DOI: 10.1111/pde.

14291

Pediatric
REVIEW ARTICLE Dermatology

A practical review of dermoscopy for pediatric dermatology

part I: Melanocytic growths

Anshika Kaushik MD1,2  | Nicola Natsis BA1,3  | Samantha C. Gordon MD4  |

Elizabeth V. Seiverling MD4,5

1
Division of Pediatric and Adolescent
Dermatology, Rady Children’s Hospital-San Abstract
Diego, San Diego, CA, USA The value of dermoscopy in the detection of skin cancer is well established. Less is
2
Department of Dermatology, University
published on the utility of dermoscopy in the evaluation of pediatric skin disease.
of California San Diego School of Medicine,
San Diego, CA, USA Our review (in two parts) aims to serve as an update on pediatric dermoscopy and to
3
University of California San Diego School of provide readers with a practical application for the use of dermoscopy in pediatric
Medicine, San Diego, CA, USA
4
dermatology clinics. In part I, we propose a dermoscopy algorithm for pediatric skin
Department of Dermatology, Tufts Medical
Center, Boston, MA, USA disease and melanocytic growths, and in part II, we address vascular growths, com-
5
Division of Dermatology, Maine Medical mon skin infections, and inflammatory conditions for which dermoscopy is valuable.
Center & Maine Medical Partners, Portland,
ME, USA
KEYWORDS

Correspondence acquired nevus, algorithm, dermatology, dermoscopy, melanocytic nevus, melanoma,

Elizabeth V. Seiverling, MD, Division of pediatrics, pigmented nevus, scalp nevus, skin neoplasms, Spitz nevus
Dermatology, Maine Medical Center &
Maine Medical Partners, 265 Western Ave,
South Portland, ME 04106, USA.
Email: Eseiverlin@mmc.org

1 |  I NTRO D U C TI O N
The value of dermoscopy in the detection of skin cancer is well es-
tablished.1-3 Less is published on the utility of dermoscopy in the
evaluation of pediatric skin disease. Haliasos, Marghoob, and col-
leagues presented a comprehensive review of pediatric dermoscopy
in this journal in 2013.4-6 These manuscripts serve as an update on
the topic. In this section, we propose a dermoscopy algorithm for
pediatric skin disease and melanocytic growths.
Through the use of 10× magnification and cross-polarized light,
dermoscopy allows for improved visualization of skin conditions.
Cross-polarization enables the user to see vessels and shiny white
structures that cannot be detected with the naked eye. In addition,
many dermatoscopes offer the ability to toggle between polarized
and non-polarized light, further enhancing the potential to recog-
nize regression structures and other indicators of both malignant
and benign lesions. These dermoscopic features are sometimes the
only findings indicative of a melanoma, especially non-pigmented
spitzoid melanomas in children.7 Dermoscopy allows for improved
diagnostic accuracy for some of the trickiest lesions seen in pediatric
dermatology clinics. For instance, the diagnostic accuracy for Spitz
nevi with the naked eye is 56%, but with dermoscopy this is in-
creased to 93%.8
Dermoscopy is not only useful in accurately diagnosing rare me-
lanocytic growths like spitzoid tumors, but dermoscopy is also very
helpful in confirming an enlarging nevus is following an expected
nevus pattern in a child and, therefore, is safe to monitor. Thirty
percent of referrals to pediatric dermatology clinics are for mela-
nocytic growths.9,10 Thus, the dermatoscope is an essential tool for
the evaluation of skin growths in children. Furthermore, the non-in-
vasive nature of dermoscopy makes it ideally suited for pediatric pa-
tients. Much of the literature on dermoscopy has focused on skin
cancer detection in adults. In that setting, dermoscopy drastically
reduces the number of benign growths removed for every skin can-
cer found.11-13 In children, there are as many as 1,000 biopsies per-
formed for every melanoma detected.14 Many of these biopsies are
performed in children under age 4 years and require sedation, which
confers additional risks.
While not all biopsies can be avoided, as malignant skin tumors
do occur in children, one of the goals of dermoscopy is to reduce the

Pediatric Dermatology. 2020;00:1–9. wileyonlinelibrary.com/journal/pde© 2020 Wiley Periodicals LLC.     1 |

