Dermal Melanocytosis

Rare Diseases / By

Dermal Melanocytosis – Introduction

  • Usually benign patches of dark blue-gray or brown skin hyperpigmentation present in newborns and typically located on the face (nevus of Ota), or the shoulder or neck area (nevus of Ito)(1,2,3,4)
  • > 50% of nevus of Ota or Ito lesions are present at birth, but may also develop later in life, usually at puberty (J Cutan Pathol 2007 Aug;34(8):640)

Synonyms

  • nevus of Ota is also called
    •  oculodermal melanocytosis
    •  nevus fusco-caeruleus ophthalmo-maxillaris
  • nevus of Ito is also called
    •  nevus fusco-ceruleus acromiodeltoideus
    •  nevus fusco-ceruleus acromioclavicularis

Definitions

  • Fitzpatrick skin typing system
    •  I – always burns, never tan
    •  II – usually burns, less than average tan with difficulty
    •  III – mild burns occasionally, average tan
    •  IV – rarely burns, tans with ease
    •  V – does not burn, always tans (usually brown persons)
    •  VI – does not burn, always tans (usually Black persons)
    •  Reference – Arch Dermatol 1988 Jun;124(6):869

Types

  • nevus of Ota (oculodermal melanocytosis)(1,2,3,4)
    •  increased melanocytic pigment distributed along the first 2 branches of trigeminal nerve without extension beyond the nasolabial fold
    •  typically affects the orbital skin of 1 eye, temples, zygomatic region, forehead, and/or nasopharyngeal, tympanic, and palatal mucosa
    •  > 50% of lesions are present at birth, but may also develop later in life, usually at puberty
    •  lesions usually unilateral; bilateral lesions occur in 5%-15% of patients
    •  lesions usually lack hair
    •  increased pigmentation of the sclera in approximately 50%-66% of patients
    •  typically sporadic, familial cases are rare
    •  perilesional and intralesional blue papules resembling blue nevi may be present
  • classification systems for nevus of Ota describing extent of cutaneous involvement(2)
    • Tanino
      •  type I, mild
      •  type Ia, eye region
      •  type Ib, zygomatic region
      •  type Ic, forehead
      •  type Id, nostril
    • Peking Union Medical College Hospital (PUMCH) for types and subtypes of cutaneous nevus of Ota
      •  type I, pigmentation macules involving 1 branch of the trigeminal nerve
      •  type Ia, ophthalmic nerve
      •  type Ib, maxillary nerve
      •  type Ic, mandibular nerve
      •  type II, pigmentation macules involve 2 branches of the trigeminal nerve
      •  type IIa, ophthalmic and maxillary nerves
      •  type IIb, maxillary and mandibular nerves
      •  type III, pigmentation macules involve all 3 branches of the trigeminal nerve
  • nevus of Ito(1,3)
    •  less common, rarely occurs in conjunction with nevus of Ota
    •  typically occurs unilaterally on the shoulder or side of the neck
    •  distribution follows lateral cutaneous brachial and posterior supraclavicular nerves
  • acquired dermal melanocytosis

Epidemiology

Who Is Most Affected

  •  nevi of Ota and Ito each are more common in females with 5:1 predominance(1,3,4)
  • nevus of Ota(1,2,3,4)
    •  most common in patients of Asian (particularly Japanese) and African descent but may occur in individuals of any race
    •  more common in infants and children

Incidence/Prevalence

  •  reported prevalence of nevus of Ota 0.034% of Asian population(2,4)
  •  oculodermal melanocytosis identified in 1 patient (0.014%) of 6,915 Black patients screened in Canada (Ophthalmology 1982 Aug;89(8):950)
  •  nevus of Ito is less common than nevus of Ota(1)

Associated Conditions

Etiology and Pathogenesis

Causes

  •  caused by increased depth and number of melanocytes in the dermis layer of skin(1,3)
  • nevus of Ota typically sporadic, reported to be heritable in several cases(1,3)
  •  mutations in guanine nucleotide-binding protein G(q) subunit alpha (GNAQ) protein present in roughly 6% of cases of nevus of Ota(1)

