Halo Nevi: Diagnosis and Management
Clinical Diagnosis
Halo nevi (Sutton nevi) are benign melanocytic nevi surrounded by a depigmented halo that require clinical recognition and reassurance, with intervention reserved only for atypical features suggesting melanoma. 1
Key Diagnostic Features
- Classic presentation: Brown nevus with surrounding rim of depigmentation, most commonly occurring in children and young adults (mean age 15 years) with approximately 1% population incidence 1
- Typical location: Multiple lesions frequently localized on the back 1
- Clinical stages to recognize:
- Stage I: Brown nevus with surrounding depigmentation (classic presentation)
- Stage II: Central nevus loses pigmentation, appears pink with halo
- Stage III: Central papule disappears, leaving circular depigmented area
- Stage IV: Depigmented area repigments, potentially leaving no trace 2
Differential Diagnosis Considerations
Halo nevi must be distinguished from vitiligo and other depigmenting conditions, as they are listed in the differential diagnosis of vitiligo 3. Key distinguishing features include:
- Halo nevi-associated leucoderma: Variable asymmetric distribution, limited extent, lack of progression, high number of halo nevi, absence of vitiligo family history, and absence of autoimmune diseases 4
- Classic vitiligo: Symmetrical depigmented areas, progressive course, often associated with autoimmune thyroid disease (34% of adults), family history in 32% of patients 3
- Other considerations: Hypopigmented nevus, idiopathic guttate hypomelanosis, postinflammatory depigmentation 3
Management Approach
Initial Assessment
- Examine for atypical features that would warrant biopsy or excision: asymmetry, irregular borders, color variation, diameter >6mm, evolution/change, or symptoms (bleeding, pain) 1, 5
- Document number and location of halo nevi, as multiple lesions are common 1
- Screen for associated conditions: vitiligo, autoimmune thyroid disease (Hashimoto thyroiditis), alopecia areata, celiac disease, atopic dermatitis 1
- Obtain family history for vitiligo, autoimmune diseases, and melanoma 1, 4
Observation Strategy
Most halo nevi require only observation and reassurance, as they represent a benign autoimmune response with T lymphocytes progressively destroying nevus cells 1.
- Monitor clinically for concerning changes: rapid growth, bleeding, ulceration, pain, nodule development, or color changes 6
- Serial photographs can help track changes over time 6
- Reassure patients that spontaneous resolution typically occurs through the natural stages described above 2
When to Intervene
Excisional biopsy is indicated for:
- Any atypical clinical features suggesting melanoma 1
- Suspicious changes within the nevus (complete excisional biopsy preferred over shave biopsy for comprehensive histological assessment) 6
- Patient or family anxiety that cannot be managed with reassurance alone
Special Considerations
- Sun exposure: Halo nevi are detected after intense sun exposure, especially sunburns; counsel on sun protection 1
- Unusual presentations: Rarely, the central nevus may darken rather than lighten following halo appearance, representing postinflammatory hyperpigmentation from infiltrating lymphocytes 2
- Associated leucoderma: In patients with multiple halo nevi who develop additional depigmentations, consider "halo nevi-associated leucoderma" rather than classic vitiligo, as the prognosis is less progressive 4
Follow-up Protocol
- No routine dermatology referral needed for typical halo nevi in otherwise healthy children and adolescents 1
- Prompt dermatology evaluation for any atypical features or concerning changes 6
- Screen for thyroid disease if multiple autoimmune features present, particularly in adults 3
Key Clinical Pitfalls
- Do not confuse with melanoma: The halo phenomenon can occur around melanoma, but typical halo nevi in young patients with multiple lesions and classic appearance are benign 1, 5
- Do not misdiagnose as vitiligo: Halo nevi have central nevus (at least initially), while vitiligo presents as depigmented patches without central lesions 3
- Do not overlook Meyerson's nevus (halo dermatitis): This inflammatory, eczematous eruption around a nevus resolves spontaneously within weeks without causing nevus regression, unlike true halo nevi 7