10.5826/dpc.1301a41
Introduction: Spitz nevi (SN) are benign melanocytic proliferations frequently occurring in children. Some pigmented SN with starburst pattern evolve into the “stardust” one, which is characterized by a central, black to gray, hyperpigmented area and remnants of a brown network at the periphery. These dermoscopy changes are often the first alert to induce excision.
Objectives: The aim of this study is to enlarge the case series of stardust SN in children, in order to increase confidence with this new dermoscopic pattern and reduce unnecessary excisions.
Methods: This retrospective observational study was conducted with SN cases received from IDS members. The inclusion criteria were: clinical and/or histopathologic diagnosis of Spitz naevus with starburst appearance in children &lt;12 years old, availability of a dermoscopic image at baseline and after follow-up of at least 1 year, availability of patient’ data. The dermoscopic images and their changes over time were assessed by three evaluators in consensus.
Results: 38 SN were enrolled, with median age of 7 years and median FUP duration of 15,5 months. Comparing the evolution with time of FUP, no significant differences were found between growing and involuting lesions in terms of patient age and sex, location and palpability of lesions. &nbsp;
Conclusions: The long follow up reported in our study could really support the concept of benignity of changing SN.&nbsp; A conservative approach is acceptable for nevi showing the stardust pattern, because it may be considered a physiological evolution of pigmented Spitz nevus, and urgent surgeries could be avoided.
&nbsp;
text/xml
2160-9381
2547
en
Gabriella Brancaccio
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
stardust
Stardust Pattern As Evolution Of Pigmented Spitz Nevi During Childhood
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-01-31
2022-04-19
2023-01-31
2023-02-27
e2023041
Dermatol Pract Concept
Introduction: Spitz nevi (SN) are benign melanocytic proliferations frequently occurring in children. Some pigmented SN with starburst pattern evolve into the “stardust” one, which is characterized by a central, black to gray, hyperpigmented area and remnants of a brown network at the periphery. These dermoscopy changes are often the first alert to induce excision.
Objectives: The aim of this study is to enlarge the case series of stardust SN in children, in order to increase confidence with this new dermoscopic pattern and reduce unnecessary excisions.
Methods: This retrospective observational study was conducted with SN cases received from IDS members. The inclusion criteria were: clinical and/or histopathologic diagnosis of Spitz naevus with starburst appearance in children &lt;12 years old, availability of a dermoscopic image at baseline and after follow-up of at least 1 year, availability of patient’ data. The dermoscopic images and their changes over time were assessed by three evaluators in consensus.
Results: 38 SN were enrolled, with median age of 7 years and median FUP duration of 15,5 months. Comparing the evolution with time of FUP, no significant differences were found between growing and involuting lesions in terms of patient age and sex, location and palpability of lesions. &nbsp;
Conclusions: The long follow up reported in our study could really support the concept of benignity of changing SN.&nbsp; A conservative approach is acceptable for nevi showing the stardust pattern, because it may be considered a physiological evolution of pigmented Spitz nevus, and urgent surgeries could be avoided.
&nbsp;
Gabriella Brancaccio
2023/01/31
10.5826/dpc.1301a41
e2023041
Dermatology Unit, University of Campania, Naples, Italy
2160-9381
stardust
en
e2023041
Haliasos, H. C. et al. Dermoscopy of Benign and Malignant Neoplasms in the Pediatric Population. Semin. Cutan. Med. Surg. 29, 218–231 (2010).
Stardust Pattern As Evolution Of Pigmented Spitz Nevi During Childhood
https://dpcj.org/index.php/dpc/article/download/2547/1957
           Stardust Pattern as Evolution of Pigmented
                  Spitz Nevi During Childhood
 Bruno Brunetti,1 Giulia Briatico2, Camila Scharf 2, Horacio Cabo3, Massimiliano Scalvenzi4,
      Filomena Barbato5, Francesco Savoia6, Luc Thomas7-8-9, Giuseppe Argenziano2,
                                     Gabriella Brancaccio2


