An immunohistochemical analysis of pseudomelanocytic nests mimicking melanoma in situ: Report of 2 cases

Several case reports have discussed the difficulty in differentiating junctional pseudomelanocytic nests as a result of lichenoid inflammation from a true melanocytic neoplasm. Even immunohistochemistry can be misleading in these cases with both Melan-A and Mart-1 frequently resulting in false positivity as a result of nonspecific labeling of nonmelanocytic cells containing melanosomes. We present a series of 2 similar cases which were initially misdiagnosed as melanoma in situ likely as a result of Mart-1 positivity of the pseudomelanocytic nests. However, in our review, a significant lichenoid reaction was apparent at the dermal-epidermal junction. Staining with microphthalmia-associated transcription factor (MITF) showed a normal density of melanocytes along the dermal-epidermal junction and failed to uniformly label the Mart-1-positive pseudomelanocytic nests. In both patients, medications frequently resulting in fixed drug eruptions were identified, and a final diagnosis of fixed drug eruption was rendered in both cases. In light of these findings we suggest MITF is a more useful marker for evaluating lentiginous proliferations along the dermal-epidermal junction particularly when dealing with the differential diagnosis of lichenoid reaction with pseudomelanocytic nests versus melanoma in situ.