Derm Dilemma
by Amanda Ederle , MD
A healthy , 16-year-old boy is brought into clinic by his parents , who are concerned about a white ring that was recently noticed around a mole on his back . The parents state that over the last several weeks , white rings have developed around other preexisting moles . The parents are understandably concerned about the significance , if any , of these changes . Physical examination is significant for multiple pink-brown papules surrounded by an areola of hypopigmentation on the patient ’ s back .
The next step in management should be :
A . Excision of all the moles B . Biopsy of one of the moles for histologic evaluation to aid in diagnosis C . Obtain scrapings for potassium hydroxide examination , as these changes likely represent tinea versicolor D . Reassurance
Answer : D – Reassurance
The patient above has multiple halo nevi ( Sutton ' s nevi ). Halo nevi are melanocytic nevi that are surrounded by symmetric circular areas of hypoor depigmentation . Halo nevi are not uncommon , occurring in about 1-5 % of children and adolescents . The areola of pigment loss portends spontaneous regression of the surrounded nevus , usually a benign , common-acquired melanocytic nevus via a T-cell mediated immunologic cascade . Typically , halo nevi appear on the back or trunk , with multiple lesions being present in half of those affected . If the central nevus does not have features concerning for malignancy , such as asymmetry , dark non-uniform pigmentation , or irregular borders , biopsy is not warranted , and the provider may provide reassurance to patients . However , halo nevi are quite uncommon in middle-aged and older adults and may represent an immune response to a cutaneous or ocular
melanoma , so thorough skin and eye examination in this demographic is imperative . Halo nevi tend to follow a stepwise progression : 1 ) development of an annular area of depigmentation ; 2 ) the central nevus fades from brown to pink ; 3 ) the nevus disappears completely , leaving behind a circular area of depigmentation ; and 4 ) repigmentation gradually occurs . This process may take years , so it is important to educate patients on the length of the process . Because many patients with halo nevi have an increased number of common acquired nevi , total body skin examination is recommended .
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82 • The Journal of the Arkansas Medical Society www . ArkMed . org