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2       Pediatric
Dermatology
number of unnecessary biopsies and to aid in mole monitoring. The
modified ABCDs of pediatric melanoma and the traditional ABCDEs
are used to evaluate a growth clinically, but do not apply to der-
moscopy.15,16 The pediatric modified ABCD stands for amelanosis,
bleeding, bump, uniform color, and de novo at any diameter.17 While
the ABCDEs and the ABCDs aid in melanoma detection, dermoscopy
is more sensitive.7 To be able to use dermoscopy effectively, training
is necessary.18 Traditional dermoscopy algorithms like the Modified
2-Step Algorithm and Chaos and Clues are aimed at the evaluation
19,20
of skin growths in adults. To our knowledge, there has been no
published dermoscopic algorithm for the evaluation of skin growths
in children. Thus, we propose a pediatric-centric algorithm aimed at
differentiating melanocytic growths from vascular tumors. In the
second article, we also review the expanding literature supporting
the use of dermoscopy for inflammatory conditions and skin infec-
tions in the pediatric population. 21-23
One of the most frequently used dermoscopic algorithms is the
19
modified two-step dermoscopy algorithm. It is based on pattern
recognition (pattern analysis) and the user’s ability to differentiate
melanocytic growths from other skin neoplasms. It results in high
sensitivity and specificity for malignant growths. We sought to re-
vise this algorithm to better reflect the skin conditions we see in
children. Thus, we present the “pediatric dermoscopy two-step al-
gorithm” (Figure 1). This algorithm is not suitable for glabrous skin.
Because of the specialized anatomy of mucosa, nails, and volar skin,
alternative dermoscopic algorithms are needed for these locations.
The first step is to determine whether the growth is melano-
cytic. The hallmarks of melanocytic growths are pigment globules
or streaks, homogeneous color, brown or black blotches, or a pig-
ment network (Figure 2). Pigment globules are brown circular struc-
tures, which represent nests of melanocytes at the dermoepidermal
junction. Typically, globules are round to oval structures that may
be brown, black, and blue-gray and are> 0.1 mm. Streaks are linear
pigmented projections at the periphery of a growth. A growth is also
categorized as melanocytic if it has a pigment or reticular network. A
pigment network is created by intersecting brown circles, which rep-
resent melanin in the rete ridges. The pigment network often appears
KAUSHIK et al.
as a honeycomb under dermoscopy. Some melanocytic neoplasms
have hypopigmented serpiginous lines, referred to as negative (or
inverse) network. A negative network is seen in spitzoid neoplasms
(Figure 8C) and melanoma and correlates with elongated rete ridges
and tumor islands in the papillary dermis. Lastly, a growth can fall in
the melanocytic category if it has a homogeneous color. Nevi and
pediatric melanoma can be homogeneous brown, blue, black, or
pink. Some melanocytic neoplasms have pigment blotches. Blotches
are heavily pigmented structureless areas of brown or black color.
Once a growth has been deemed melanocytic, the next step is
to determine whether it has a benign nevus pattern or features wor-
risome for an atypical spitzoid neoplasm or a melanoma. There are
many benign nevus patterns, but globular nevi are most common in
children. 24
2 | CO N G E N ITA L M E L A N O C Y TI C N E V I
Congenital melanocytic nevi (CMN) are dark to tan macules or
plaques typically on the trunk. CMN are found in 0.5-6% of chil-
dren. 25-27 They present at birth or within the first month or two of
life. CMN often have irregular borders and multiple tones. CMN pro-
portionately increase in size as the child grows.
CMN are categorized based on their projected adult size as
small (<1.5 cm in size), medium (M1 1.5-10cm, M2> 10-20 cm), large
(L1> 20-30 cm, L2> 30-40 cm), or giant (G1 40-60 cm, G2> 60 cm). 28
Large and giant CMN have an increased risk of melanoma, with rates
as high as 2% and 10%, respectively. 29,30 There is increasing consid-
eration that the risk of melanoma is higher in patients with multiple
congenital nevi.31-33 There is also increased concern for neurocuta-
neous melanocytosis for patients with giant CMN, particularly if the
large lesion is on the posterior axis or with 20 or more satellite le-
sions.31 Given small and medium CMN are more common than large
CMN, here we will focus on small and medium CMN for which the
risk of melanoma is ~ 1%.34,35
Dermoscopic evaluation may provide a means for thorough serial
examination and reduce the frequency of biopsies of benign CMN,
F I G U R E 1   Pediatric dermoscopy two-
step. An algorithm designed for lesions
found on non-glabrous skin
KAUSHIK et al.
(A) (B)
(C)
