Recurrent Nevus Phenomenon Developing within a Keloid
Round 1
Reviewer 1 Report
In this paper the authors describe the occurrence of a melanocytic atypical proliferation developing in a keloid. This is a rare phenomenon and I think this paper contains interesting information and I have only a few comments/questions/suggestions:
-What color is tan-white?
- - The authors report their case as a “Recurrent nevus phenomenon” and use this term in all the manuscript. However this has also been described as “persistent nevus” or “pseudomenlanoma”. I think that the authors should describe an explain these other terms in the present report.
Author Response
REVIEWER 1
POINT 1: What color is tan-white?
RESPONSE 1: We apologize for any confusion caused by our use of the term "tan-white." Upon chart review we believe that a better characterization of the color of this lesion is “Skin-colored”; we have now made the change in the revised manuscript.
POINT 2: The authors report their case as a “Recurrent nevus phenomenon” and use this term in all the manuscript. However this has also been described as “persistent nevus” or “pseudomelanoma”. I think that the authors should describe an explain these other terms in the present report.
RESPONSE 2: Thank you for pointing out the alternate terms used to describe this phenomenon. We acknowledge that "persistent nevus" and "pseudomelanoma" are indeed used to refer to this condition. Thus, in the revised manuscript we are now including also this terminology for completeness.
We have also attempted to explain in the revised discussion section the explanation for each of these terms for clarity.
Reviewer 2 Report
The reviewer wishes to thank the editor and the authors for the opportunity to review this well written manuscript. This article describes the case of a 43- year-old female who developed what appears to be an atypical melanocytic proliferation at the edge of a keloid from a previous piercing. The authors identify the various challenges with encountering an atypical melanocytic lesion in the setting of a scar and put forth a thought provoking discussion as to the etiology of such a lesion.
While I agree that this may represent a pre-existing melanocytic proliferation that was secondarily involved by the keloid, possibly made worse in appearance by exposure “ to dermal proteins resulting in aberrant activation and proliferation,” I struggled with the term “recurrent nevus phenomenon.” Conventionally, a pre-existing nevus is needed. However, I do like your example in the SJS patient. I wonder if further mention of things like EB nevus and recurrent nevus in the setting of other chronic conditions such as Hailey Hailey1 may further give power to your claim of a recurrent nevus in keloid. A clinical photo would also be helpful.
Otherwise, Figure 1 may be more attractive to our readers with a few changes. The background of figure 1 A, C, D, E, F should be white balanced or at minimum homogenized. Currently the use of an “eraser tool” is evident in A, C, and E. Additionally, in the figure legend addition of the exact power of each image (i.e. 10x, 40x, 200x, 400x etc) would be favorable.
Figure 2 may also be more attractive to readers with similar changes to figure 1. Currently the images appear dark or somewhat yellow and the power of each image should be added to the figure legend.
Reference:
11. Noor O, Elston D, Flamm A, Hall LD, Cha J. A recurrent melanocytic nevus phenomenon in the setting of Hailey-Hailey disease. J Cutan Pathol. 2015 Aug;42(8):574-7. doi: 10.1111/cup.12511. Epub 2015 May 26. PMID: 25950447.
Author Response
REVIEWER 2
POINT 1: While I agree that this may represent a pre-existing melanocytic proliferation that was secondarily involved by the keloid, possibly made worse in appearance by exposure “ to dermal proteins resulting in aberrant activation and proliferation,” I struggled with the term “recurrent nevus phenomenon.” Conventionally, a pre-existing nevus is needed. However, I do like your example in the SJS patient. I wonder if further mention of things like EB nevus and recurrent nevus in the setting of other chronic conditions such as Hailey Hailey1 may further give power to your claim of a recurrent nevus in keloid. .
Noor O, Elston D, Flamm A, Hall LD, Cha J. A recurrent melanocytic nevus phenomenon in the setting of Hailey-Hailey disease. J Cutan Pathol. 2015 Aug;42(8):574-7. doi: 10.1111/cup.12511. Epub 2015 May 26. PMID: 25950447.
RESPONSE 1: We appreciate your feedback and insightful suggestions. You raise an important point regarding the conventionally recognized requirement of a pre-existing nevus for the term "recurrent nevus phenomenon." We provided more clarity in our manuscript around this and describe the recurrent nevus as traditionally requiring a pre-existing melanocytic lesion. We agree that further references to conditions such as Hailey-Hailey disease and examples like the SJS patient can strengthen our claim of a recurrent nevus in the context of keloid. We will include additional discussion and references to these relevant cases in order to enhance the validity and support of our findings.
POINT 2: A clinical photo would also be helpful.
RESPONSE 2: Thank you for your suggestion. Regrettably, we do not have a clinical photo available for inclusion in the manuscript. However, we have ensured that our written descriptions are detailed and comprehensive to compensate for the absence of a clinical photo.
POINT 3: Otherwise, Figure 1 may be more attractive to our readers with a few changes. The background of figure 1 A, C, D, E, F should be white balanced or at minimum homogenized. Currently the use of an “eraser tool” is evident in A, C, and E. Additionally, in the figure legend addition of the exact power of each image (i.e. 10x, 40x, 200x, 400x etc) would be favorable.
RESPONSE 3: We appreciate your feedback regarding Figure 1. We acknowledge the need for improvement in terms of background homogenization and the removal of any traces of editing tools. We will carefully address these issues and ensure that the revised figures maintain high quality and clarity. Furthermore, we will revise the figure legend to include the exact power of each image, providing the necessary information for our readers.
POINT 4: Figure 2 may also be more attractive to readers with similar changes to Figure 1. Currently, the images appear dark or somewhat yellow and the power of each image should be added to the figure legend.
RESPONSE 4: Thank you for your valuable input regarding Figure 2. In the revised manuscript, we have now made the necessary adjustments to improve the quality and appearance of the images. Additionally, we will include the power of each image in the figure legend to enhance the understanding and utility of the figures for our readers.
Reviewer 3 Report
The authors submit an interesting case report of a recurrent nevus phenomenon (so-called pseudomelanoma) in a keloid. It alerts for a potential caveat in the diagnosis of melanocytic lesions.
The article needs some corrections of language and grammar mistakes; please revise carefully.
The pictures need some improvement, especially in terms of contrast and white balance; especially immunohistochemical pictures have a very dark background.
In the description of the histology, I wouldn't probably classify the pattern as pagetoid; there is some upward migration of small melanocytes but it does not seem overtly pagetoid.
English language needs general improvement to correct some minor grammatical errors and language inaccuracies, but I think this can be accomplished appropriately.
Author Response
REVIEWER 3
POINT 1: The article needs some corrections of language and grammar mistakes; please revise carefully.
RESPONSE 1: We appreciate your feedback and apologize for any language and grammar mistakes that may have occurred in the manuscript. We will diligently revise and carefully proofread the entire article to ensure accurate and polished language throughout. We will make the necessary corrections to enhance the readability and clarity of our work.
POINT 2: The pictures need some improvement, especially in terms of contrast and white balance; especially immunohistochemical pictures have a very dark background.
RESPONSE 2: Thank you for your observation regarding the quality of the pictures. We understand the importance of proper contrast and white balance, particularly in immunohistochemical images. We have now revised the images to improve contrast and optimal white balance.
POINT 3: In the description of the histology, I wouldn't probably classify the pattern as pagetoid; there is some upward migration of small melanocytes but it does not seem overtly pagetoid.
RESPONSE 3: We appreciate your evaluation of the histological description. We agree with your assessment that the pattern may not be overtly pagetoid, so we have revised the text in the manuscript to reflect your suggestion.
