Clinical and Experimental Dermatology
Clinical dermatology • Concise report
Eruptive disseminated Spitz naevi: dermatoscopic features I. Kilinc Karaarslan, F. Ozdemir, T. Akalin,* G. Ozturk, B. G. Turk and G. Kandiloglu* Departments of Dermatology and *Pathology, Medical Faculty, Ege University, Izmir, Turkey doi:10.1111/j.1365-2230.2009.03540.x
Summary
Eruptive disseminated Spitz naevi is a rarely reported condition. Although the dermatoscopic features of nondisseminated, solitary forms of Spitz naevi are well known, there are no reports describing the dermatoscopic features of eruptive disseminated variant. We report an additional case and describe the dermatoscopic features. Two patterns were observed. In all pink lesions, the vascular pattern was seen, composed of dotted, linear or comma-like vessels located at the centre of the meshes of the reticular depigmentation. In all brown lesions, we observed only the reticular pattern, which is quite interesting as the reticular pattern is a rare feature of Spitz naevi. This observation may be a special feature particularly seen in the eruptive disseminated variant. A superficial black network also accompanied reticular pattern in some lesions. In dichromatic lesions, both patterns were observed in different areas of the body.
Spitz naevi are benign melanocytic skin lesions with distinct clinical and histopathological features. They are classified as solitary, agminated, or eruptive disseminated,1 according to their distribution on the body. The eruptive disseminated variant is the rarest form reported in the literature, and no report has described the dermatoscopic features. We report an additional case of eruptive disseminated Spitz naevi (EDSN) and describe the dermatoscopic features of the lesions.
Report A 16-year-old girl presented with a 2-year history of innumerable asymptomatic papular lesions on her body. The lesions were initially located on the buttocks; they later spread to her legs and more recently to her abdomen, chest and arms. There was no history of rapid growth, bleeding or itching in any of the lesions. No excision or other surgical procedure had been
Correspondence: Dr Isil Kilinc Karaarslan, Department of Dermatology, Medical Faculty, Ege University, 35100 Bornova, Izmir, Turkey E-mail:
[email protected] Conflict of interest: none declared. Accepted for publication 6 January 2009
performed. The patient did not have any history of sunburn, systemic disease or medication. On physical examination, hundreds of papular lesions were seen, located on the buttocks and legs, with smaller numbers on the abdomen, trunk and arms (Fig. 1a). The scalp, genital region, palms and soles were spared. The lesions were 10–50 mm in diameter, and pink or brown in colour (approximately equal numbers of both colours). A few lesions were partly pink and partly brown in colour (dichromatic) (Fig. 1b). None of the lesions was hyperkeratotic. On dermatoscopy (DermLite Foto; 3Gen, LLC, Dana Point, CA, USA), according to the revised pattern analysis,2 the pink lesions exhibited a vascular pattern with dotted (Fig. 2a), linear (Fig. 2b) or comma-like (Fig. 2c) vessels located at the centre of the meshes of the reticular depigmentation, evenly distributed throughout the lesion. In the brown lesions, dermatoscopy revealed a coarse pigment network gradually thinning at the periphery (reticular pattern) (Fig. 3a). Some of the brown lesions showed a superficial black network, together with a reticular pattern. In the dichromatic lesions, dermatoscopy revealed vascular and reticular patterns in different areas (Fig. 3b). All lesions had similar morphological and dermatoscopic features, and there was no evidence of malignancy.
2009 The Author(s) Journal compilation 2009 British Association of Dermatologists • Clinical and Experimental Dermatology, 34, e807–e810
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Eruptive disseminated Spitz naevi • I. K. Karaarslan et al.
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Figure 1 (a) Numerous papular lesions on the buttocks; (b) close-up view of each morphological type [pink, brown and dichromatic (arrow) lesions].
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Figure 2 Dermatoscopy showed (a) dotted vessels (arrows) located at the centre of the meshes of the reticular depigmentation all through the lesion; (b) linear vessels (arrows); (c) comma-like vessels (arrows).
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Figure 3 Dermatoscopy showed (a) pure reticular pattern in two brown lesions; (b) vascular and reticular patterns in different parts of a dichromatic lesion (arrow).
We excised 14 lesions for histopathological examination, which represented each morphological type [7 pink (5 large, 2 small); 4 brown (2 with pure reticular pattern, 2 with reticular pattern and superficial black network); and 3 dichromatic lesions].
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All lesions had features compatible with Spitz naevi. The pink lesions were compatible with classic Spitz naevi, and were characterized by large predominantly epitheloid cells located mostly in large nests. The interface between the nests and epidermis was sharp, and clefting was
2009 The Author(s) Journal compilation 2009 British Association of Dermatologists • Clinical and Experimental Dermatology, 34, e807–e810
Eruptive disseminated Spitz naevi • I. K. Karaarslan et al.