1 Ospedale Santa Maria della Speranza, Battipaglia, Italy
2 Dermatology Unit, University of Campania, Naples, Italy
3 Dermatology Section- Instituto de Investigaciones Médicas Universidad de Buenos Aires, Argentina
4 Dermatology Unit, University “Federico II”, Naples, Italy
5 AORN Santobono – Pausilipon, Naples, Italy;
6 Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Skin Cancer Unit, Meldola (FC), Italy
7 Department of Dermatology Centre Hospitalier Lyon Sud, France
8 Lyons cancer research center UMR INSERM U1052 - CNRS5286 - UCBL1, France
9 Lyon 1 University, France



Key words: spitz nevus, starburst, stardust
Citation: Brunetti B, Briatico G, Cabo H, et al. Stardust pattern as evolution of pigmented Spitz nevi during childhood. Dermatol Pract
Concept. 2023;13(1):e2023041. DOI: https://doi.org/10.5826/dpc.1301a41
Accepted: July 4, 2022; Published: January 2023
Copyright: ©2023 Brunetti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Gabriella Brancaccio, MD, Dermatology Unit, University of Campania, Via Pansini 5, 80131, Napoli, Italy.
E-mail: gabri.brancaccio@gmail.com




  ABSTRACT              Introduction: Spitz nevi (SN) are benign melanocytic proliferations frequently occurring in children.
                        Some pigmented SN with a starburst pattern evolve into the “stardust” one, which is characterized
                        by a central, black to gray, hyperpigmented area and remnants of a brown network at the periphery.
                        These dermoscopy changes are often the first alert to induce excision.
                        Objectives: The aim of this study is to enlarge the case series of stardust SN in children, in order to
                        increase confidence with this new dermoscopic pattern and reduce unnecessary excisions.
                        Methods: This retrospective observational study was conducted with SN cases received from IDS
                        members. The inclusion criteria were: clinical and/or histopathologic diagnosis of Spitz naevus with
                        starburst appearance in children <12 years old, availability of a dermoscopic image at baseline and af-
                        ter follow-up of at least 1 year, availability of patient data. The dermoscopic images and their changes
                        over time were assessed by three evaluators in consensus.




Original Article | Dermatol Pract Concept. 2023;13(1):e2023041                                                                            1
                      Results: 38 SN were enrolled, with a median age of 7 years and a median FUP duration of 15,5
                      months. Comparing the evolution with time of FUP, no significant differences were found between
                      growing and involuting lesions in terms of patient age and sex, location and palpability of lesions.
                      Conclusions: The long follow-up reported in our study could really support the concept of benignity
                      of changing SN. A conservative approach is acceptable for nevi showing the stardust pattern, because
                      it may be considered a physiological evolution of pigmented Spitz nevus, and urgent surgeries could
                      be avoided.