F I G U R E 2   Melanocytic lesion patterns under dermoscopy: (A) Cobblestone (Pigment globules throughout) (B) Homogenous (Blue nevus)
(C) Reticular (Pigment network)
particularly in the age group 1-4 years, in which the largest number
of CMN are excised.36,37
Dermoscopy focuses on the content of a growth rather than the
border. Under polarized dermoscopy, CMN often have both a pig-
ment network and globules. Many CMN have irregular borders and
by focusing on the content, dermoscopy enables accurate classifica-
tion as benign.
The typical dermoscopic features of CMN include the following:
dots and globules, reticular network, focal hypopigmentation, and
perifollicular hypopigmentation.38 Globular patterns are the most
common CMN pattern on the head, neck, and torso.38 These find-
ings were further reinforced in an observational study of 108 CMN
Pediatric |
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Dermatology
in which the globular pattern was most common in patients under
16 years of age.38 Globules can be larger in size and take on a jigsaw
appearance in CMN, often called cobblestone globules (Figure 2A).39
Globular patterns are frequently seen with associated milia-like
cysts, hypertrichosis, or perifollicular pigment changes. CMN with a
globular pattern typically persist into adulthood and maintain their
globular appearance. This contrasts with the globular pattern in ac-
quired nevi, which often evolve into reticular pattern (see below).
CMN with a reticular pattern often have a honeycomb like net-
work that corresponds to melanin in the rete edges. The quality of
the network may be fine or thick. The distribution can either be
homogenous in color or patchy, particularly at the periphery. An
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4       Pediatric
Dermatology
observational study of 77 patients demonstrated that reticular pat-
terns in CMN are more commonly seen in patients aged 12 years
or older. In addition, 40% of reticulated patterns were seen on the
extremities or head and neck.40-42
Lastly, CMN on volar skin have a distinct dermoscopic appear-
ance. Because of the unique anatomy of volar skin, pigment is not
classically seen as reticular network. Instead, many CMN on volar
skin have a combination of a parallel furrow pattern and a crista dot-
ted pattern. This consists of pigment in the furrows with dots and
globules on the ridges, sometimes referred to a “peas-in-a-pod” pat-
tern (Figure 3).43,44
3 |  ACQ U I R E D M E L A N O C Y TI C N E V I
Dermoscopic discussion of acquired nevi (AN) requires an under-
standing of nevogenesis and nevus evolution. AN begin to appear
during the first decade of life and increase in number during adoles-
cence.45 During childhood, AN most frequently have a globular pat-
46
tern on dermoscopy and are located on the torso, head, and neck.
The brown globules are of similar size, shape, and color (Figure 2A).
As children enter adolescence, new patterns appear. Mixed or com-
plex patterns with both globules and reticulation are common in the
second decade.47,48
One example of a mixed pattern is central homogeneity or re-
ticulation with peripheral globules. This is most often seen on the
backs of adolescents (Figure 4). This pattern represents enlargement
of a melanocytic growth. The globules are present circumferentially
and distributed in an organized fashion. The single greatest discrim-
inator between benign nevi and melanoma is whether the growth is
dermoscopically organized or disorganized.49 Disorganized growths
have a chaotic distribution of the shapes and colors and are more
likely to be malignant (Figure 5B).
While nevus evolution is a dynamic process, the organized dis-
tribution of the globules and reticulation is generally maintained in
benign growths even during periods of enlargement. As patients age,
F I G U R E 3   Parallel furrow with dots on the ridge (Green arrows-
pigment in the furrows, blue arrow- dots on the ridge). Image
courtesy of Ashfaq Marghoob, MD
KAUSHIK et al.
the globular pattern is less common and reticular patterns are seen
more frequently for patients between 20 and 60 years old. Reticular
nevi are more common on the extremities than on the torso. A new
melanocytic growth with a globular pattern in an adult or elderly
person is worrisome, especially if globules are present in a chaotic
distribution and the growth is on an extremity. 20,50 Melanomas with
globular nests in elderly patients are sometimes termed “nested mel-
anoma of the elderly” and have been associated with rapid growth.40
In sum, CMN and AN in children often have a globular pattern, but
new melanocytic growths with globules should raise the potential
for melanoma in older patients.51
Scalp nevi often pose a diagnostic dilemma for families and clini-
cians. These nevi frequently change in appearance over time, even