Pathogenesis

  • pathogenesis thought to be due to abnormal melanocyte migration or arrest of migration(1,2,3,4)
    •  melanocytes normally migrate from neural crest to the epidermis during gestational weeks 2.5-8
    •  by gestational week 20 melanocytes are typically absent from dermis due to migration and clearance by macrophages
    •  dermal melanocytosis thought to result from failure of these migration and clearance mechanisms
    •  differences in melanocyte density and depth account for color differences between lesions
  •  abnormal melanocyte migration may be influenced by hypothalamic-pituitary-ovarian axis(4)
  •  association of congenital dermal melanocytosis with inborn errors of metabolism not well understood, but mechanisms may include sphingolipid metabolism abnormalities such as in GM1 gangliosidosis(3)
  • proposed origins of acquired dermal melanocytosis include

History and Physical

History

Chief Concern

  • areas of increased melanocytic skin pigmentation in distinctive pattern of distribution, usually present at birth(1,2,3)
    •  nevus of Ota presents on the face, usually around the orbital skin of 1 eye, in distribution of trigeminal nerve without extension beyond the nasolabial fold
    •  nevus of Ito presents on shoulder or side of the neck in distribution of lateral cutaneous brachial and posterior supraclavicular nerves, usually unilaterally
  •  nevus of Ota may be associated with psychosocial and emotional distress due to cosmetic disfigurement(2)
  •  nevus of Ota or Ito may present later in life in up to 50% of cases(1,3)
  •  presentation of late-onset nevus of Ito in White patient aged 72 years in case report (J Cutan Pathol 2007 Aug;34(8):640)

Physical

Skin

  • nevus of Ota is characterized by blue-black or gray macules and papules(1,2,3,4)
    •  pigmentation typically
      •  corresponds with distribution of first 2 branches of trigeminal nerve
      •  does not extend beyond nasolabial fold
      •  occurs unilaterally but may also occur bilaterally
    •  blue papules resembling blue nevi may occur within or near nevus of Ota lesions
    •  lesions usually lack hair
  • nevus of Ito is characterized by unilateral blue-black or gray macules and papules on the shoulder/deltoid area, side of neck, and/or supraclavicular or scapular regions(1,3)
    •  pigmentation typically occurs along the distribution of posterior supraclavicular and lateral cutaneous brachial nerves
    •  nonpigmented, fast-growing nodules should be suspected for malignant melanoma (rare)

HEENT

  •  look for melanin deposits in eye, as sclera pigmentation is reported in two-thirds of patients with nevus of Ota(1,2,3)
  •  if sclera is pigmented, look for iris heterochromia or iris mammillations (dome-shaped protuberations of the iris surface) (Semin Ophthalmol 2017;32(4):524)
  •  look for mucus membrane pigmentation of ear canal, nose, pharynx, and/or hard palate, which usually accompanies nevus of Ota(3)

Diagnosis

Making the Diagnosis

  • diagnosis usually made clinically based on characteristic appearance and location of lesions(1,3,4)
    •  nevus of Ota, characterized by periorbital/trigeminal distribution of melanocytic pigmentation
    •  nevus of Ito, characterized by acromioclavicular distribution of melanocytic pigmentation
  • biopsy may be indicated in cases of uncertain diagnosis or with rapidly expanding or nodular lesions to rule out melanoma(4)

Differential Diagnosis

  • differential diagnoses for dermal melanocytosis(1,3,4)
    • Mongolian spot
    •  cellular or common blue nevi
    •  Hori macule or nevus (acquired bilateral nevus of Ota-like macules)
    •  lentigo maligna
    •  ochronosis
    •  phytophotodermatitis
    •  Riehl melanosis
    •  melasma (for nevus of Ota)
    •  incontinentia pigmenti
    •  neurocutaneous melanosis
    •  bruising
    •  physical abuse
  • other pigmentation disorders resembling nevus of Ota include

Testing Overview

  • consider biopsy(4)
    •  if diagnosis is uncertain, or
    •  if lesions expand rapidly or are nodular at any age, suggesting melanoma, especially in light-skinned patients
  • typical histological findings include(1,4)
    •  band-like pattern of melanocytic proliferation
    •  lack of inflammation at the dermoepidermal junction
    •  bipolar, fusiform, highly pigmented dendritic melanocytes within the mid and upper dermis
  • histological classification system(2)
    •  superficial – dermal melanocytes are located in the superficial layer of the dermis
    •  deep – dermal melanocytes are located in the deep layer of the dermis
    •  diffuse – dermal melanocytes are evenly spread throughout the dermis
    •  superficial dominant – greater concentration of melanocytes in the superficial layer of the dermis
    •  deep dominant – greater concentration of melanocytes in the deep layer of the dermis
  •  for eye involvement, consider evaluations with an ophthalmologist(1,3,4)

