Long term clinical and dermoscopic follow-up of a child with a Spitz nevus

doi:10.4236/ojped.2012.23040

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Open Journal of Pediatrics, 2012, 2, 253-256 OJPed

http://dx.doi.org/10.4236/ojped.2012.23040 Published Online September 2012 (http://www.SciRP.org/journal/ojped/)

Long term clinical and dermoscopic follow-up of a child

with a Spitz nevus*

Massimiliano Scalvenzi#, Maria Grazia Francia, Franco Palmisano, Claudia Costa

Department of Dermatology, University of Naples Federico II, Naples, Italy

Email: #[email protected]

Received 31 May 2012; revised 17 July 2012; accepted 25 July 2012

ABSTRACT

Background: Spitz nevus is uncommon, benign mel-

anocytic neoplasm that may show some clinical, der-

moscopical and histological features of melanoma. It

occurs often in childhood, but may appear also in

early adulthood. Rare congenital cases have been re-

ported in literature. It is frequently located on the

face and the lower extremities, but in some cases may

appears on the trunk. Methods: We report a case of a

9-year-old girl presented to our Dermatology Unit

because of the presence of a pigmented lesion on her

right leg, 4 mm in diameter, which was clinically and

dermoscopically diagnosed as Spitz nevus. We de-

scribed the clinical and dermoscopic features that we

observed every six months, over 11 years follow-up

period. Objective: Our observation show that the glo-

bular, the starburst, the homogeneous patterns and

diffuse brown colour with diffuse hypopigmented areas

may be the different expression that correspond to

possible evolutionary phases of pigmented Spitz nevus.

Keywords: Spitz Nevus; Evolution; Dermoscopy

1. INTRODUCTION

Spitz nevus in its classic clinical appearance is described

as a rapidly growing, pink or flesh-coloured papule or

nodule of the face or the lower extremities in childhood;

however brown and even black pigmentation is common

as well. Described for the first time by Sophie Spitz in

1948 as melanoma of childhood, is now considered as a

benign melanocytic neoplasm.

In the last 20 years dermoscopy has been increasingly

used as a non invasive diagnostic technique for the in

vivo observation of pigmented skin lesions. Dermoscopy

is a very useful method in the study of Spitz nevi in order

to understand its evolution, which until now was un-

known, and subsequently this will lead to a better man-

agement [1].

Specific dermoscopy criteria have been described for

differentiating Spitz nevi from cutaneous melanoma [2].

Spitz nevi can be easily identified by a prominent sym-

metrical starburst or globular pattern, with a central, bi-

zarre or reticular depigmentation, and a rim of brown

globules at the periphery, which in some instances may

mimic pseudopods. In addition, Spitz nevi can often

show a pattern characterized by an uneven distribution of

colours and structures, and an irregular diffuse pigmenta-

tion resembling blue-white veil or irregular extensions

(black blotches) [2].

In contrast cutaneous melanoma is asymmetrical and

irregularly pigmented with variable combinations of

broadened pigmented network, blue-white veil, irregular

black dots or brown globules, peripheral depigmentation,

irregular extensions and radial streaming at the edge of

the lesion.

2. CASE REPORT

A 9-year-old girl was examinated at our Dermatology

Unit for the presence of a pigmented lesion located on

her left leg, 4 mm in diameter, that at the dermoscopic

examination revealed the typical features of a pigmented

Spitz nevus consisting of a central prominent grey-blue

pigmentation and a rim of peripheral large blue-black

globules (Figure 1). Because of the dermoscopic pattern

strongly suggestive of Spitz nevus no biopsy were per-

formed.

Dermoscopic images have been made with Nikon

Coolpix 4500 digital camera (4.0 mega pixels 4× zoom)

and Dermlite foto (3GEN).

Six months later, the lesion enlarged, measuring 6.3

mm in its largest diameter; dermoscopy showed a star-

burst pattern with radial streaks regularly distributed over

the entire lesion, that was unchanged during the next two

years follow-up (Figure 2).

In March 2004, a homogeneous pattern with blue-brown

pigmentation in the center of lesion was identified and

has still been observed for the following 2 examinations.

*Conflict of Interest: None.

#Corresponding author. Since March 2005 the pattern has been stable, while

OPEN ACCESS

M. Scalvenzi et al. / Open Journal of Pediatrics 2 (2012) 253-256

254

Figure 1. Clinical and dermoscopic typical features of pig-

mented Spitz nevus consisting of a central prominent grey-blue

pigmentation and a rim of peripheral large blue-black globules.

Figure 2. Clinical and dermoscopic features after six month

showed a starburst pattern with radial streaks regularly distrib-

uted over the entire lesion.

less intensity of the blue-white structures and pigmenta-

tion was seen. From June 2006 the lesion showed a ho-

mogeneous brown pigmentation with a further reduction

of the blue-white structures (Figure 3). In September

2007 we observed at dermoscopic examination the com-

plete regression of the blue-white structures and the

presence of multiphocal central hypopigmented areas,

and has still been observed for the following follow-up.

In November 2008 the lesion showed only remnants of

light-brown pigmentation with large hypopigmented ar-

eas (Figure 4).

