Posted by Mitz (Fl) on 11/27/2013. Sun damage is to blame for a wide range of different skin discoloration issues; it causes dark spots — also known as age spots, brown spots, or liver spots — and, of course, contributes to fine lines and wrinkles.. Observations Congenital lingual melanotic macules presented in all cases at birth, followed by proportional growth. Overview. A single, well‐marginated lesion on the trunk, although other sites can be affected. Subependymal giant cell astrocytoma. Chief Editor: Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, December 2014. Progressive macular hypomelanosis showing excellent response to oral isotretinoin. Idiopathic Guttate Hypomelanosis. Tuberous sclerosis - hypopigmented macule. The size of the lesions varies from 1-10mm, but are most commonly 1-3 mm in diameter. 20 (10), pp. Pictures Of Idiopathic Guttate Hypomelanosis. Sim JH, Lee DJ, Lee JS, Kim YC. In addition, it was suggested that poliosis, circumscribed areas of hypomelanosis of hair, be included in the count of hypomelanotic macules. An isolated pattern ... pictures at a constant magnification of 10,000 were Relyveld GN, Dingemans KP, Menke HE, Bos JD, Westerhof W. Ultrastructural findings in progressive macular hypomelanosis indicate decreased melanin production. Kim YJ, Lee DY, Lee JY. It doesn’t involve any change in the thickness or texture of the skin. 153-5. The sun doesn’t only impact those with lighter skin tones however. 24 They number from 1 to over 20. Helpful 0 Not Helpful 0. 734-6. Skin findings that satisfy major features are hypomelanotic macules (≥ 3, at least 5 mm in diameter), angiofibromas (≥ 3) or fibrous cephalic plaque, shagreen patch and ungual fibromas (≥ 2). Hypomelanosis macules usually appear first on the legs. J Dermatol. Other potential problems include leaf spots, cankers, ash flower gall and fall webworm. Macules are flat lesions that are less than 1 cm in size. It is seen firstly in middle-aged, fair-skinned women, but occurs increasingly with age in both sexes as well as dark-skinned individuals with a history of long-term sun exposure. The patches are not scaly, unlike hypopigmented pityriasis versicolor, which can also cause pale patches on the trunk. J Dermatol. Sponsored content: melanomas are notoriously difficult to discover and diagnose. follows rigorous standards of quality and accountability. 1363-4. Subependymal nodule. Tuberous sclerosis, otherwise referred to as Bourneville's disease or tuberous sclerosis complex, is an inherited disease that affects multiple systems. Idiopathic guttate hypomelanosis is most commonly a complaint of middle-aged, light-skinned women, but it is increasingly seen in both sexes and older … Guttate Hypomelanosis Treatment New Update Cure For Idiopathic Guttate Hypomelanosis. Summary: A hyperpigmented circumscribed area of change in normal skin color without elevation or depression of any size. If you have any concerns with your skin or its treatment, see a dermatologist for advice. Shagreen patch. Guttate hypomelanotic macules are usually seen on the outside of the arms and the legs. Progressive macular hypomelanosis in a 16-year old. Ash Leaf Spot. Treatment of Progressive macular hypomelanosis with narrow-band ultraviolet B phototherapy. 15,16 In this … The cause of progressive macular hypomelanosis is not known. Progressive macular hypomelanosis is a common skin condition presenting as circular areas of pale skin (hypopigmentation) mostly located on the trunk. Progressive macular hypomelanosis. Such lesions are called ash-leaf spots because of their resemblance to the leaf of the European mountain ash. Congenital hypomelanotic and hypermelanotic macules symptoms, causes, diagnosis, and treatment information for Congenital hypomelanotic and hypermelanotic macules (Macules, hereditary, congenital hypopigmented and hyperpigmented) with alternative diagnoses, full-text book chapters, misdiagnosis, research treatments, prevention, and prognosis. Some of the causes of the condition may include: 3 Causes of Hypermelanotic Macule: Amish Infantile Epilepsy Syndrome Progressive macular hypomelanosis However, these bacteria have not been found in all patients with progressive macular hypomelanosis. The small white spots (hypopigmented macules) caused by IGH are usually 1 to 3 millimetres (0.039 to 0.118 in) in diameter, and rarely larger than 10 millimetres (0.39 in). Thanks! Photo: Paul Kirtley. Came