NEVI

BENIGN OR MALIGNANT?
CELLULAR NEVI, NEVOCYTIC NEVUS

• appear in the first years of life and increase in

prevalence and number of lesions over the following
2-3 decades, after which there is a steady decline
• females have more nevi than males, and whites
more than blacks
• sun exposure appears to increase the number of
moles in the exposed skin
• less common in covered areas such as the buttocks,
except in the dysplastic nevus syndrome
• women have more nevi on the legs, and men
on the trunk
• blacks have more nevi than whites on the
palms, soles, conjunctivae and nail beds
• plantar nevi > palmar nevi
• mucous membrane and nail bed nevi unusual
in all patients
What is the average number of
moles in a person’s body?
• A. 10
• B. 20
• C. 30
• D. 40
Do our moles change?
• Yes
• No
Incidence and Prevalence
• not stable, grows, going through changes of
maturation, and even of senescence
• maximum number of nevi is present between
the ages 20 and 25, and the average number
is 40 — flatten and fade, disappear
completely by age 90
• nevi begin as small, flat pigmented macules
— junctional nevi — compound nevi —
intradermal nevi
Clinical and histologic features:
JUNCTIONAL NEVUS:
• smooth, hairless, light to dark brown macule
• may have the characteristic target or fried egg
appearance
• sites: palms, soles, scrotum
• may be present at birth, but usually appear
between 3-18 y/o
• adolescence and adulthood — become
compound or intradermal
JUNCTIONAL NEVUS
COMPOUND NEVUS
• both junctional and intradermal
• nevus cells extend into the dermis
• later, nevus cells become separated from the
epidermis by a band of connective tissue —
Intradermal Nevus
COMPOUND NEVUS
INTRADERMAL NEVUS
• found in middle-aged persons
• dome-shaped, sessile, warty or smooth
papules, flesh-colored, brown to black, and
with or without hairs
INTRADERMAL NEVUS
• junctional nevus: single or groups of
melanocytes in the lower levels of epidermis
• compound nevus: still manifesting junctional
activity (accumulation of melanocytes in
theques in the epidermis) but has the formed
structure of a cellular nevus in the dermis
• intradermal nevus: no junctional activity and
all the nevus cells are in the dermis
Signs of malignant degeneration:
• recent enlargement
• irregular or scalloped border
• asymmetry
• changes or variegation in color (red, white or blue)
• surface changes (scaling, erosion, oozing,
crusting, ulceration, or bleeding)
• palpable thickening
• pain or tenderness
• signs of inflammation
• satellite pigmentation
Signs of malignant degeneration:
• “ugly duckling sign”: a nevi that does not share the
same characteristics as the majority —> biopsy
• nevi with small dark dots that do not lie entirely
within the lesion, but produce a small extension
beyond the border
• perifollicular hypopigmentation giving a notched
appearance
• new pigmented nevus in a patient > 35 y/o
• Hutchinson’ sign: pigmentation over the nail fold
Signs of benignancy:
• diameter ≤ 3 mm
• perfectly uniform pigmentation
• flaccid epidermis
• smooth, uniform border
• unchanging size and color
Treatment:
Indications for removal and biopsy:
> signs of malignant transformation
> cosmetic
> located in areas of irritation
> nevi on the hairy scalp, oral or vaginal mucous
membrane
> an acquired longitudinal pigmented band in an
adult involving only one nail
> conjunctival nevi in the palpebral or formiceal
conjunctiva, extension into the cornea or canalicular
obstruction
> tarsal pigmentation
BALLOON CELL NEVUS
• a pigmented nevus, from 1-5 mm,
indistinguishable from the ordinary pigmented
or nonpigmented nevus, usually occuring on
the head, neck, trunk and occasionally, the
arm and foot
• histologically, lesions are composed of peculiar vesicular c
HALO NEVUS (Sutton’s nevus, Perinevoid
Vitiligo, and Leukoderma Acquisitum Centrifugum)

