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
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

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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