Becker Nevus: Clinical Presentation, Diagnostic Evaluation, Management, and Outcomes – A Case Report

Abstract

Becker nevus is a benign cutaneous hamartoma characterized by hyperpigmentation and often associated with hypertrichosis. It typically presents during adolescence and shows a strong male predominance. Although primarily a cosmetic concern, it may occasionally be associated with underlying developmental anomalies, constituting Becker nevus syndrome.

We report the case of a 19-year-old male who presented with a gradually enlarging hyperpigmented patch over the left shoulder associated with increased hair growth. Clinical and dermoscopic evaluation confirmed the diagnosis of Becker nevus. The patient was managed conservatively with counseling and offered laser therapy for cosmetic improvement, resulting in satisfactory outcomes.

This case underscores the importance of accurate clinical diagnosis, differentiation from other pigmented lesions, and individualized management strategies in patients with Becker nevus.

Introduction

Becker nevus, also referred to as Becker melanosis, is a cutaneous hamartoma involving epidermal and adnexal structures. First described in 1949, it typically manifests as a unilateral, irregularly bordered hyperpigmented patch, most commonly located on the upper trunk, shoulder, or chest.

The lesion often becomes apparent during adolescence, coinciding with hormonal changes, and may progressively darken and develop hypertrichosis. The condition is thought to be androgen-dependent, which explains its higher prevalence in males and the presence of terminal hair growth within the lesion.

Although Becker nevus is benign, its clinical significance lies in its potential association with musculoskeletal or developmental abnormalities in rare cases, termed Becker nevus syndrome.

Risk factors and associations include:
• Male gender predominance
• Onset during puberty
• Hormonal influence (androgen sensitivity)
• Rare association with skeletal or breast hypoplasia

Clinically, patients often present with cosmetic concerns due to pigmentation and hair growth rather than functional impairment.

Case Report

Patient History

A 19-year-old male presented to the dermatology outpatient department with complaints of:
• A dark patch over the left shoulder
• Gradual increase in size over 3 years
• Excessive hair growth over the lesion
• No associated itching, pain, or discharge

The lesion was first noticed at the age of 16 and had progressively increased in pigmentation and hair density. There was no history of trauma, drug intake, or preceding inflammation in the affected area.

The patient had no significant past medical history and no family history of similar lesions or dermatological conditions.

Clinical Examination

General Examination

• Patient was well-built and well-nourished
• Vital signs were stable
• No systemic abnormalities detected

Dermatological Examination

• A single, well-defined but irregularly bordered hyperpigmented patch measuring approximately 12 × 8 cm over the left shoulder
• Color varied from light brown to dark brown
• Presence of coarse terminal hair over the lesion (hypertrichosis)
• Surface was smooth, with no scaling or nodularity
• No signs of inflammation or ulceration

There were no similar lesions elsewhere on the body.

Systemic Examination

• No evidence of musculoskeletal deformities
• No breast asymmetry or hypoplasia
• Neurological examination was normal

Clinical Evaluation

Differential Diagnosis

Based on clinical presentation, the following conditions were considered:
• Becker nevus
• Congenital melanocytic nevus
• Café-au-lait macule
• Post-inflammatory hyperpigmentation
• Nevus spilus

The presence of late onset, hypertrichosis, and progressive pigmentation strongly suggested Becker nevus.

Investigations

Dermoscopy

Dermoscopy revealed:
• Irregular pigment network
• Perifollicular hypopigmentation
• Increased hair follicles
• No atypical vascular structures

These findings were consistent with Becker nevus.

Histopathology (Optional, not performed in this case)

Although not required due to classical presentation, histopathological features typically include:
• Acanthosis and hyperkeratosis
• Increased basal layer pigmentation
• Smooth muscle hyperplasia in the dermis
• Increased melanocyte activity

Laboratory Investigations

• Routine blood investigations were within normal limits

No imaging was required as there were no associated systemic abnormalities.

Diagnosis

Based on clinical and dermoscopic findings, a diagnosis of Becker nevus involving the left shoulder was established.

Management and Outcome

Management Strategy

The treatment approach was guided by:
• Cosmetic concerns
• Extent of pigmentation
• Presence of hypertrichosis
• Patient preference

Since Becker nevus is a benign condition, management focused primarily on cosmetic improvement and patient reassurance.