Introduction                                                         Pigmented variants were first investigated and shown to
                                                                  display the so-called ‘starburst’ pattern, consisting of a cen-
Spitz nevi (SN) are benign melanocytic proliferations that        tral area of homogeneous black-blue pigmentation and sym-
frequently occur in children [1]. 50% to 75% of patients          metrically distributed peripheral streaks or pseudopods [6].
with a diagnosis of Spitz nevi are found to be younger than          Several additional patterns were later found to be associ-
20 years of age and the overall incidence has been esti-          ated with pigmented Spitz naevus, including globular, homo-
mated between 1.4 and 7 new cases per 100,000 persons             geneous, reticular and multicomponent patterns.
per year [2].                                                        Histologically, Spitz nevi are composed of spindled and/
    Before 1948, this entity was defined as Juvenile mela-        or epithelioid melanocytes with large nuclei and abundant
noma, as the clinical and histological differentiation between    cytoplasm [7]. The melanocytes seen in Spitz nevi are often
Spitz Nevus and melanoma of the adult could not be made           larger than those in other types of nevi, arranged perpen-
with certainty in several cases.                                  dicular and parallel to the skin surface, highly cohesive, and
    Sophie Spitz [3] first noted a difference in the biologi-     they do not destroy the nearby keratinocytes. These spindle
cal behavior of Spitz nevus compared to adult melanoma.           cells contain melanin pigment. Additionally, Kamino bod-
In a series of 13 lesions diagnosed as malignant melanoma         ies, which are rounded eosinophilic globules, are often seen.
in children, only one patient died from melanoma metasta-         Frequently, solitary melanocytes and nests of melanocytes
ses. The other 12 participants had lesions that were locally      occurring above the dermo-epidermal junction are detected.
excised without recurrence or metastases. Sophie Spitz con-       Dermal nests and cords of cells could be seen if a dermal
cluded that, since metastases from juvenile melanomas occur       component is present. The lack of ulceration, dermal sheets
only rarely, conservative surgery, rather than the radical sur-   of cells, or significant mitotic activity could exclude the di-
gery usually indicated for adult melanomas, seems justified.      agnosis of malignant tumors [8]. Guidelines for the manage-
The study challenged the standard of practice at that time        ment of spitzoid-looking tumors have been proposed by the
relating to the diagnosis of melanomas and benign nevi in         International Dermoscopy Society (IDS) in 2017 [6]. The
children [4].                                                     first management criterium is symmetry. Lesions display-
    However, in the late 1990s, a new era of controversies on     ing asymmetrically distributed spitzoid features (peripheral
the management of spitzoid lesions started, because cases of      streaks/pseudopods, dotted vessels, reticular depigmenta-
spitzoid lesions without malignant histopathological criteria     tion) should be excised to rule out melanoma. In symmetrical
but with nodal metastasis were described. New histological        lesions, the second management-driven criterium is age. Der-
entities were introduced attempting to classify spitzoid tu-      moscopically symmetric spitzoid-looking lesions developing
mours with intermediate histopathological features between        after the age of 12 years should be managed with caution
Spitz naevus and spitzoid melanoma (Spitz naevus with             because there is a considerable probability that these lesions
atypia and metastasis, metastasizing Spitz tumour, atypical       actually constitute melanoma. Below the age of 12 years, the
Spitz tumour, atypical Spitz naevus, melanocytic tumour of        recommended management of dermoscopically symmetric
unknown malignant potential, melanocytoma). The worry-            spitzoid-looking lesions depends if the lesion is nodular or
ing scenario of possible loco-regional dissemination in con-      flat, which is the third criterium. For nodular lesions, the
nection with the medico-legal liability could lead to the risk    recommended management is excision, mainly because the
of overcalling [5].                                               possibility of an atypical Spitz tumor cannot be excluded
    The introduction of dermoscopy significantly improved         on the basis of dermoscopic morphology. For flat/raised le-
the diagnosis of Spitz naevi, as they were shown to ex-           sions, ­follow-up until stabilization is suggested. Monitoring
hibit a peculiar and characteristic pattern of dermoscopic        is highly recommended in the subset of lesions displaying a
structures.                                                       starburst pattern (Reed naevi). Lesions displaying a starburst



2                                                                     Original Article | Dermatol Pract Concept. 2023;13(1):e2023041
pattern are expected to grow (Fig 1.), reach stabilization and,        center of the lesion, while the peripheral part of the naevus
then, involute. Ideally, the typical Reed naevus grows sym-            exhibits remnants of a delicate brown network. (Fig 2-3-4).
metrically and gradually acquires a blue-black homogeneous             This pattern, which may anticipate the involution of the le-
aspect with the disappearance of peripheral projections. After         sion, was first described by Argenziano et al. [1] and later
years, the dark pigmented area is gradually restricted to the          named “stardust” pattern.




Figure 1. A-B) Male patient aged 5, at his first visit for a SN on the knee. Dermoscopy shows typical SN with hyperpigmented central area
and pseudopods at the periphery. C-D) After 1 year, the lesion starts losing pseudopods and grows symmetrically.




Figure 2. First and last image of SN in a female patient aged 11 and 20 respectively. The classic stardust pattern is evident in the second
dermoscopy.



Original Article | Dermatol Pract Concept. 2023;13(1):e2023041                                                                           3
Figure 3. A-B) Female patient, 3 years old at first visit. C-D) FUP visit at 6 years old, where the involution is almost completed, with only
brown not organized network.


    In the IDS guidelines6 “Reed” and “Spitz” names are used            primary lesion, sex, date of birth, age at first and at last visit,
interchangeably since a pathological distinction between the            number of follow-up visits and number of total months of
two entities cannot be made [9,10].                                     follow-up. The dermoscopic images were assessed by three
                                                                        evaluators in consensus (GB, CS and GA), with the stardust
Objectives                                                              feature scored as present when at least two of them were in
                                                                        agreement. Cases not assessed as “starburst pattern” were
The aim of this study is to enlarge the case series of stardust         excluded. Moreover, change in dimension (if present stated
spitz nevi in children, in order to increase confidence with            as growth or involution), palpability at first visit, and even-
this new dermoscopic pattern, limit physicians’ concerns,               tually change over time were also scored as present when at
and avoid unnecessary excisions.                                        least two evaluators were in agreement.


