0.108 Images of memorable cases: case 121

121. hypomelanotic (“ash-leaf”) macules of tuberous sclerosis

Also known as Bournville disease and epiloia, this multisystem, autosomal dominant disorder has a wide variety of manifestations,chief of which are skin abnormalities, tonic-clonic seizures, and mental retardation.

The hypomelanotic macules (arrows, image below) are pathognomonic of tuberous sclerosis. They are the earliest and most commoncutaneous sign, occurring in almost 90% of the patients. Usually evident at birth or during the first year of life, these lesions may involve any part ofthe body’s surface, vary in number from four to 100, typically exceed 1 cm in diameter, are dull-white in color, and are lance-oval in shape (tapered at oneend and round at the other—the same shape as that of leaflets from the mountain- ash tree).

Other pathognomonic skin lesions of tuberous sclerosis generally appear years later and include adenoma sebaceum on the face,shagreen (shark-skin) patches in the lumbar area, and periungual and gingival fibromas.