Treatment Options Discussed

Conservative Management

• Patient education regarding benign nature of the condition
• Reassurance to alleviate anxiety
• Regular follow-up to monitor any changes

Medical Therapy

Topical therapies have limited effectiveness but may include:
• Topical anti-androgens (in selected cases)
• Pigment-reducing agents (variable response)

Laser Therapy

The patient was counseled regarding laser-based interventions:
• Q-switched lasers for pigmentation reduction
• Long-pulsed lasers for hair removal

Laser therapy offers moderate improvement but may require multiple sessions and has variable outcomes.

Intervention and Follow-Up

The patient opted for conservative management initially, with consideration for future laser therapy.

At 3-Month Follow-Up:

• No progression in lesion size
• Patient reassured and satisfied with counseling

At 6-Month Follow-Up:

• Lesion remained stable
• Patient opted for trial of laser hair reduction

At 9-Month Follow-Up:

• Mild reduction in hair density
• Slight improvement in pigmentation
• No complications observed

Overall, the patient reported improved cosmetic satisfaction.

Discussion

Pathophysiology

Becker nevus is considered a cutaneous hamartoma involving:
• Epidermal melanocytes
• Hair follicles
• Smooth muscle components

The exact etiology remains unclear, but androgen receptor hypersensitivity is believed to play a key role. Increased androgen activity explains:
• Onset during puberty
• Male predominance
• Associated hypertrichosis

Epidemiology

• More common in males (male-to-female ratio approximately 5:1)
• Typically appears during adolescence
• Most commonly affects the upper trunk and shoulders

Becker Nevus Syndrome

In rare cases, Becker nevus may be associated with:
• Ipsilateral breast hypoplasia
• Skeletal abnormalities
• Muscular defects

This constellation is termed Becker nevus syndrome and requires thorough evaluation.

Diagnostic Considerations

Diagnosis is primarily clinical. Key distinguishing features include:
• Late onset (adolescence)
• Hyperpigmentation with irregular borders
• Hypertrichosis
• Unilateral distribution

Dermoscopy aids in confirmation, while biopsy is reserved for atypical cases.

Treatment Considerations

There is no definitive cure for Becker nevus. Management focuses on cosmetic improvement.

Pigmentation Treatment:
• Q-switched Nd:YAG laser
• Fractional lasers

Hair Removal:
• Laser hair reduction (diode or alexandrite lasers)

Limitations:
• Variable response
• Risk of recurrence
• Multiple sessions required

Complications

Becker nevus itself is benign and not associated with malignant transformation. However, potential concerns include:
• Cosmetic disfigurement
• Psychological impact
• Rare association with syndromic features

Laser therapy complications may include:
• Post-inflammatory hyperpigmentation
• Hypopigmentation
• Skin irritation

Prognosis

The prognosis of Becker nevus is excellent.

Key factors influencing outcomes:
• Extent of lesion
• Patient expectations
• Response to cosmetic treatments

The lesion typically stabilizes after adolescence and does not progress significantly thereafter.

Conclusion

Becker nevus is a benign dermatological condition characterized by hyperpigmentation and hypertrichosis, most commonly presenting during adolescence. Although it poses no medical risk, it can have significant cosmetic and psychological implications.

This case highlights the importance of recognizing classical clinical features to avoid unnecessary investigations and interventions. Dermoscopy serves as a useful non-invasive diagnostic tool, while biopsy is rarely required.

Management should be individualized, focusing on patient education, reassurance, and cosmetic improvement when desired. Laser therapies offer promising results, although outcomes may vary.

Early identification and appropriate counseling play a crucial role in improving patient satisfaction and quality of life. Increased awareness among clinicians can facilitate accurate diagnosis and prevent mismanagement of this benign condition.

References

1. Becker, S. W. (1949). Concurrent melanosis and hypertrichosis in distribution of nevus unius lateris. Archives of Dermatology and Syphilology. https://pubmed.ncbi.nlm.nih.gov/18116269/
2. Happle, R. (1997). Becker nevus syndrome. Journal of the American Academy of Dermatology. https://pubmed.ncbi.nlm.nih.gov/9039171/
3. Kim, Y. J., et al. (2008). Clinical and histopathological characteristics of Becker's nevus. Journal of Dermatology. https://pubmed.ncbi.nlm.nih.gov/18789063/
4. Patrizi, A., et al. (2012). Becker nevus: Clinical features and treatment options. Pediatric Dermatology. https://pubmed.ncbi.nlm.nih.gov/22384933/
5. Sardana, K., et al. (2014). Lasers for Becker’s nevus: A systematic review. Journal of Cutaneous and Aesthetic Surgery. https://pubmed.ncbi.nlm.nih.gov/25284856/

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