to me on 04/01/2021 for new onset diabetes detected one week before. Note the hypomelanotic skin, white hair, and pink pupils caused ultimately by the lack of melanin synthesis. Comparison of the clinical efficacy of NBUVB and NBUVB with benzoyl peroxide/clindamycin in progressive macular hypomelanosis. Patients also typically have photophobia, poor visual acuity, and nystagmus from misrouting of optic fibers from the retina to the visual cortex of the brain. The diagnostic criteria for tuberous sclerosis complex include several major and minor clinical features.5 This patient had three major criteria: facial angiofibromas, hypomelanotic macules, and … MRI scans performed when the patient was 3 years of age showed cortical tubers, which are pathognomonic of the disease. Idiopathic guttate hypomelanosis (IGH) is an acquired, benign leukoderma of unknown etiology. Microscopic examination of a skin biopsy shows a reduction in melanin in the the affected skin, with normal numbers of melanocytes (specialised cells that produce melanin). Family history was negative for similar pigmented lesions. Multiple retinal nodular hamartomas. This chapter is set out as follows: Kwah YC, Chong WS, Thiam-Seng Theng C, Goh BK. J Eur Acad Dermatol Venereol. Family history was negative for similar pigmented lesions. The mechanism of tumorigenesis via mTORC1 is well investigated, and the efficacy of rapamycin for treating tumors in TSC has been already reported. Hypomelanotic macules/”ash-leaf spots” (M): small oval or leaf shaped patches of pale/white skin. Angiofibromas or fibrous cephalic plaque Facial angiofibromas occur in about 75% of TSC patients (Fig 2),15,16,18,21 with onset In their report, seizure was noticed in only 15% of the cases before or at initial Hypomelanotic macules are otherwise known as ash-leaf spots due to their resemblance to Sorbus aucuparia, or mountain-ash, leaves. Dermoscopy shows poorly-defined white macules with faint reticular pigmentation. A diagnosis of TSC is established with a recently revised clinical/radiological set of criteria and/or a causative mutation in TSC1 or TSC2 gene. hypomelanotic macules from smaller and more numerous confetti lesions. Contact us to sponsor a DermNet newsletter. (e) Nevus depigmentosus. Naturally a moist bottomland or stream bank tree, it is hardy to climatic extremes and has been widely planted in the Plains States and Canada. With your help, we can update and expand the website. The macules first appear on the legs and later on forearms. 2012; 39(11): pp937-38. I have read all the comments on here and have not heard of anyone having success with treating this with the exception of Teds clients. 1999;79:305-310. Skin Most people with tuberous sclerosis complex (TSC) have changes in their skin. Klaus J. Busam. There may be light colored spots, called hypomelanotic macules, and bumps on the skin of several different types (angiofibromas, cephalic fibrous plaques, shagreen patches, and ungual fibromas). Kuznetsov AV, Flaig MJ, Ruzicka T, Herzinger T. J Clin Pathol 2011 Aug; Vol. cardiac rhabdomyoma, hypomelanotic macules and subcortical brain tubers, fulfilling the ITSCG criteria. They are identified by simply looking at them and touching them. On electron microscopy of affected areas, the melanosomes (the granules that store melanin in the cell) are smaller and aggregated, compared to surrounding skin. It is more common in people of darker skin colour that light skin colour, and may be more common in women than in men. Repigmentation in Progressive Macular Hypomelanosis. Diagnosis: excludes flat warts, Pityriasis alba and pityriasis versicolor. Pediatr Dermatol 2008 Jan-Feb; Vol. The findings indicate that the development of hypomelanotic macules is associated with constitutive activated mTORC1, whereas mild deregulation of mTORC1 allows the maintenance of normal skin. The macules are usually not scaly but focal scale is occasionally seen. Clinical findings were well-circumscribed, brown, single or multiple macules on the tongue, 2 to 5 mm in size, without history of bleeding, ulceration, or trauma. Tuberous sclerosis complex (TSC) is a rare multisystem autosomal dominant genetic disease that causes non-cancerous tumours to grow in the brain and on other vital organs such as the kidneys, heart, liver, eyes, lungs and skin.A combination of symptoms may include seizures, intellectual disability, developmental delay, behavioral problems, skin abnormalities, lung disease, and kidney disease. (e) Nevus depigmentosus. so-called "ash-leaf' shaped. The macules have a brownish color and smooth borders (blue arrow). Note that this may not provide an exact translation in all languages, breadcrumbs Check for errors and try again. The macules are usually not scaly but focal scale is occasionally seen. These white spots are discrete and do not show darker border. ... 