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Figure 4 (a) Classic Spitz naevus, showing the symmetry of the lesion; (b) uniform spitzoid cytology of naevus cells. Haematoxylin and eosin, original magnification (a) · 40; (b) · 100.
evident in some of the nests (Fig. 4). The brown lesions were compatible with pigmented Spitz naevi, and were characterized by pigmented large epitheloid and spindle cells located both in the nests and at the dermoepidermal junction, with a lentiginous pattern. There was an inflammatory infiltrate of variable intensity in all of the lesions, which was relatively heavy in the pigmented Spitz naevi. There was neither pagetoid spread nor evident cytological atypia in any of the lesions. Lymph nodes were not palpable clinically. Abdominal ultrasonography, chest radiography, computed tomography of the chest and abdomen and electroencephalography scans were within normal limits. Hence, follow-up using a hand-held dermatoscope at 6-monthly intervals was recommended without any further surgical procedure. EDSN is an extremely rare variant of Spitz naevi. It has been described as numerous asymptomatic domeshaped papules on the body with an eruptive onset. Precipitating factors such as pregnancy,3 intravenous drug misuse,4 and tonsillectomy and postoperative fever5 have been reported in some of the cases. There have also been some cases associated with central nervous system disease.6,7 Our patient’s personal medical history was unremarkable for any precipitating factor or neurological abnormality, and the morphology and distribution of lesions were consistent with earlier reports. The clinical differential diagnosis included eruptive melanocytic naevi, urticaria pigmentosa and dysplastic naevus syndrome. The dermatoscopic features of EDSN have not been described in any of the previous reports. For
nondisseminated, solitary forms, the vascular pattern, which is described as monomorphic and regularly distributed dotted vessels surrounded by reticular depigmentation,8 has been found in the classic solitary pinkish lesions. In the present case of EDSN, it was notable that the vascular pattern seen in the pinkish lesions was composed of various types of vessels, not only dotted, but also linear or comma-like. The localization of each individual vascular structure at the centre of the meshes of the reticular depigmentation and the regular distribution of all these vessels throughout the lesion were the most important features in differentiating this vascular pattern from the atypical vascular pattern (irregular ⁄ polymorphous vessels), which is suspicious for melanoma and includes irregular distribution of multiple vessels of various shapes (linear, dotted or globular red vessels).8 Solitary pigmented Spitz naevi have been reported to exhibit a variety of patterns, including starburst, globular and homogeneous patterns, and superficial black network.8 In our case, we observed only the reticular pattern in all brown lesions. This observation is interesting because the reticular pattern is a rare feature in Spitz naevi. It was seen only in 2 of 83 solitary Spitz naevi in a study reported by Ferrara et al.9 The presence of melanocytes at the dermoepidermal junction with a lentiginous pattern is the histopathological counterpart of the pigmented network seen on dermatoscopy. The observation of the reticular pattern in all brown lesions may be a special feature particularly seen in the eruptive disseminated variant of Spitz naevi. The challenging issue in EDSN is the assessment of the risk of developing malignancy. However,
2009 The Author(s) Journal compilation 2009 British Association of Dermatologists • Clinical and Experimental Dermatology, 34, e807–e810
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malignancy was not reported in any of the cases in the literature. Levy et al.1 followed up a case of EDSN for 19 years without finding any development of malignancy. In our patient, all the lesions were evenly distributed, symmetrical in shape and had similar morphological and dermatoscopic features. None of them had features suspicious for malignancy, such as large size, rapidly changing morphology or ulceration. Hence, follow-up was recommended without any further surgical procedure.
References 1 Levy RM, Ming ME, Shapiro M et al. Eruptive disseminated Spitz nevi. J Am Acad Dermatol 2007; 57: 519–23. 2 Argenziano G, Soyer HP, Chimenti S et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet. J Am Acad Dermatol 2003; 48: 679–93.
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3 Onsun N, Sarac¸og˘lu S, Demirkesen C et al. Eruptive widespread Spitz nevi: can pregnancy be a stimulating factor? J Am Acad Dermatol 1999; 40: 866–7. 4 Fass J, Grimwood RE, Kraus E, Hyman J. Adult onset of eruptive widespread Spitz’s nevi. J Am Acad Dermatol 2002; 46: 142–3. 5 Smith SA, Day CL Jr, Vander Ploeg DE. Eruptive widespread Spitz nevi. J Am Acad Dermatol 1986; 15: 1155–9. 6 Wallace HJ. Eruptive juvenile melanomata. Br J Dermatol 1974; 91: 37–8. 7 Capetanakis J. Juvenile melanoma disseminatum. Br J Dermatol 1975; 92: 207–11. 8 Soyer P, Argenziano G, Hofmann-Wellenhof R, Johr R, eds. Color Atlas of Melanocytic Lesions of the Skin. Berlin: Springer, 2007: 151–63. 9 Ferrara G, Argenziano G, Soyer HP et al. The spectrum of Spitz nevi: a clinicopathologic study of 83 cases. Arch Dermatol 2005; 141: 1381–7.
2009 The Author(s) Journal compilation 2009 British Association of Dermatologists • Clinical and Experimental Dermatology, 34, e807–e810
