations. The
patient’s antenatal history included normal vaginal delivery with no complications, as well as full-term and
1 1 2
Open Access Case
Report DOI: 10.7759/cureus.34594
How to cite this article
Abdulwahab R A, Banjar T A, Alharbi E A (February 03, 2023) Bilateral, Symmetrical, Congenital Becker’s Nevus Melanosis: A Rare Presentation
and Review of the Literature. Cureus 15(2): e34594. DOI 10.7759/cureus.34594
up-to-date immunization records. The mother was healthy, and she did not receive any medications during
pregnancy. Body, hair, nails, and mucous membrane examinations were normal, and the patient had not
previously received any treatment for this lesion and had not sought medical care. On local skin
examination, the lesions were bilaterally and symmetrically hyperpigmented patches on the upper back,
with the right one measuring 15 × 7 cm (Figure 1) and the left one measuring 17 × 9 cm in diameter (Figure
2). Both were homogeneous and brown in color with irregular borders and blotchy hyperpigmented macules
on either side of the upper back, and they were associated with sparse hair development (Figure 3). There
was no difference in skin texture compared to normal skin. A 4-mm skin punch biopsy was obtained from the
back. Histopathological examination revealed epidermal hyperkeratosis, acanthosis, and focal regular
elongation of rete ridges with clubbing. There was increased basal layer pigmentation. The dermis revealed
focal areas with pigment incontinence. There was no increase in smooth muscle in the dermis or hyperplasia
of the hair follicles (Figure 4). Chest X-ray, spine X-ray, and abdominal ultrasound were done to rule out
systemic involvement, and they were all unremarkable. Based on the above clinicopathological findings, the
patient was diagnosed with Becker’s melanosis. He was referred to the laser clinic for further treatment.
2023 Abdulwahab et al. Cureus 15(2): e34594. DOI 10.7759/cureus.34594 2 of 7
FIGURE 4: The histopathology pictures, epidermal hyperkeratosis,
acanthosis, and focal regular elongation of rete ridges with clubbing.
Increased basal layer pigmentation is noticed. The dermis shows focal
areas with pigment incontinence.
Discussion
BN lesions may develop for a year or two after they first appear before becoming fixed in size. Pigmentation
fades with time, but associated hypertrichosis persists. The specific genetic basis of BN is unknown. Given
the mosaic/regional distribution of BN and the presence of sporadic and familial instances, a dominant
mechanism of inheritance is proposed [1]. According to the literature, there is a disturbance in the androgen
receptor activity in BN, as evidenced by increased androgen receptor density [4,5]. Our case represents a
congenital, bilateral, symmetrical, atypical BN in a male of Arabic descent, not associated with syndromic
features, which is a rare presentation. However, the histopathological features were typical for BN. Bilateral
BN has not yet been documented in Middle Eastern countries; to our knowledge, only one case has been
published by Alhuqayl et al. Table 1 summarizes a literature review of the published case reports with a
similar presentation. To our knowledge, previous recent published studies reported a few cases of
symmetrical or asymmetrical bilateral presentation [3-5]. Multiple and bilateral BN is rarely reported in the
literature, and there are few reported cases in Arabic countries. BN in combination with ipsilateral muscular
and skeletal defects such as breast hypoplasia, scoliosis, vertebral defects, and hypoplasia of the muscles in
the upper trunk is known as BNS [1,2]. BNS is most commonly found around the anterior upper trunk, with
or without hypertrichosis and/or acneiform lesions. Our patient had bilateral, symmetrical BN of both
scapular regions. However, a neurological, genital, and limb examination revealed no abnormalities, and
abdominal ultrasound and skeletal radiographic imaging revealed no abnormalities. Our differential
diagnosis included cafe au lait macules, congenital melanocytic nevus, congenital smooth muscle
hamartoma, and plexiform neurofibroma. All were excluded because of the presence of clinical and
histopathological features of BN. The therapeutic modalities were limited and mainly indicated for cosmetic
reasons. Various types of lasers have been shown to be effective in BN. Two types of lasers are mostly used,
namely, Q-switched ruby lasers and Q-switched Nd-YAG lasers. However, both are associated with a high
recurrence rate [1]. Our patient was referred to the laser clinic for further treatment.
2023 Abdulwahab et al. Cureus 15(2): e34594. DOI 10.7759/cureus.34594 6 of 7
Author Year Sex Age
(years) Duration Site Congenital/Acquired
Current
report 2022 Male 27 Since birth Both scapular regions Congenital
Rao [4] 2021 Male 23 Since birth Both scapular and suprascapular regions, both the
shoulders, arms, and the extensor aspect of forearms Congenital
Alhuqayl et
al. [3] 2019 Female 20 Four years Over the upper back, chest, and breasts Acquired
Yeşilova et
al. [6] 2013 Male 16 Five years Abdominal region Acquired
Grim et al.
[7] 2009 Male 45 Adolescence The front of the chest Acquired
Khatami et
al. [8] 2008 Male 14 Six years Both scapular regions, anterior chest, and upper arm Acquired
Ferreira et
al. [9] 1998 Female 4 Since birth Scapular region, shoulders, and arms Congenital
TABLE 1: Summary of a literature review of seven cases of Becker ’s nevus.
Conclusions
BN is a type of acquired hyperpigmentation characterized by a well-defined, unilateral lesion with irregular
borders. It is associated with hypertrichosis and hyperpigmented brownish patches. It can be found in any
area of the body, but it is rare when it appears as a bilateral lesion. Our case represents a congenital,
bilateral, symmetrical, atypical BN not associated with syndromic features, which is a rare presentation. The
purpose of reporting this case is to increase the understanding of the various manifestations of this disease.
Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
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