when benign. Thorough dermoscopic evaluation can facilitate im-
proved management. Scalp nevi display solid, cockade, or eclipse
patterns on clinical examination.52 On dermoscopy, the scalp nevi
are most frequently globular (Figure 6). Other common patterns
are reticular with perifollicular hypopigmentation and scalloped
borders.52 Cockade nevi have a pigmented center which is globular
or homogeneous surrounded by a non-pigmented ring and then an
outer ring of reticulation. Eclipse nevi have central light brown or tan
color with an outer pigmented rim.53
4 | S PIT Z N E V I
A Spitz nevus (SN) is a solitary pink, brown, or red macule or pap-
ule found on the head, neck, and extremities. The lesions are
typically found in patients less than 20 years of age (Figure 7).
Dermoscopically, SN are typified by three main patterns: starburst
pattern (51%), a pattern of regularly distributed dotted vessels (19%),
F I G U R E 4   Nevus with peripheral globular pattern and central
reticular network in an adolescent
KAUSHIK et al.
(A)
F I G U R E 5   Beauty and the Beast. (A) Organized nevus with central globules and peripheral reticular network (B) Disorganized melanoma
with atypical network and blue-white veil (Red arrow: Atypical network, Green arrow: Blue-white veil)
F I G U R E 6   Six-year-old boy with new scalp nevus, globular
pattern under dermoscopy
and globular pattern with reticular depigmentation (17%) (Figure 8A-
C).6,54,55 The starburst pattern is the most common dermoscopic pat-
tern seen in SN, present in more than 50% of SN and 96% sensitive
for SN (Figure 8A).56 It is indicated by the presence of pseudopods
or radial streaming present circumferentially around the growth.57
Many starburst pattern SN evolve to reticular or homogeneous and
then regress.58,59 Overall, 79.7 % SN involute within 25 months.60
Another pattern in SN is globular pattern with reticular depig-
mentation also called negative pigment network (Figure 8C). A neg-
ative network is created by hypopigmented serpiginous lines around
brown dots and represent fibrosis and tumor islands in the papillary
61,62
dermis. Because of the tumor islands, the rete ridges are com-
pressed, and the pigment cannot be appreciated. Spitz nevi may also
be pink with small dotted vessels (Figure 8B).62Vessels are best visu-
alized in polarized non-contact mode. Dotted vessels are not unique
Pediatric |
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Dermatology
(B)
F I G U R E 7   Spitz nevus on clinical examination
to SN. They can also be seen in psoriasis and porokeratosis. SN re-
quire careful evaluation as they share morphologic, dermoscopic,
and histopathologic traits with melanoma.63 The most powerful dis-
criminator between a starburst pattern SN and malignant lesions on
dermoscopy is whether pseudopods or radial streaming are regularly
distributed (as seen in SN) or with an irregular distribution, which is
concerning for melanoma.7,49
Management of SN remains a conundrum. If the growth is spit-
zoid, dermoscopy aids in determining whether the neoplasm man-
ifests a subtype that might be conducive to monitoring, such as
starburst pattern in a young child. The International Dermoscopy
Society published an update on the management of Spitz/Reed
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6       Pediatric
Dermatology
(A)
(C)
F I G U R E 8   Spitz nevi patterns under dermoscopy (A) Starburst pattern (Image courtesy of Ashfaq Marghoob, MD) (B) Regularly
distributed dotted vessels (C) Negative pigment network (Blue arrows indicate hypopigmented lines seen in negative network)
nevi in 2017. 23 In the guidelines, they suggest biopsy or excision
of all “spitzoid-looking tumors” that are asymmetric or nodular.
Furthermore, they recommend removal of spitzoid tumors in pa-
tients over age 12 and if the neoplasm has a pattern other than star-
burst (Figure 8A).
Dermoscopy is perhaps most helpful in differentiating Spitz nevi
from non-melanocytic neoplasms. In up to 80% of Spitz nevi that are
biopsied, the diagnosis of a Spitz was not considered at the time of
the biopsy.64 The growths were thought to be dermatofibromas, pyo-
64
genic granulomas, juvenile xanthogranulomas, or verrucae. In part
II of this manuscript, we provide the dermoscopic findings of some of
the mimickers of Spitz nevi. The diagnostic accuracy of Spitz nevi with
dermoscopy is over 90%.8 Thus, in some clinical scenarios, reassur-
ance or monitoring might be appropriate, such as a child under age 12
with a macular starburst pattern Spitz nevus.65-67 Lastly, while moni-
toring Spitz nevi is sometimes recommended, the majority of the liter-
ature on digital dermoscopic monitoring is based on adult data.67 Nevi
KAUSHIK et al.
(B)
(congenital, acquired, and spitzoid) in children are more dynamic that
those in adults. Changes in melanocytic growths in children are not