Treatment

Treatment Overview

  •  typically no treatment is necessary for dermal melanocytosis (nevus of Ota, nevus of Ito)(1,2,3)
  • laser treatment may be considered for cosmetic improvement of nevus of Ota(1,2)
  • advise ongoing follow-up(1,3)
    •  for patients with nevus of Ota, advise regular follow-up evaluations with an ophthalmologist for increased risks of glaucoma and melanoma (especially uveal melanoma) of affected eye
    •  for patients with nevus of Ota or Ito, advise follow-up evaluations for increased risk of malignant melanoma, especially in White patients

Surgery and Procedures

  •  consider laser therapy for cosmetic improvement(1,2)
  • early treatment associated with best cosmetic results, as treatment later in life may be more difficult due to personal and environmental factors including(2)
    •  exposure to weather and ultraviolet light
    •  sexual hormone development in adolescence
  • superficial lesions typically more amenable to therapy(4)
  •  Q-switched lasers commonly considered for treatment of nevus of Ota or Ito(2)

Table 1: Types of Q-switched (QS) Lasers for Treatment of Nevus of Ota

LaserWavelengthIndicated for Fitzpatrick Skin TypeDisadvantage
QS ruby694 nmI-IIIHypopigmentation and hyperpigmentation
QS alexandrite755 nmMostHypopigmentation and hyperpigmentation
QS Nd:YAG532 nmI-VIGreater risk of damage to epidermis
QS Nd:YAG1,064 nmI-VIPainful, often requiring anesthesia

Citation: Abbreviations: Nd:YAG, neodymium: yttrium-aluminium-garnet; QS, Q-switched.