• pigmented nevus, with a surrounding

depigmented zone
• usually a compound or intradermal nevus
with a concentric area of depigmentation that
has a regular, sharply demarcated border
• may be single or multiple and occurs most
frequently on the trunk
• develop mostly in teenagers
HALO NEVUS
• Pathogenesis: immunologically induced
rejection of melanin or of a melanoma
beginning in the nevus
• Treatment: not indicated —regress
spontaneously with time
EPITHELIOID and SPINDLE CELL NEVUS
(Benign Juvenile Melanoma, Spitz Nevus)
• smooth-surfaced, raised, round, slightly
scaly, firm papule with a distinctive pink,
brownish red or purplish red color, 3-10 mm in
diameter
• occur during the first two decades of life
• site: face (cheek), legs (pigmented type)
• preponderance in females
• may occur as clustered papules in children
and adults
EPITHELIOID and SPINDLE CELL NEVUS
• a variant of compound nevus
• histologic: nevus cells are pleomorphic,
mostly spindle-shaped, or less often
polygonal, giant cells may be seen
Treatment:
• excision biopsy
 CONGENITAL
NEVOCYTIC NEVUS
GIANT PIGMENTED NEVUS (Giant
Hairy Nevus, Bathing Trunk Nevus)

• large, > 20 cm in diameter, darkly pigmented hairy

patch in which smaller, darker patches are
interspersed or present as small satellite lesions
• skin may be thickened and verrucous
• site: trunk (upper and lower back), usually
dermatomal
• present at birth and grow proportionally to the site of
the body on which they are located
• incidence of developing into melanomas is 3-
7%
• 40% of malignant melanomas in children occur
in large congenital nevi
• risk is greatest for axial lesions
• when it involves the axial skin, may be
associated with neurocutaneous melanocytosis
• if neurocutaneous melanocytosis is present,
the risk of dying at a young age is high
secondary to hydrocephalus or leptomeningeal
melanoma
• Histologically: nevus cells in the lower 2/3 of the de
Treatment:
• total surgical excision and resurfacing with
autografts
• dermabrasion, curettage and laser ablation
Small and Medium-sized
Congenital Nevocytic Nevus
• small congenital nevocytic nevi: <1.5 cm
• medium congenital nevi: 1.5-20 cm
• found in 1% of newborns, half eventually
become hairy
• Histologically: similar to acquired nevi, but
deeper, consisting of spindle cells that may
extend into the subcutaneous tissue and may
surround the adnexa, vessels, and nerves
Congenital Nevocytic Nevus
Congenital Nevocytic Nevus
Treatment:
• excision is recommended for lesions of the
hairy scalp, or those of great cosmetic
concern, or nevi that have unusual clinical
features
DYSPLASTIC NEVUS
• a variegated tan, brown, and pink coloration,
with the pink hues seen mainly in the macular
portion of the nevus
• a macular component is always present and
may comprise the entire lesion but frequently
surrounds a papular center
• larger than common nevi, usually 5-12 mm
• have irregular shape, with frequent indistinct
borders
DYSPLASTIC NEVUS
Dysplastic Nevus Syndrome
• patients with dysplastic nevi who have at
least two blood relatives with dysplastic nevi
and melanoma
• there is a 100% lifetime risk
• an associated increased risk of developing
pancreatic carcinoma in some families
Dysplastic Nevus Syndrome
Dysplastic Nevus
• may occur in patients without a personal or
family history of melanoma, with 5-20% of
patients having at least one clinically
dysplastic nevus
• the relative risk defined by the presence of
these lesions is strong, depending on the
number of dysplastic nevi present
Management:
• initial examination of a patient with a dysplastic
nevus should include a total body inspection,
including the scalp
• family history of moles, skin cancer and melanoma
• baseline dermatologic photography
• excision biopsy of dysplastic nevi
• advise sun avoidance and sunscreen use
• self-examination
• yearly dermatologic examination in low risk patients
or every 3-6 months in patients with a (+) family
history of melanoma