In the Pediatric Dermatology Clinic at the Johns Hopkins Children's Center, we evaluate over 5000 children each year, and at least 40% of visits include a full skin examination for assessment of melanocytic nevi. Melanocytic nevi of the scalp constitute a significant subset of referrals, and queries regarding removal of these lesions are often associated with unfounded fear of their malignant potential among primary care providers, dermatologists, and parents.
Dermatologists frequently recommend that melanocytic nevi of the scalp be excised, resulting in unsightly football-shaped scars and permanent localized hair loss (Figure 1). Unfortunately, surgery begets surgery, and some patients are subjected to recurrent procedures because parents and pediatricians become involved in notifying dermatologists of new scalp nevi as they appear. Although for darkly pigmented nevi that either fulfill some of the ABCDE criteria for melanoma (asymmetry, border irregularity, color variegation, diameter ≥6 mm, and/or evolution) or are difficult to follow clinically, removal might be justified, 2 particular clinical variants of scalp nevi that may appear worrisome for having malignant features are actually benign: they evolve in an innocent fashion and require observation only. These nevi, while frequently larger than 6 mm in diameter and multicolored, are notable for their often striking symmetry and distinctively bland and reassuring appearance to the trained eye. We encourage both dermatologists and pediatricians to be aware of the frequency and innocence of these lesions to prevent unnecessary concern, referrals, and surgical procedures.
Scar after removal of a scalp nevus. The dime is placed for size comparison.
Herein we describe the eclipse nevus and the cockade nevus. These nevi may look different from the garden-variety uniformly pigmented round nevus (Figure 2), but their different appearance should not trigger the alarm for melanoma, and they do not require excision. Rather, these scalp nevi should be considered markers for a potentially higher lifetime risk of melanoma because they are seen more frequently in children who will develop many nevi overall,1 which is itself a risk factor for melanoma.2
A two-toned melanocytic nevus, the eclipse nevus has a tan center that may be elevated, a brown rim, and sometimes a stellate border (Figure 3 and Figure 4). It is one of the most common scalp nevi found in children, and it is the coronalike border that garners attention. Dermoscopy, a clinical viewing technique that allows the clinician to detect subtle atypical changes in pigmented lesions, reveals that the central portion does not have a pigment network, whereas the brown rim exhibits a regular pigmented network (Figure 5). These findings should reassure dermatologists that the lesion is not melanoma. Moreover, when biopsy specimens are stained for melanin, most of the melanin is found along the border, presenting an innocent “shoulder” effect (Figure 6).
Dermoscopic image of an eclipse nevus. The central portion does not have a pigmented network, whereas the brown rim exhibits a regular pigmented network. Each scale mark represents 0.5 mm.
Eclipse nevus specimen demonstrating melanin deposition on the junctional shoulder (hematoxylin-eosin, original magnification ×10).
Characterized by a pigmented center surrounded by a hypopigmented ring inside an outer pigmented border (Figure 7), the cockade nevus may be solitary or occur with eclipse nevi on the scalp. Dermoscopy of the cockade nevus reveals innocent regular pigmented networks within the pigmented portions of the nevus and a structureless nonpigmented annulus (Figure 8). Histologic examination of a cockade nevus shows a central compound nevus with a peripheral, nonpigmented junctional pattern (Figure 9).3
Dermoscopic image of a cockade nevus. The pigmented portions are composed of regular pigmented networks surrounded by a structureless nonpigmented annulus. Each scale mark represents 1.0 mm.
Cockade nevus demonstrating a central compound nevus with a peripheral, nonpigmented junctional pattern (hematoxylin-eosin, original magnification ×10).
While scalp nevi should not be excised unnecessarily, their presence may be a marker for children who will eventually develop an above average number of moles on their bodies,1,4 which is itself a risk factor for developing melanoma in adulthood.2 To our knowledge, previous studies assessing the risk for melanoma in children with scalp nevi have not described the clinical appearance of scalp nevi. It has been reported that children with dysplastic nevus syndrome often present with prominent scalp lesions5 and that scalp nevi are more likely to be dysplastic than are nevi elsewhere on the body.6 Moreover, scalp nevi may have clinically worrisome features, but their unique histologic characteristics often do not meet the criteria for melanoma, a dysplastic nevus, or a Clark nevus.7
In our experience, nevi that fit the clinical description of a cockade or eclipse nevus do not warrant surgical excision. Consequently, children with these nevi do not need surgery. However, they would benefit from parental instruction on how to conduct home mole checks, and if they have numerous melanocytic nevi, multiple atypical nevi, and/or a history of melanoma in a first-degree family member, they should undergo regular skin examinations by a dermatologist.
Correspondence: Dr Cohen, Johns Hopkins Hospital, Child Health Bldg, Room 2105, 200 N Wolfe St, Baltimore, MD 21287 (firstname.lastname@example.org).
Accepted for Publication: June 17, 2009.
Author Affiliations: Sidney Kimmel Comprehensive Cancer Center (Ms Kessides) and Department of Dermatology (Drs Puttgen and Cohen), Johns Hopkins University School of Medicine, Baltimore, Maryland.
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Kessides and Cohen. Acquisition of data: Puttgen and Cohen. Analysis and interpretation of data: Kessides, Puttgen, and Cohen. Drafting of the manuscript: Kessides. Critical revision of the manuscript for important intellectual content: Kessides, Puttgen, and Cohen. Administrative, technical, and material support: Kessides, Puttgen, and Cohen. Study supervision: Puttgen and Cohen.
Financial Disclosure: None reported.
Funding/Support: This work was supported by a grant from the Doris Duke Charitable Foundation to Johns Hopkins University School of Medicine (Ms Kessides).
Role of the Sponsors: The Doris Duke Charitable Foundation had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Additional Contributions: Jean Bolognia, MD, Earl Glusac, MD, and Ayca Yazici, MD, provided photographic contributions.
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