What is the management approach for a patient presenting with a halo nevus?

Management of Halo Nevus

Halo nevi should be clinically monitored with regular follow-up, and only biopsied if there are concerning features such as color variation, nodules, or symptoms that suggest malignant transformation. 1, 2

What is a Halo Nevus?

A halo nevus (also known as Sutton's nevus) is a benign melanocytic nevus surrounded by a rim of depigmentation or "halo." It represents an immunological response of the body toward the nevus, which destroys melanocytes in the surrounding skin, leading to the depigmented halo 3. Halo nevi typically progress through several clinical stages:

• Stage I: Brown central nevus with surrounding rim of depigmentation
• Stage II: Central nevus loses pigmentation and appears pink with surrounding halo
• Stage III: Central papule disappears leaving a circular area of depigmentation
• Stage IV: Depigmented area repigments, leaving no trace 4

Evaluation Approach

Initial Assessment

• Perform thorough visual inspection and palpation of the halo nevus 1
• Dermoscopic evaluation is helpful for better characterization 1, 5
• Assess for concerning features:
  • Color variation
  • Nodules
  • Symptoms (pain, bleeding, rapid growth)
  • Ulceration 1

Risk Stratification

• Higher risk features requiring closer monitoring or biopsy:
  • Atypical appearance of central nevus
  • Rapid changes in appearance
  • Irregular borders
  • Multiple halo nevi (may be associated with increased melanoma risk) 6
  • Unusual darkening of central nevus rather than expected lightening 4

Management Algorithm

1. For typical, unconcerning halo nevi:

   • Clinical monitoring with regular follow-up
   • Patient education about self-examination
   • Documentation with clinical photographs for monitoring changes 2

2. For halo nevi with concerning features:

   • Consider excisional biopsy with 2mm margins 2
   • Avoid shave, punch, or incisional biopsies as they may underestimate depth 2
   • Orient excision to facilitate possible subsequent wide local excision if needed 2

3. When single halo nevus is present:

   • Consider biopsy to exclude melanoma
   • Examine patient's entire skin surface
   • Consider ophthalmologic examination to exclude intraocular melanoma 6

4. For multiple halo nevi:

   • More vigilant monitoring due to potential association with melanoma or vitiligo 6, 7
   • Consider referral to dermatology for specialized care 1

Follow-up Recommendations

• For typical halo nevi without concerning features:

  • Follow-up every 3-6 months initially
  • Document with clinical photographs to monitor changes
  • Gradually decrease frequency if stable 2

• For patients with multiple halo nevi or atypical features:

  • More frequent follow-up (every 3 months)
  • Consider referral to dermatology specialist 1, 2

• Between visits, patients should be instructed to:

  • Self-examine the halo nevus
  • Report concerning changes (rapid growth, bleeding, pain, nodule development, ulceration) 1

Special Considerations

• Halo nevi are more common in children and young adults, particularly on the trunk 3
• There is an increased frequency of halo nevi in patients with vitiligo 3, 7
• For persistent halo nevi causing cosmetic concerns, treatment options include:
  • Excision of the central nevus
  • Dermabrasion with epithelial grafting followed by narrow-band UVB phototherapy for resistant cases 7

Pitfalls to Avoid

• Don't assume all halo nevi are benign without proper evaluation
• Don't overlook the possibility of melanoma elsewhere in patients with halo nevi 6
• Don't perform shave biopsies on suspicious pigmented lesions 2
• Don't forget to examine the entire skin surface in patients presenting with halo nevi 6