  •  complications of laser treatment may include hypopigmentation (reported to be permanent), hyperpigmentation, and risk of nevus recurrence(2)
  • Q-switched alexandrite laser may be more effective and have fewer complications than Q-switched Nd:YAG in Asian patients with nevus of Ota (level 2 [mid-level] evidence)
    •  based on systematic review of observational studies
    • systematic review of 13 observational studies comparing efficacy and complications of Q-switched alexandrite vs. neodymium: yttrium-aluminium-garnet (Nd:YAG) laser treatment in 2,469 patients with nevus of Ota
      •  most patients were adults, female, and Asian
      •  2,153 patients received treatment with Q-switched alexandrite laser
      •  316 patients received treatment with Q-switched Nd:YAG laser
    •  duration of follow-up and number of treatment sessions not reported
    •  treatment success defined as > 75% pigment clearance in 9 studies, and 60%-100% in 4 studies
    •  complications included lesion recurrence, hypopigmentation, hyperpigmentation, textural change, and scarring
    • comparing Q-switched alexandrite laser vs. Q-switched Nd:YAG in analysis of 13 studies with 2,469 patients
      •  treatment success in 48.3% vs. 41% (p = 0.017)
      •  complications in 8% vs. 13.4% (p < 0.0001)
      •  hypopigmentation in 2.1% vs. 5.7% (p = 0.001)
      •  hyperpigmentation in 3.5% vs. 7.9% (p = 0.001)
      •  scarring in 2.1% vs. 4.3% (not significant)
    •  Reference – Lasers Med Sci 2016 Apr;31(3):581
    • low-fluence Q-switched Nd:YAG laser reported to be effective for reducing nevus of Ota skin pigmentation in children < 10 years old (level 3 [lacking direct] evidence)
      •  based on case series
      •  31 children and adults (mean age 14 years, 68% female) with nevus of Ota and Fitzpatrick skin type IV (rarely burns, tans with ease) had 1,064-nm Q-switched Nd:YAG laser in 2- to 3-week intervals
      •  mean number of treatment sessions 17.5 (range 6-32 sessions)
      • mean number of treatment sessions required for improvement
        •  4.1 for moderate
        •  8.2 for significant
        •  12.4 for near total
      •  patients < 10 years old had similar time to improvement but with lower mean fluence compared to patients ≥ 10 years old (p = 0.006)
      •  adverse effects included petechia in 9, pain in 5, erythema in 1, and hyperpigmentation in 1
      •  Reference – Dermatol Surg 2015 Jan;41(1):142
  • 755-nm alexandrite picosecond and Q-switched nanosecond lasers reported to improve skin dyspigmentation in patients with Fitzpatrick skin types III-VI (level 3 [lacking direct] evidence)
    •  based on retrospective cohort study
    • 42 patients with pigmentary disorders and Fitzpatrick skin type III-VI were treated with 755-nm alexandrite picosecond laser or Q-switched nanosecond lasers (694 nm ruby, 532 nm, or 1064 nm Nd:YAG) and evaluated for clinical efficacy
      • of 17 patients (mean age 24 years) receiving picosecond laser treatment
        •  35% had nevus of Ota and 6% had nevus of Ito
        •  mean number of treatments 4.1
        •  length of treatment 18.2 weeks
      • of 25 patients (mean age 62.5 years) receiving nanosecond laser treatment
        •  40% had nevus of Ota and none had nevus of Ito
        •  mean number of treatments 5.5
        •  length of treatment 120.6 weeks
    •  response to treatment was based on visual analog scale (VAS) (defined as 0 no change, 1 is < 25% improvement, 2 is 25%-40% improvement, 3 is 50%-74% improvement, 4 is 75%-99% improvement, and 5 is complete improvement)
    • comparing alexandrite picosecond laser vs. Q-switched nanosecond lasers
      •  response to treatment by VAS score 2.25 vs. 2.8 (not significant) in patients with nevus of Ota
      •  response to treatment by VAS score 0.72 vs. 2.33 (p = 0.005) in patients with pigmentary disorders on trunk or extremities
    •  permanent dyspigmentation in 16% of patients (Fitzpatrick skin types V or VI) receiving Q-switched nanosecond laser treatment
    •  transient hyperpigmentation observed in 3 patients receiving alexandrite picosecond laser treatment
    •  Reference – Lasers Surg Med 2016 Feb;48(2):181
  • 755-nm alexandrite picosecond laser therapy reported to result in 95%-100% pigment clearance in 96% of children (Fitzpatrick skin type III-IV) with various types of nevus of Ota, but relapse in 21% after 12-24 months (level 3 [lacking direct] evidence)
    •  based on case series
    • 86 children (median age 3 years, 80% female) with various types of nevus of Ota had 755-nm alexandrite picosecond laser therapy at single center in Taiwan between 2017 and 2020
      • 81% of patients had Fitzpatrick skin type III, 19% had Fitzpatrick skin type II, and 67% had eyelid involvement
      • most nevi were Tanino type II (in 32%) or type III (in 38%) or Peking Union Medical College Hospital type IIb (in 33%) or type IIIb (in 26%)
    • laser therapy performed at fluence 1.96-2.08 J/cm2, spot size 3.5-4 mm diameter, mean number of pulses/session 800-2,200, and pulse width 750 picoseconds performed every 3-4 months under local (in 73%) or general anesthesia (patients received 4-6 treatments)
    • pigment clearance assessed on photographs by 2 dermatologists
    • mean follow-up of 20.9 months after treatment
    • outcomes
      • pigment clearance of 95%-100% after mean 4.3 sessions in 96.5%
      • pigment clearance of 75%-94% in 3.5%