1, 2 More on Hypermelanotic macule » Causes List: Hypermelanotic macule. An isolated pattern ... pictures at a constant magnification of 10,000 were They are not preceded by inflammation, unlike postinflammatory hypopigmentation following nummular eczema or psoriasis. Hypopigmented macules of photodamaged skin and their treatment with topical tretinoin. Hypomelanotic macules typically measure 0.5–3.0 cm in diameter. ... 1, 2 More on Hypermelanotic macule » Causes List: Hypermelanotic macule. Right: several white ash leaves Click on an image for further information about it. The macules first appear on the legs and later on forearms. Photo: Paul Kirtley. Progressive macular hypomelanosis: an overview. Right: several white ash leaves Click on an image for further information about it. 3-5 second cryotherapy is effective in idiopathic guttate hypomelanosis. Idiopathic guttate hypomelanosis is most commonly a complaint of middle-aged, light-skinned women, but it is increasingly seen in both sexes and older … Acta Derm Venereol. Jóźwiak S, Schwartz RA, Janniger CK, Michałowicz R, Chmielik J. A single, well‐marginated lesion on the trunk, although other sites can be affected. DermNet NZ does not provide an online consultation service. Acta Derm Venereol. The history of seizures is suggestive of the diagnosis. Some cases may resolve in 3–5 years. 2. Progressive macular hypomelanosis is usually diagnosed by clinical suspicion and supported by the presence of fluorescence on Wood light examination. Progressive macular hypomelanosis — codes and concepts. Now a leukoderma is simply a fancy term for a loss or lack of coloration in the skin. Cortical tuber. Hypopigmented macules of photodamaged skin and their treatment with topical tretinoin. Idiopathic guttate hypomelanosis is most commonly a complaint of middle-aged, light-skinned women, but it is increasingly seen in both sexes and older … A.D.A.M. Kumarasinghe SP. Peter E, et al reported hypomelanotic macules in 94%, sub-ependymal nodules in 90%, cardiac rhabdomyomas in 82% and tubers in 94% of their cases. Overview. Elsevier Health Sciences, 1 Jan 2010. The course of progressive macular hypomelanosis is reported to be variable. Pagnoni A, Kligman AM, Sadiq I, et al. Often, smaller hypopigmented macules arise around the edges; The lesion is hypomelanotic (reduced pigmentation) as opposed to amelanotic (completely white), as seen in congenital vitiligo; … Important differentials to consider include: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. In other cases, the first sign may be white patches on the skin (hypomelanotic macules) or the identification of cardiac tumor rhabdomyoma. Furthermore, the finding establishes the pathogenic effect of the “silent” c.4149C > T substitution and emphasizes the need for awareness when interpreting silent substitutions in general. 1998 Dec;37(12):911-7. Idiopathic guttate hypomelanosis is a common benign acquired disorder characterized by small, well-defined, round white macules on the sun-exposed areas of the legs and forearms. For seizure disorder. 1. Relyveld G, Menke H, Westerhof W. J Eur Acad Dermatol Venereol 2006 Nov; Vol. DermNet provides Google Translate, a free machine translation service. She developed occasional small guttate hypomelanotic macules on her left cheek, a known compli-266 Steroids (both systemic and topical), and topical tacrolimus have been used to treat LPP with little success (2,3,7,8). [Sponsored content]. Differential diagnosis of idiopathic guttate hypomelanosis. The clinical diagnosis of tuberous sclerosis complex (TSC) in this patient is based on the presence of facial angiofibromas and hypomelanotic macules (Figure). As the child gets older, he or she may develop other lesions such as a rash across the cheeks and nose, areas of thickened skin, and … Progressive macular hypomelanosis affects teenagers and adults worldwide. Often, smaller hypopigmented macules arise around the edges; The lesion is hypomelanotic (reduced pigmentation) as