necessarily worrisome, adding to the conundrum of removal versus
continued monitoring.68 Monitoring spitzoid neoplasms in children is
likely to be reserved for macular starburst Spitz nevi in children under
age 12. The use of dermoscopy might allow for fewer biopsies/exci-
sions in this scenario. A more conservative approach to management
of typical spitzoid neoplasms is further supported by Bartenstein
et al’s cohort study reporting no deaths in over 500 patients with
spitzoid tumors followed for more than four years.69
5 | PE D I ATR I C M E L A N O M A
Nevi, both congenital and acquired, differ from pediatric melanoma
in their clinical and dermoscopic appearance. Pediatric melanomas
tend to be solitary, rapidly enlarging, with a propensity to bleed or
KAUSHIK et al.
F I G U R E 9   (A) Pigmented spitzoid
(A)
melanoma on the lower leg. (B) Spitzoid
melanoma on dermoscopy (Blue arrow
indicates atypical globules, red arrow
indicates shiny white structure)
ulcerate. Dermoscopy is more sensitive and specific in the diagno-
sis of pediatric melanoma when compared to the clinical ABCDEs
7,17
and the pediatric modified ABCDs. In a retrospective study of 52
pediatric melanoma cases, all tumors had dermoscopic features of
melanoma.11
Pediatric melanoma cases are typically classified as spitzoid or
non-spitzoid. Non-spitzoid melanomas clinically resemble adult su-
perficial spreading melanomas and are more likely to occur in adoles-
cents. On dermoscopy, they often have a disorganized appearance
due to the presence of multiple melanoma structures. Non-spitzoid
melanomas in children are more likely to arise within a pre-exist-
ing nevus and to have irregular globules and negative pigment
network.70 Additional dermoscopic features of melanoma include
F I G U R E 1 0   Non-pigmented melanoma (Blue arrows indicate
atypical/polymorphous vessels)
Pediatric |
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Dermatology
(B)
an atypical network or a blue-white veil, structureless areas, shiny
white lines, and atypical vessels (Figure 5B).7,71
Spitzoid pediatric melanomas can be pigmented or non-pig-
mented. They are more common on the limbs and often arise de novo
(Figure 9A,B).7 In non-pigmented spitzoid melanomas, dermoscopy al-
lows for visualization of shiny white lines and atypical vessels, which
might be the only clues to the diagnosis of melanoma (Figure 10). The
presence of shiny white structures and atypical vessels (including ir-
regular dotted vessels) allows for differentiation from more common
entities, such as pyogenic granuloma or verruca, which will be dis-
cussed in part II.
While rare, pediatric melanoma does occur. Oliveria et al re-
ported 16 melanomas in 18,601 specimen removed from children.14
Clearly, many benign neoplasms are being removed for every ma-
lignant melanoma detected in children. It is important to acknowl-
edge that many growths in adults and children are removed, not
because of suspicion of melanoma, but for other reasons such as
irritation or cosmesis. Overall, dermoscopy improves diagnostic
accuracy by allowing more definitive pre-biopsy classification of
a growth as melanocytic or not. Thus, potential melanoma or spit-
zoid neoplasms are better able to be differentiated from benign
mimickers (such as verruca), which might be managed with less
invasive means. Furthermore, if a growth is identified as melano-
cytic, dermoscopy also allows for potential digital monitoring to
aid with determining whether a growth is changing in a reassuring,
expected pattern for a child, or is taking on worrisome features
that might warrant removal.47 Pizzzichetta et al followed 19 me-
lanocytic growths in children and noted many initially “atypical”
neoplasms evolved to have common nevus patterns and did not
require removal.68 More studies are needed to fully evaluate the
benefits of dermoscopy with respect to biopsy rates in children.
C O N FL I C T O F I N T E R E S T
No conflict of interest.
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8       Pediatric KAUSHIK et al.
Dermatology
ORCID dermatology residents and program directors. Dermatol Pract
Concept. 2017;7(2):17–22.
Anshika Kaushik  https://orcid.org/0000-0003-3141-4401
19. Marghoob AA, Braun R. Proposal for a revised 2-step algorithm
Nicola Natsis  https://orcid.org/0000-0003-1655-3411 for the classification of lesions of the skin using dermoscopy. Arch
Samantha C. Gordon  https://orcid.org/0000-0001-6923-5244 Dermatol. 2010;146(4):426–428.
20. Ramji R, Valdes-Gonzalez G, Oakley A, Rademaker M. Dermoscopic
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How to cite this article: Kaushik A, Natsis N, Gordon SC,
Seiverling EV. A practical review of dermoscopy for pediatric
dermatology part I: Melanocytic growths. Pediatr Dermatol.
2020;00:1–9. https://doi.org/10.1111/pde.14291