Methods                                                                 Results
This retrospective observational study was conducted with               We reviewed clinical and dermoscopic images of 38 SN
cases received from members of the International Dermoscopy             in p
                                                                           ­ atients aged from 1 to 12 years (median age, 7 years
Society. Inclusion criteria were clinical and/or histopathologic        p<0.01). 21 males and 17 females were included. All pa-
diagnosis of Spitz naevus with starburst appearance in chil-            tients were Caucasian. The follow-up period varied from a
dren <12 years old, availability of a dermoscopic image at              minimum of 3 to a maximum of 120 months, with the me-
baseline and after follow-up of at least 1 year, availability of        dian FUP duration of 15,5 months. The median number of
patient’ demographics, lesion location, follow-up duration.             follow-up visits was 2.0 with a minimum of 1 and a maxi-
Cases lacking adequate clinical information were excluded.              mum of 10 (IQR 3.75).
    The centers were asked to provide, with images, a data-                 Of 32 SN, 27 (71.1%) were located on the extremities,
base containing the following information: location of the              3 (7.9 %) on the head and 8 (21 %) on the trunk.



4                                                                            Original Article | Dermatol Pract Concept. 2023;13(1):e2023041
    With regards to the clinical presentation at baseline, 36           brown network. Successively, an involution phase starts with
SN were flat/raised (94.7% - 95% CI: 80.9% to 99.1%,                    regression of the network in the periphery and ends with a
p<0.01) and only 2 were nodular (5.3% - 95% CI: 0.9% to                 grey granular pattern in the center of the lesion.
19%, p<0.01). Almost all the lesions remained flat at the last
follow-up visit (97.4% - 95% CI: 84.6% to 99.9%, p<0.01)
                                                                        Conclusions
while 1 of the 2 nodular lesions became flat after regres-
sion (2.6% - 95% CI: 0.1). Between the first and the last               Our study revealed that the Stardust pattern is more frequent
visit 63.2% of the lesions (N:24 – 95%CI: 46% to 77.6%,                 in the extremities, with no differences between sex. The me-
p<0.01) had an increase in size, 26.3% had a reduction in               dian age is consistent with the literature.
size (N:10 – 95%CI: 14% to 43.4%, p=0.05) while 10.5%                       Barnhill et al. [11] already described an association be-
(N:4 – 95%CI: 3.4% to 25.7%, p=0.14) had only dermo-                    tween pigmented SN and thighs, whereas the rapidly grow-
scopic changes without variation in dimension.                          ing, pink-to-reddish papule variant is more frequent in the
    Comparing the evolution with time of follow-up, no sig-             head and neck region.
nificant differences were found between growing and invo-                   Analyzing the follow-up, we noted that the time needed
luting lesions in terms of patient age and sex, location and            to pass into a growth phase and then into an involuting
palpability of lesions.                                                 one is very variable. The onset of the growth phase ranged
    Dermoscopic examination showed findings consistent                  between 4 to 24 months from first appearance. Surprisingly,
with the literature.                                                    we observed a SN that turned into stardust pattern after
    The starburst pattern evolved into stardust over time.              being stable for 10 years (Fig 4), while another SN after
First, a growing phase is observed in which the center of               10 years was almost completely involved showing greyish
the lesion remains black/blue and the periphery presents a              remnants of the network (Fig 5). It should be remembered




Figure 4. A-B) SN in a patient aged 6 at first visit. At dermoscopy, the lesion shows blue-white center with brown streaks at periphery. C-D)
Same lesion at 17 years old. Dermoscopy highlights stardust pattern with blue globules in the center on a brown background and brown
network fading out at the periphery.



