A New Nevus on a Child's Eyelid: Urgent Evaluation Required
A new nevus appearing on a child's eyelid warrants urgent referral to a pediatric dermatologist or ophthalmologist within days to weeks, as any growth in this location requires close evaluation to exclude malignant transformation, though benign congenital melanocytic nevi are far more common in children. 1
Immediate Red Flags Requiring Urgent Referral
The following features necessitate immediate specialist evaluation within days:
- Rapid or asymmetric growth beyond what would be expected with normal proportional growth of the child 1
- Color variation or heterogeneous darkening within the lesion 1
- Development of nodules or papules, particularly deep, palpable masses 1
- Bleeding, ulceration, or persistent erosions 1
- Pain or significant pruritus 1
Critical Examination Components
Palpation of the lesion is essential because melanoma arising in congenital melanocytic nevi can present as deep dermal or subcutaneous nodules without any overlying color change on visual inspection alone. 1, 2 This makes tactile examination as important as visual assessment.
Document the lesion with serial photographs to enable objective monitoring of changes over time. 1, 3
Most Likely Diagnosis: Congenital Melanocytic Nevus
Congenital melanocytic nevi (CMN) are the most probable diagnosis, as these lesions commonly exhibit proportional growth with the child and can develop predictable surface changes including:
- Becoming more raised, hypertrichotic (hairy), or papillated 1
- Pigmentation becoming more mottled or speckled 1
- Homogeneous or heterogeneous darkening or lightening 1
These benign changes are expected and do not necessarily indicate malignancy. 1
Melanoma Risk Context
While melanoma in congenital melanocytic nevi is rare (0.7-1.7% overall risk), the risk increases with certain features:
Critically, melanoma can present as deep nodules without overlying color change, making palpation mandatory at every visit. 1, 2 In one cohort of patients with multiple CMN, melanoma incidence was 8%, with the majority presenting in the central nervous system. 4
Monitoring Protocol
Every 3 months during the first year given the growth pattern and eyelid location. 1, 2
Annual dermatology evaluation minimum after the first year if the lesion remains stable. 1, 3, 2
Between visits, parents should visually inspect and palpate the nevus, reporting any concerning changes immediately. 3, 2
MRI Screening Considerations
Consider MRI of brain and spine (without contrast, without anesthesia in young infants) if:
- The nevus is medium-to-large size 1, 2
- Multiple congenital melanocytic nevi are present 1, 2
- There are ≥10 satellite lesions 4
This screens for neurocutaneous melanosis, which carries the highest melanoma risk. 1 Among patients with multiple CMN who underwent screening MRI, 79% showed normal findings, but 10% had intraparenchymal melanosis. 4
Biopsy Indications
Complete excisional biopsy is strongly preferred over shave biopsy if suspicious changes are present, as this allows comprehensive histological assessment. 1, 3, 2
Early surgical treatment in the first few months of life gives the best cosmetic results for medium and large congenital melanocytic nevi of the eyelid. 5
Critical Pitfalls to Avoid
Never perform ablative procedures (pigment-specific lasers, curettage, dermabrasion) as these obscure future melanoma evaluation and cause frequent pigment recurrence. 4, 2
Do not assume irritation or growth is benign without proper evaluation, as melanoma in congenital nevi can present as deep nodules without overlying color change. 2
Do not delay referral - the eyelid location adds functional and aesthetic concerns that benefit from early specialist involvement. 6, 5
Differential Diagnoses to Consider
While congenital melanocytic nevus is most likely, other possibilities include:
- Sebaceous nevus: appears as yellowish-orange plaques that become more verrucous and raised during childhood, particularly around puberty 1
- Spitz nevus: can arise in teenagers as lightly pigmented lesions that develop over weeks to months 7
- Nevus simplex (salmon patch): common vascular birthmark on eyelids, but typically present from birth and does not grow 8