Pigmented Spitz nevus simulating a solitary angiokeratoma Stefano Cavicchini, MD, Gianluca Nazzaro, MD, Ylenia Balice, MD, and Roberta Fiorani, MD Milan, Italy

CLINICAL PRESENTATION A 11-year-old child presented with a black 4-mm slow-growing tumor on her left shoulder. The lesion was symmetrical, slightly elevated, and had a mamillated surface with sharp margins.

DERMOSCOPIC APPEARANCE The dermoscopic analysis revealed multiple violaceous large and round structures under a diffuse whitish veil. Rare smaller brown and black globules were also evident. A diagnosis of solitary angiokeratoma versus a Spitzoid lesion was made (Fig 1). A follow-up visit was scheduled after 3 months when the dermoscopic photograph showed a globular pattern with large brown-black globules and small areas with hyperkeratotic scales (Fig 2). The lesion was excised with the suspicion of Spitz nevus.

Fig 1. A, Clinical photograph of the 4-mm papular, mamillated neoplasm. B, At dermoscopy, multiple violaceous, round structures and a diffuse whitish veil.

From the Dipartimento di Fisiopatologia medico-chirurgica e dei trapianti, Universita degli Studi di Milano - Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico. Funding sources: None. Conflicts of interest: None declared. Reprint requests: Gianluca Nazzaro, MD, Dipartimento di Fisiopatologia medico-chirurgica e dei trapianti, Universita

degli Studi di Milano - Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Pace 9, 20122 Milan, Italy. E-mail: [email protected] J Am Acad Dermatol 2015;72:e99-100. 0190-9622/$36.00 ª 2015 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2015.01.016

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Fig 2. A, The same lesion (Fig 1) after 3 months of follow-up. B, Dermoscopy showed a globular pattern with large black globules and hyperkeratotic scales in the middle of the lesion.

HISTOLOGIC DIAGNOSIS The histologic examination revealed a pigmented Spitz nevus (Fig 3).

Fig 3. Pigmented Spitz nevus. A, A symmetrical well-circumscribed melanocytic neoplasia in the dermis associated with mild inflammatory infiltrate. B, Large and fusiform nonjunctional hyperpigmented melanocytes gathered in nests that show maturation while descending into the dermis. (A and B, Hematoxylin-eosin stain; original magnifications: A, 34; B, 320.)

KEY MESSAGE Pigmented Spitz nevus may sometimes clinically simulate a solitary angiokeratoma but it can usually be distinguished because dermoscopy shows a globular or a starburst pattern.1 In this patient, the confounding dermoscopic aspect was the presence of lacune-like violaceous structures associated with a whitish veil, generally observed in angiokeratoma.2 On the contrary, the dermoscopic pattern encountered after 3 months was more clearly that of a Spitzoid neoplasm. This case further confirms that Spitz nevus is a simulator of a large amount of skin moles and that solitary angiokeratoma is not only a clinical differential diagnosis but also a dermoscopic one. Lastly, we underline how the use of dermoscopic follow-up of Spitzoid lesions in well-selected cases can help to avoid diagnostic pitfalls.

REFERENCES 1. Ferrara G, Gianotti R, Cavicchini S, Salviato T, Zalaudek I, Argenziano G. Spitz nevus, Spitz tumor, and Spitzoid melanoma: a comprehensive clinicopathologic overview. Dermatol Clin. 2013;31:589-598. 2. Zaballos P, Daufi C, Piug S, et al. Dermoscopy of solitary angiokeratomas. Arch Dermatol. 2007;143:318-325.

Pigmented Spitz nevus simulating a solitary angiokeratoma.

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