      • relapse of pigmentation in
        • 0% by 6 months
        • 21% between 12 and 24 months
        • 14% between 25 and 36 months
      • adverse events
        • transient hypopigmentation in 17% (resolution < 6 months)
        • transient hyperpigmentation in 12% (resolution < 2 months)
        • mild blistering in 7%
        • mild bleeding in 2%
        • transient mild swelling, erythema, and crusting in 100%
        • no scarring reported
    • Reference – Lasers Surg Med 2022 Mar;54(3):355
  • surgical reduction combined with Q-switched Nd:YAG laser treatment reported to be effective for reducing ocular pigmentation in adolescents and adults with nevus of Ota (level 3 [lacking direct] evidence)
    •  based on case series
    • 47 patients (mean age 24 years, 81% female) in Korea with oculodermal melanocytosis (nevus of Ota) were treated with combination of surgical reduction and 532-nm Q-switched Nd:YAG laser for reducing ocular pigmentation
      •  all patients had pigmentation on iris and angle of eye
      •  mean number of operations 1.6
      •  mean follow-up after surgery 17 months
    • significant postoperative reduction in ocular pigmentation occurred in all patients
      •  cosmetic results (assessed by independent observer) were “excellent” in 40 patients and “good” in 7 patients
      •  strong satisfaction with cosmetic result in 44 patients (94%)
    •  no significant difference in preoperative and postoperative best-corrected visual acuity, spherical equivalent, or mean keratometry
    •  mean intraocular pressure reduced from 18 mm Hg preoperatively to 15 mm Hg postoperatively at 1 month (p = 0.03) and 3 months (p = 0.047)
    •  complications during follow-up included cosmetically noticeable conjunctival neovascularization in 4 patients, conjunctival inclusion cyst in 4 patients, and both in 1 patient
    •  Reference – Cornea 2014 Aug;33(8):832
  • 1,064-nm picosecond Nd:YAG laser therapy reported to improve dyspigmentation in patients (Fitzpatrick skin type IV) with nevus of Ota (level 3 [lacking direct] evidence)
    •  based on case series
    • 16 patients (mean age 16 years, range 4 months to 59 years) with nevus of Ota and Fitzpatrick skin type IV had 1,064-nm picosecond Nd:YAG laser therapy at single center in China between 2017 and 2020
      • laser therapy performed at 1.84-4.3 J/cm2 fluence, spot size 3-4 mm, and frequency 5 hertz for 450-picosecond pulse duration every 3-12 months under local anesthesia followed by ice application immediately after therapy, and then antibiotic ointment twice daily for 1 week
      • 19% had 1 session, 25% had 2 sessions, 50% had 3 sessions, and 6% had 5 sessions
    • 69% had brownish lesions, and 31% had blue-black lesions
    • pigment clearance assessed on photographs by 3 dermatologists using VAS (range 1-5 points, with 1 indicating 0%-24% pigmentary clearance and 5 points indicating 95%-100% pigmentary clearance)
    • patient satisfaction assessed using 5-point scale, with 1 indicating “very dissatisfied” and 5 indicating “very satisfied”
    • outcomes
      • 62% “very satisfied” with treatment
      • 38% “satisfied” with treatment
      • mean pigment clearance score after
        • 1 treatment 2.5 points
        • 2 treatments 3.2 points
        • 3 treatments 3.5 points
      • 100% had clearance score correlating to ≥ 50% pigment clearance
      • 100% had transient erythema, mild edema, or crusting
      • 6.2% had postinflammatory hyperpigmentation
      • 0% had hypopigmentation
      • clearance of blue-black lesions was better than brownish lesions (p = 0.001)
    • Reference – Dermatol Ther 2021 Nov;34(6):e15152
  •  laser treatment of nevus of Ota pigmentation before age 12 years reported to have > 96% cure rate in case series of 106 children in China (J Cosmet Laser Ther 2014 Aug;16(4):156)
  • laser treatment for phakomatosis pigmentovascularis (PPV)
    • Q-switched ruby, Q-switched alexandrite, and flashlamp-pumped pulsed dye laser treatment reported to improve lesions associated with PPV
      •  based on case series
      •  2 patients (3-year-old girl with PPV type IIb and 23-year-old woman with PPV type IIa) received laser treatment of vascular and pigmented lesions with Q-switched ruby and Q-switched alexandrite laser then port-wine stain treatment with flashlamp-pumped pulsed dye laser
      •  lesion improvement after 6 sessions in 3-year-old girl and 31 sessions in 23-year-old woman
      •  Reference – Dermatol Surg 2003 Jun;29(6):642
    • combined laser therapy using Q-switched alexandrite and long-pulsed dye laser treatment reported to improve phakomatosis pigmentovascularis (level 3 [lacking direct] evidence)
      •  based on case reports
      •  newborn girl aged 2 weeks with phakomatosis pigmentovascularis type II and Klippel-Trénaunay syndrome treated with Q-switched alexandrite (6 joules/cm2) to dermal melanosis and long-pulsed dye laser (10 joules/cm2 and 1.5 millisecond) to port-wine stain for 5 sessions had 80% decrease in pigmentation of Mongolian spots and port-wine stains
      •  infant boy aged 4 months with phakomatosis pigmentovascularis type II treated with Q-switched alexandrite (6 joules/cm2) to dermal melanosis and long-pulsed dye laser (10 joules/cm2 and 1.5 millisecond) to port-wine stain for 3 sessions had 60% decrease in pigmentation of Mongolian spots and port-wine stains
      •  Reference – J Med Case Rep 2013 Feb 27;7:55full-text