From November 2008 to May 2012 the lesion showed

a further reduction of the light-brown pigmentation (Fig-

ure 5).

3. DISCUSSION

The natural history of melanocytic nevi is poorly understood

Figure 3. Clinical and dermoscopic features after three years of

follow-up showed a homogeneous brown pigmentation with

more reduction of blue-white structures.

Figure 4. Clinical and dermoscopic features after eight years of

follow-up showed only remnants of light-brown pigmentation

with large hypopigmented areas.

Figure 5. Clinical and dermoscopic features after eleven years

of follow-up showed only a further reduction of light-brown

pigmentation.

M. Scalvenzi et al. / Open Journal of Pediatrics 2 (2012) 253-256 255

owing the lack of follow-up studies investigating their

long-term evolution.

Spitz nevus is a solitary dome-shaped papule, measur-

ing up to 1 cm in diameter. Its surface is smooth or kera-

totic/verrucous and occasionally even papillomatous.

Although initially described as a non-pigmented lesion,

recent data underline that Spitz nevi are brown to black

in 80% of histological examinated cases. Large (>1 cm)

nodular and/or ulcerated lesions must be always regarded

as worrisome even in childhood.

Six main dermoscopic patterns can be described in

Spitz nevus: vascular, globular, reticular, starburst, poly-

morphous and homogeneous [3]. The vascular pattern is

characterised by dotted vessels, which are responsible of

its pink colour, regularly distributed throughout the le-

sion. The globular pattern shows the presence of brown

to black globules, large and regularly distributed at the

periphery. They are most frequent in pigmented Spitz

nevus where often they are fused with the central body of

the lesion. The reticular pattern shows a heavy pigmenta-

tion rise to a regular black network, which rest above the

lesion and can be removed by tape stripping. The star-

burst pattern is characterised by radial projections, also

called streaks, that from the centre of lesion came to the

periphery. Several of this dermoscopic features can be

simultaneously present in the lesion with an irregular

distribution in the polymorphous pattern also known as

“melanoma-like” pattern. Most of this different dermo-

scopic pattern simply corresponds to different phases of

the natural evolution of Spitz nevus.

Spitz nevus must be differentiated from viral warts,

pyogenic granuloma, lymphoid infiltration of the skin,

verrucous epidermal nevus, etc. The uniform distribution

of vascular pattern in Spitz nevus can also help in the

differential diagnosis with amelanotic melanoma. Dif-

ferential diagnosis of pigmented Spitz nevus may include

hyperpigmented Clark nevus and melanoma [4,5]. The

occurrence of an atypical dermoscopic pattern in Spitz

nevus is well recognized as is the occurrence of mela-

noma showing very few or no dermoscopic features

suggestive of malignancy but exhibiting either the globu-

lar or the starburst pattern.

There is no consensus about the benign nature of Spitz

nevus, but its natural history is not fully understood and

the histopathological differentiation from “spitzoid le-

sions” as spitzoid melanoma, is often difficult as the

management of this lesions.

There are different choices of management [6]: Spitz

nevus appearing up to the age of 12 years that can be

easily diagnosed and managed conservatively if it is

small (up to1 cm) and shows no atypical clinical and

dermoscopic features, can be followed-up every six

months for the first 2 - 3 years and then just once a year.

Large (>1 cm), ulcerated, rapidly changing, or atypical

Spitz nevus of childhood must be excised. Surgical exci-

sion is also recommended when Spitz nevus appear in

the adulthood.

The limited numerousness of sampling is balanced by

the long length of the follow-up, hardly performable on a

larger sampling due to a low compliance especially in the

late phases of the evolution of the lesion when the Spitz

nevus, in its involutional phase, is not perceived by the

patient as a potentially dangerous lesion to be inspected

again.

4. CONCLUSIONS

Spitz nevus is a clinical entity with clinical ambiguity

that makes problematic the diagnosis and the manage-

ment of the patient.

On the basis of our observation the complete regres-

sion of the blue-white structures and the presence of

multiphocal central hypopigmented areas might reflect a

further evolutionary phase of pigmented Spitz nevus of

childhood.

We support the hypothesis, yet described by other au-

thors [6-8], that the globular and the starburst pattern and

the homogeneous pigmentation might represent the

natural evolution of the Spitz nevus in childhood rather

than the expression of different clinicopathologic enti-

ties.

There are two extremes of management: Spitz nevus

can be always periodically controlled, or should be al-

ways excised [9].

Based on this consideration, Spitz nevus appearing up

to the age of 12 years can be easily diagnosed and man-

aged conservatively if it is relatively small and shows no

atypical clinical and dermoscopic features. Under these

circumstances, a follow-up can be scheduled with control

every 3 - 6 months [6]. In the absence of dramatic

changes in colour, shape or size, such a follow-up proto-

col can be held until the appearance of a homogeneous

pattern; since then, a 1-year follow-up can be employed

[6].

The long term follow-up of Spitz nevus is recom-

mended to avoid surgical excision of these lesions in

childhood.

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Dermatoscopic pitfalls in differentiating pigmented Spitz

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