Management of Spitz Nevus in Children
Typical Spitz nevi in children should be completely excised with narrow margins (1-2 mm), as they are considered benign lesions. 1, 2
Diagnostic Approach
When evaluating a suspected Spitz nevus in a child, consider:
- Complete excisional biopsy with narrow margins is the preferred approach for initial diagnosis, as recommended by the American Academy of Dermatology 1
- Avoid shave biopsies when possible, as they have a high incidence (67%) of involved margins 3
- Dermoscopy can aid in evaluation but cannot reliably distinguish benign Spitz nevi from spitzoid melanoma 4
Management Algorithm
For Typical Spitz Nevi
- Complete excision with 1-2 mm margins is recommended 2, 5
- Pediatric dermatologists overwhelmingly (80%) recommend narrow margins of 1-2 mm 5
For Atypical Spitz Tumors
- For children <14 years with atypical or malignant spitzoid lesions, a 1-cm margin is recommended regardless of measured thickness 2, 1
- Consider additional molecular and immunohistochemical testing to assess malignant potential 2, 1
- Histopathologic evaluation should include assessment for:
For Incompletely Excised Spitz Nevi
- 69% of dermatologists recommend complete re-excision of incompletely removed Spitz nevi 5
- For atypical Spitz nevi with positive margins, narrow re-excision (average 2.2 mm) is typically performed 3
Follow-up Recommendations
- For typical Spitz nevi that have been completely excised, routine follow-up may be sufficient 5
- For atypical Spitz tumors, close clinical follow-up is recommended 6
- Consider dermoscopic monitoring every 6 months for Spitz nevi that are not excised, particularly in young children 7
Important Considerations
- Sentinel lymph node biopsy (SLNB) may be considered for lesions ≥1 mm in thickness when melanoma cannot be excluded 2, 1, but evidence suggests SLNB may not be warranted in routine management of pediatric atypical Spitz tumors 6
- A significant study of 24 children with atypical Spitz tumors treated with excision alone (without SLNB) showed no recurrence, additional lesions, or metastases after a mean follow-up of 8.4 years 6
Potential Pitfalls
- Differentiating between Spitz nevi and spitzoid melanoma remains difficult even for experienced dermatopathologists 2, 1
- Labeling a benign lesion as malignant can lead to unnecessary wide re-excisions and morbidity 2, 1
- Conversely, misdiagnosing a spitzoid melanoma as benign could lead to inadequate treatment 4
- While 74% of dermatologists believe Spitz nevi are entirely benign, 22% remain unsure about their biological potential 5
For optimal management, referral to a pediatric dermatologist or dermatologist with expertise in pigmented lesions is recommended for children with concerning spitzoid lesions.