Follow-up

  •  patients with nevus of Ota should have regular evaluations with an ophthalmologist due to an increased risk of glaucoma and melanoma(1,3,4)
  •  patients with nevus of Ota or Ito should be evaluated for life due to increased risk of malignant melanoma(1)

Complications and Prognosis

Complications

  • risk of melanoma appears increased with nevus of Ota(1,2,3,4)
    •  occurs most commonly in ipsilateral choroid, and particularly when sclera is pigmented
    •  other reported sites include central nervous system (especially meninges and frontal brain) and ipsilateral skin, including sites of clinically resolved lesions
    •  majority of malignancies reported with nevus of Ota are ipsilateral and occurred in White or light-skinned patients
    •  average age of melanoma diagnosis is 60 years
    •  review of 36 patients with nevus of Ota and malignant melanoma found 68% were female and 76% White (Dermatology 1992;185(2):146)
    •  pigmentation of sclera with nevus of Ota associated with increased risk of uveal melanoma and glaucoma in involved eye(1)
  •  malignant transformation with nevus of Ito is rare but may affect skin and reported to present with rapidly growing, nonpigmented nodules similar to melanoma associated with nevus of Ota(1,4)
  • oculodermal melanocytosis (nevus of Ota) associated with increased risk of metastasis in patients with uveal melanoma (level 2 [mid-level] evidence)
    •  based on retrospective cohort study
    •  7,872 patients (mean age 58 years) with uveal melanoma were evaluated for presence of oculodermal melanocytosis (nevus of Ota) and followed for > 30 years
    •  oculodermal melanocytosis in 230 patients (3%)
    •  in patients with oculodermal melanocytosis, relative risk (RR) for metastasis 1.6 times higher compared to those with no melanocytosis (p < 0.001)
    • melanocytosis in certain areas of eye associated with higher risk of metastasis including
      •  iris (RR 2.8, p < 0.001)
      •  choroid (RR 2.6, p = 0.02)
      •  sclera (RR 1.9, p < 0.001)
    • metastasis in patients with oculodermal melanocytosis vs. no melanocytosis (p < 0.001 for each)
      •  2% vs. 1.8% at 1 year
      •  27% vs. 15% at 5 years
      •  48% vs. 24% at 10 years
      •  48% vs. 36% at 20 years
    •  increased tumor thickness associated with increased mortality (p = 0.009) and metastasis (p = 0.001)
    •  presence of subretinal fluid associated with increased rate of metastasis (p = 0.05)
    •  Reference – JAMA Ophthalmol 2013 Aug;131(8):993
  • genetic mutations in guanine nucleotide-binding protein G(q) subunit alpha (GNAQ), loss of BRCA1-associated protein 1 (BAP1) expression, and/or tumor protein 53 (TP53) reported to be associated with development of melanoma in patients with nevus of Ota or Ito
  •  orbital melanocytoma associated with ipsilateral nevus of Ota (present from birth) in 28-year-old man in Brazil in case report (Head Neck 2015 Apr;37(4):E49)
  •  fatal metastatic melanoma in 12-year-old boy with nevus of Ota in case report (J Am Acad Dermatol 2013 Oct;69(4):e195)

Prognosis

  • nevi of Ota and Ito(1,4)
    •  may darken and enlarge with age, particularly after puberty
    •  do not spontaneously regress

Guidelines and Resources

Guidelines

  •  no relevant guidelines for Dermal melanocytosis (nevus of Ota, nevus of Ito) found 2016 May 19 on MEDLINE search using guidelines limiter

Review Articles

  •  to search MEDLINE for (nevus of Ota) with targeted search (Clinical Queries), click therapy, diagnosis, or prognosis
  •  to search MEDLINE for (nevus of Ito) with targeted search (Clinical Queries), click therapy, diagnosis, or prognosis

Patient Information

References

General References Used

  1. Franceschini D, Dinulos JG. Dermal melanocytosis and associated disorders. Curr Opin Pediatr. 2015 Aug;27(4):480-5.
  2. Shah VV, Bray FN, Aldahan AS, Mlacker S, Nouri K. Lasers and nevus of Ota: a comprehensive review. Lasers Med Sci. 2016 Jan;31(1):179-85.
  3. Taïeb A, Boralevi F. Hypermelanoses of the newborn and of the infant. Dermatol Clin. 2007 Jul;25(3):327-36.
  4. Sinha S, Cohen PJ, Schwartz RA. Nevus of Ota in children. Cutis. 2008 Jul;82(1):25-9.

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