Original Article | Dermatol Pract Concept. 2023;13(1):e2023041                                                                             5
Figure 5. SN on upper back of male patient. A-B )10 years old. C-D) 20 years old. In D the final involuting phase with greyish remnants of
the network.




that the IDS guidelines suggest continuing follow-up also for          biological behavior, regardless of dermoscopic changes.
nevi undergoing involution until stabilization (documented             Moreover, a flat/raised dermoscopically symmetric spit-
evidence of no change for at least 6 months) or complete               zoid-looking lesion below the age of 12 has an extremely
disappearance. The reason for this SN dynamic behavior is              low possibility to be a melanoma as pediatric melanoma is
not clear, but can be related to the genetics of melanocytic           very rare and melanomas arising in children are often nodu-
cells. The most frequently observed genetic alterations in             lar and/or amelanotic [13].
Spitz nevi involve the HRAS gene that drives the symmet-                   A limitation of our study is that our sample is small and
rical overgrowth of cells with epithelioid morphology via              descriptive estimates are weighted by large confidence inter-
preferential PI3K/AKT activation [12]. The acquisition and             vals. Other studies are needed to explore the different pat-
loss of mutations are responsible for the growth and invo-             terns of evolving SN, and to combine dermoscopy, confocal
lution of Spitz nevi.                                                  microscopy and genetic mutations in the optics of the new
    In our series, despite the change in dimension or in der-          concept of deep phenotyping.
moscopy pattern, the symmetry was always maintained as                     In conclusion, although the decision to cut off a lesion is
well as the flat/raised appearance as none became nodular.             demanded to an overall consideration of clinical context (age,
    The long follow-up reported in our study could really              site) and guidelines management, a conservative approach is
support the concept of benignity of changing SN. Since                 acceptable for nevi showing the stardust pattern, because it
Spitz nevi are not precursors of melanoma6, clinically and             resulted to be a physiological evolution of pigmented Spitz ne-
dermoscopically typical cases of SN will maintain the same             vus, and urgent surgeries could be avoided for these patients.




6                                                                           Original Article | Dermatol Pract Concept. 2023;13(1):e2023041
References                                                                    8. Ferrara, G. et al. Spitz Nevus, Spitz Tumor, and Spitzoid Mela-
                                                                                  noma. A Comprehensive Clinicopathologic Overview. Dermatol.
 1. Argenziano, G. et al. Natural evolution of spitz nevi. Dermatol-              Clin. 31, 589–598 (2013).
    ogy 222, 256–260 (2011).                                                  9. Bär, M., Tschandl, P. & Kittler, H. Differentiation of pigmented
 2. Neri I, Dika E, R. G. et al. Spitz nevi: defining features and manage-        Spitz nevi and Reed nevi by integration of dermatopathologic
    ment in children. G Ital Dermatol Venereol. 149, 675–682 (2014).              and dermatoscopic findings. Dermatol. Pract. Concept. 2, 13–24
 3. S, S. Melanomas of childhood. Am. J. Pathol. 24, 591–609 (1948).             (2012).
 4. Spitz, K., Piliang, M. & Mostow, E. Sophie Spitz: A woman ahead          10. Bär, M. Spitz and Reed nevi: acquired or congenital? Dermatol.
    of her time. Int. J. Women’s Dermatology 5, 190–191 (2019).                  Pract. Concept. 2, 21–27 (2012).
 5. Piérard, G. E., Piérard-Franchimont, C. & Delvenne, P. Simulants         11. Barnhill, R. L., Barnhill, M. A., Berwick, M. & Mihm, M. C. The
    of malignant melanoma. Oncol. Rev. 9, 23–27 (2015).                          histologic spectrum of pigmented spindle cell nevus: A review of
 6. Lallas, A. et al. Update on dermoscopy of Spitz/Reed naevi and               120 cases with emphasis on atypical variants. Hum. Pathol. 22,
    management guidelines by the International Dermoscopy Soci-                  52–58 (1991).
    ety. Br. J. Dermatol. 177, 645–655 (2017).                               12. MR Roh, P Eliades, S. G. et al. Genetics of Melanocytic Nevi.
 7. Dika, E., Ravaioli, G. M., Fanti, P. A., Neri, I. & Patrizi, A. Spitz        Pigment Cell Melanoma Res 28, 661–672 (2015).
    Nevi and Other Spitzoid Neoplasms in Children: Overview of               13. Haliasos, H. C. et al. Dermoscopy of Benign and Malignant
    Incidence Data and Diagnostic Criteria. Pediatr. Dermatol. 34,               ­Neoplasms in the Pediatric Population. Semin. Cutan. Med. Surg.
    25–32 (2017).                                                                 29, 218–231 (2010).




Original Article | Dermatol Pract Concept. 2023;13(1):e2023041                                                                                 7