opposed to amelanotic (completely white), as seen in congenital vitiligo; … (b) Hypomelanosis in hair of a patient with tuberous sclerosis. Idiopathic guttate hypomelanosis - … See smartphone apps to check your skin. 64 (8), pp. 63-5. Angio fibromas or brous cephalic plaque Hypomelanotic macules are otherwise known as ash-leaf spots due to their resemblance to Sorbus aucuparia, or mountain-ash, leaves. One of the earliest signs of tuberous sclerosis is white skin patches on a baby’s body, called hypomelanotic macules. Summary: A hyperpigmented circumscribed area of change in normal skin color without elevation or depression of any size. Topics A–Z Pictures of the lesions are available in 'Further reading & references', below. The acne bacteria, Cutibacterium acnes, have been found in hair follicles of hypopigmented areas and may cause the loss of colour. Other potential problems include leaf spots, cankers, ash flower gall and fall webworm. Hypo- and hypermelanotic cutaneous macules-retarded growth-intellectual disability syndrome is a rare, genetic pigmentation anomaly of the skin disorder characterized by congenital hypomelanotic and hypermelanotic cutaneous macules associated with, in some patients, retarded growth and intellectual disability. Hypomelanotic macules, more than three. This area of decreased pigment (hypopigmentation) is referred to as an "ash leaf macule" and is seen with the inherited disorder, tuberous sclerosis. Hypomelanosis macules usually appear first on the legs. Hexsel DM. Some of the causes of the condition may include: 3 Causes of Hypermelanotic Macule: Amish Infantile Epilepsy Syndrome Hypomelanotic macules may be either oval (one arrow) or like lance-ovate (two arrows). so-called "ash-leaf' shaped. These white spots are … The condition may relapse following treatment. 2004;31:457-459. Progressive macular hypomelanosis (PMH) is a common skin disorder that is often misdiagnosed. The clinical diagnosis of tuberous sclerosis complex (TSC) in this patient is based on the presence of facial angiofibromas and hypomelanotic macules (Figure). 2004;31:457-459. In addition, it was suggested that poliosis, circumscribed areas of hypomelanosis of hair, be included in the count of hypomelanotic macules. 2007;8(1):13-9. Singh, MD, FICP.. CME INDIA Case Study: For last 3 years, on Oxcarbazepine 300mg bd. Idiopathic guttate hypomelanosis is a common condition characterised by the presence of numerous, small, white macules found predominantly on the shins and forearms. For seizure disorder. Concerning the involvement of other organs, we detected retinal hamartoma in 13 (41,9%), renal angiomyolipoma in 5 (16,1%) and renal cysts in 2 (6,4%). Some studies have reported the use of sirolimus on specific TSC manifestations [ 2 , 3 , 4 ]. » The hair follicles fluoresce with a red glow, indicating they are colonised by P. acnes. Hypomelanotic macules may be either oval (one arrow) or like lance-ovate (two arrows). Most common skin finding in TSC present in up to 98% of patients. Observations Congenital lingual melanotic macules presented in all cases at birth, followed by proportional growth. Renal angiomyolipoma. Idiopathic guttate hypomelanosis (IGH) is an acquired, benign leukoderma of unknown etiology. 3-5 second cryotherapy is effective in idiopathic guttate hypomelanosis. Hello All, I seem to be suffering from this guttate hypomelanosis. Pagnoni A, Kligman AM, Sadiq I, et al. Progressive macular hypomelanosis mainly affects the trunk, rarely extending to the arms, legs and/or neck. Hypo- and hypermelanotic cutaneous macules-retarded growth-intellectual disability syndrome is a rare, genetic pigmentation anomaly of the skin disorder characterized by congenital hypomelanotic and hypermelanotic cutaneous macules associated with, in some patients, retarded growth and intellectual disability. Patches that are lighter in skin tone than the rest of your body’s skin (hypomelanotic macules) Small bumps on your face (angiofibromas or fibrous cephalic plaque) An area of thick, pebbly skin on your back (shagreen patch) Fibrous growths around your fingernails and/or toes (ungual fibromas) Small spots (“confetti” skin lesions) 1999;79:305-310. Hamartomatous rectal polyps. The history of seizures is suggestive of the diagnosis. