31 Their frequency varies widely in different studies, from 3% in children to about 58% overall.15 and 24

Despite their relatively low frequency, confetti lesions may still be useful for diagnosis and they were retained as a minor feature. Their utility in adults is limited by the fact that many adults in the general population develop similar-appearing lesions as a consequence of chronic sun exposure. In such cases, the diagnosis of confetti lesions may be supported by a history of onset in the first decade of life or by asymmetric involvement of one body region over another. Dental enamel pits, previously included as a minor feature listed as “multiple, randomly distributed pits in dental MAPK inhibitor enamel” were again included as a minor feature (Fig 6). The designation was simplified to dental

enamel pits (≥3) for the entire dentition. Dental pits are much more common in TSC patients than the general population, with Mlynarczyk reporting 100% of adult TSC patients (n = 50) as having pitting compared with 7% of 250 adult control subjects.32 Because they are relatively common in the population, they are listed as a minor feature. Gingival fibromas have long been associated with TSC and were listed as a minor feature in the 1998 consensus document (Fig 7). They occur in about 20-50% of individuals with find more TSC, with greater frequency in adults than children.15, 21, 33 and 34 Fibromas in TSC may also be observed on the buccal or labial mucosa and even the tongue,34 so this criterion was modified to include fibromas at other intraoral sites. C59 cell line A stipulation was added for the presence of two or more intraoral fibromas because solitary oral fibromas may occur in the general population, particularly on the tongue or buccal mucosa along the bite line from

repeated trauma.35 and 36 Bone cysts were included in the 1998 criteria as a minor feature of TSC. Because of the lack of specificity for TSC and because the feature is rarely identified in the absence of additional TSC clinical features, a decision was made to delete “bone cysts” from the clinical diagnostic criteria. The finding of more than one retinal hamartoma was determined to be significant and specific enough to retain as a major feature (Fig 8). These lesions have similar histologic features to the tubers located in the brains of TSC patients. They are observed in 30-50% of TSC patients and it is not unusual to have multiple lesions in the same patient.37 and 38 The prevalence of retinal hamartomas in non-TSC populations is not known, but rare case reports have been made and a recent series of 3573 healthy term newborns identified only two cases of astrocytic hamartomas in that population.39 Fortunately, these lesions in TSC usually do not cause problems with vision and are a good marker for the disease, particularly in young children who might not yet have many other features.