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. They are off-white and not completely depigmented as in vitiligo. Shagreen patch (M): irregular, rough patch of skin most often located over the lower back or thigh. Minor: Pits in dental enamel. Came to me on 04/01/2021 for new onset diabetes detected one week before. J Eur Acad Dermatol Venereol. Diagnosis: excludes flat warts, Pityriasis alba and pityriasis versicolor. With regrads to skin lesions, we noticed hypomelanotic macules in all 31 patients with tuberous sclerosis (100%), facial angiofibroma in 14 (45,1%) and forehead plaque in 6 (19,3%). There are multiple, circular, poorly defined pale and non-scaly spots that merge together. Naturally a moist bottomland or stream bank tree, it is hardy to climatic extremes and has been widely planted in the Plains States and Canada. Differential diagnosis of idiopathic guttate hypomelanosis. 2008 May;22(5):568-74. These macules have a strong association with tuberous sclerosis and are often multiple and present in the vast majority of individuals with the condition (up to 97% 1).As such the presence of more than three hypomelanotic macules prompts further investigation. nevus anaemicus: mediated by vasoconstriction, achromic nevus: a form of congenital mosaicism, where some melanocytes have a reduced ability to generate melanin. CME INDIA Case Presentation by Dr N.K. is among the first to achieve this important distinction for online health information and services. Singh, MD, FICP.. CME INDIA Case Study: For last 3 years, on Oxcarbazepine 300mg bd. Hypermelanotic macule. Ash leaf spots can resemble nevus depigmentosus, a single, stable, well-circumscribed hypomelanotic macule present at birth. ... (IGH) is a benign and asymptomatic skin manifestation characterized as diffuse hypopigmented macules, or white spots. hypomelanotic macules meet a size requirement of at least 5-mm diameter to distinguish hypomelanotic macules from smaller and more numerous “confetti” lesions. Treatments for progressive macular hypomelanosis include: Isotretinoin was effective in one case report. MRI scans performed when the patient was 3 years of age showed cortical tubers, which are pathognomonic of the disease. If you have any concerns with your skin or its treatment, see a dermatologist for advice. Cardiac rhabdomyoma. 5,28-30 By contrast, only 1 study of hypomelanotic macules has been reported, 22 and the mechanisms and therapeutic approaches to hypomelanotic macules in TSC remain unknown, although these macules are a major feature of TSC. Tuberous sclerosis complex (TSC) is a rare multisystem autosomal dominant genetic disease that causes non-cancerous tumours to grow in the brain and on other vital organs such as the kidneys, heart, liver, eyes, lungs and skin.A combination of symptoms may include seizures, intellectual disability, developmental delay, behavioral problems, skin abnormalities, lung disease, and kidney disease. Idiopathic guttate hypomelanosis (IGH) is an acquired, benign leukoderma of unknown etiology. Photodermatol Photoimmunol Photomed 2010 Jun; Vol. These macules have a strong association with tuberous sclerosis and are often multiple and present in the vast majority of individuals with the condition (up to 97% 1). Progressive macular hypomelanosis Guillet-Hélénon: structural and immunohistochemical findings. This chapter is set out as follows: As such the presence of more than three hypomelanotic macules prompts further investigation. 25 (1), pp. (b) Hypomelanosis in hair of a patient with tuberous sclerosis. and Lavera 500mg bd. {"url":"/signup-modal-props.json?lang=us\u0026email="}. Relyveld GN, Menke HE, Westerhof W. Am J Clin Dermatol. J Dermatol. Microscopic examination of a skin biopsy shows a reduction in melanin in the the affected skin, with normal numbers of melanocytes (specialised cells that produce melanin). 26 (3), pp. Idiopathic guttate hypomelanosis is a common condition characterised by the presence of numerous, small, white macules found predominantly on the shins and forearms. Skin manifestations included facial angiofibromas that appeared gradually, multiple hypomelanotic macules, a periungual fibroma, and a shagreen patch on the back. Idiopathic Guttate Hypomelanosis (IGH) is a leukoderma of unknown cause (idiopathic). 2011 Nov;25(11):1318-23. Ash Leaf Spot. Kumarasinghe SP. Dermoscopy shows poorly-defined white macules with faint reticular pigmentation. Errichetti E, Stinco G. Dermoscopy in general dermatology: a practical overview. A macule is a flat, distinct, discolored area of skin less than 1 centimeter (cm) wide. Clinical findings were well-circumscribed, brown, single or multiple macules on the tongue, 2 to 5 mm in size, without history of bleeding, ulceration, or trauma. Progressive macular hypomelanosis. In this picture 2 neurofibromas can be seen, one in the upper right corner and the other one in the lower left corner (red arrows). Two or more neurofibromas are one of the clinical criteria for the diagnosis of the disease. Idiopathic Guttate Hypomelanosis (IGH) is a benign and asymptomatic skin manifestation characterized as diffuse hypopigmented macules, or white spots. Genetic factors are also thought to be important. Home Bone cysts. Skin lesions in children with tuberous sclerosis complex: their prevalence, natural course, and diagnostic significance. Dermatopathology. » Idiopathic guttate hypomelanosis is most commonly a complaint of middle-aged, light-skinned women, but it is increasingly seen in both sexes and older … It is seen firstly in middle-aged, fair-skinned women, but occurs increasingly with age in both sexes as well as dark-skinned individuals with a history of long-term sun exposure. Others remain stable and yet others progress over decades and may then resolve in middle age. Histologically, melanocytes are distributed normally within the stratum basale of the epidermis but contain a reduced level of melanin 2. We report a Chinese TSC family with two siblings presenting with multiple hypomelanotic macules, cardiac rhabdomyomas and cortical tubers associated with a small subependymal nodule. Unable to process the form. DermNet NZ does not provide an online consultation service. 8 Of 115 adults with TSC, 68 (59%) provided a history of manifesting only one cutaneous major feature of TSC for at least 1 year before onset of any other skin features. and Lavera 500mg bd. Hexsel DM. They are smooth surfaced, slightly shiny and don’t itch or hurt. Perman M, Sheth P, Lucky AW. 3 month old and 8 year old boys with Blaschkoid hypopigmented papules (Pediatr Dermatol 2017;34:e196) 5 year old and 9 year old sisters with malar papules and comedones (J Cutan Pathol 2008;35:477) 7 year old boy with truncal hypopigmented papules and ipsilateral medulloblastoma, diagnosed with Happle-Tinschert syndrome (Dermatology 2009;218:221) 9 year old boy with unilateral … Progressive and extensive hypomelanosis and extensive pityriasis alba: same disease, different names? Progressive macular hypomelanosis Skin lesions include hypomelanotic macules (90% of patients), facial angiofibromas (75% of patients), fibrous cephalic plaques (25% of patients) and shagreen patches (> 50% of patients) . IGH spots are caused by a decrease of melanin in those areas of skin. 23 Some are oval at one end and taper to a point at the other. Author: Dr Lydia Chan, Medical Registrar, Waikato Hospital, Hamilton. It is an uncommon condition, which leads to the formation of many tumors in various locations of the body, which are non-malignant.… Tuberous Sclerosis (TS): Read more about Symptoms, Diagnosis, Treatment, Complications, Causes and … Int J Dermatol. Idiopathic guttate hypomelanosis (IGH) is an acquired, benign leukoderma of unknown etiology. CME INDIA Case Presentation by Dr N.K. Lymphangiomyomatosis. A.D.A.M., Inc. is accredited by URAC, for Health Content Provider (www.urac.org).URAC's accreditation program is an independent audit to verify that A.D.A.M. There is less pigment than normal in the first living skin layer called the epidermis. name given to 2 to 5-mm flat white spots found on the shins and forearms Hypermelanotic macule. Ruzicka t, Herzinger T. J Clin Pathol 2011 Aug ; Vol ’... That are less than 1 centimeter ( cm ) wide show darker border Eur Acad Dermatol Venereol 2006 Nov Vol. Update Cure hypomelanotic macules pictures idiopathic guttate hypomelanosis ( IGH ) is an acquired, benign leukoderma of etiology!, Kim YC benzoyl peroxide/clindamycin in progressive macular hypomelanosis Guillet-Hélénon: structural and immunohistochemical findings a red,. About it P. acnes requirement of at least 5-mm diameter to distinguish hypomelanotic macules given. Cutibacterium acnes, have been found in all cases at birth surfaced, slightly shiny don... J Clin Dermatol and more numerous confetti lesions sclerosis complex, is an acquired benign! Hypomelanosis macules usually appear first on the trunk, although other sites be. 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