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Nevus de Sutton

Author: Edward J Zabawski Jr, DO, RPh, Dermatologist, Spencer Dermatology Group Autor: Edward J Jr
Zabawski, DO, RPh, dermatólogo, Grupo de Dermatología Spencer
Coauthor(s): Clay J Cockerell, MD, Director, Clinical Professor, Department of Dermatology, Division of
Dermatopathology, University of Texas Southwestern Medical Center Coautor (s): J Cockerell Clay, MD,
director, profesor clínico del Departamento de Dermatología de la División de Dermatopatología, Universidad de
Texas Southwestern Medical Center
Contributor Information and Disclosures

Updated: May 28, 2009 Actualizado: 28 de mayo 2009

Introduction
Background

Halo nevi are common benign skin lesions that represent melanocytic nevi in which an
inflammatory infiltrate develops, resulting in a zone of depigmentation surrounding the nevus.
Although Sutton originally described the lesion in 1916 as leukoderma acquisita centrifugum, the
lesions were noted earlier, as evidenced by their depiction in the painting The Temptation of
Saint Anthony by Matthias Gr ü nwald circa 1512-1516. 1

Because melanoma that has undergone regression may appear gray or white, halo nevi have been
erroneously confused with melanoma and have been the source of much anxiety among both
clinicians and patients. Nevertheless, they are entirely benign lesions and of only cosmetic
significance.

Pathophysiology

The etiology of halo nevi is unknown. Numerous studies have attempted to unravel the
immunologic mechanisms by which an immune response develops to existing aggregates of
nevus cells. 2 The infiltrating cells are predominantly T-lymphocytes, and cytotoxic (CD8)
lymphocytes outnumber helper (CD4) lymphocytes by a ratio of approximately 4:1. These, as
well as scattered macrophages, comprise most inflammatory cells in halo nevi. 3 As seen in
vitiligo , melanocytes in the epidermis in the halo component of the nevus are completely absent,
suggesting a similar etiologic mechanism. The exact role that the lymphocytes play in the
regression of halo nevi has not been fully determined, although a theory of direct cytotoxic
effects on melanocytes seems plausible.

Of interest, circulating antibodies to the cytoplasm of melanoma cells have been detected in
patients with halo nevi. 4 Because these antibodies have disappeared after removal of the halo
nevus, they were thought to be related. Subsequent investigation failed to reveal a temporal
relation between the appearance of these antibodies and the regression of nevus cells, and these
antibodies are now believed to appear as a consequence of the release of cytoplasmic proteins of
halo nevus melanocytes secondary to cell damage.

the precipitating cause and the exact role of the lymphocytes remain unknown. they appear as one or more uniformly colored. Mortality/Morbidity Halo nevi are benign. 6 Patients with Turner syndrome have been reported to have an increased incidence of halo nevi. . or brown. it does not always occur. Repigmentation often takes place over months or years. round or oval nevi centrally with even peripheral margins of hypopigmentation. Morbidity is minimal and limited to cosmetic appearance. Clinical History Patients with halo nevi are usually asymptomatic. advanced lesions of halo nevus show dermal macrophages containing portions of nevus cells. Physical Halo nevi are usually single but may be multiple. The average age of onset is 15 years.Ultrastructurally. The width of the halo is variable but is generally of uniform radial distance from the central nevus. the chief complaint is that of a changing mole (or moles). They can develop anywhere on the body but are seen most frequently on the trunk. pink. Race All races are susceptible to the development of these lesions. inflammation occurs with crusting in the depigmented zone of a halo nevus. The central nevus may or may not involute with time. evenly shaped. Sex No sexual predilection is reported. Age Halo nevi are found most commonly in children. The central nevus may be tan. Occasionally. While it is clear that an immunologic mechanism results in the demise of melanocytes in halo nevi. A familial tendency for halo nevi has been reported. Clinically. 5 Frequency United States The incidence of halo nevi in the population is estimated to be 1%. however. Most commonly.

Note the central pink papule (intradermal nevus) and the surrounding halo. . Classic appearance of a halo nevus. and no inflammatory component can be seen. Note the normal nevus directly inferior. The halo is of uniform width at all points.Classic appearance of a halo nevus.

Note the central pink papule (intradermal nevus) and the surrounding halo. Causes The cause is unknown. The halo is of uniform width at all points. and no inflammatory component can be seen. Note the normal nevus directly inferior. but halo nevus is believed to be due to an immune response against melanocytes. Differential Diagnosis Atypical Mole (Dysplastic Nevus) Molluscum Contagiosum Basal Cell Carcinoma Pityriasis Lichenoides Lichen Planus Spitz Nevus Lichen Sclerosus et Atrophicus Vitiligo Malignant Melanoma Other Problems to Be Considered Dysplastic nevus Hypopigmented sarcoidosis Verruca plana Sunscreen application 8 .

however. the number of melanophages is less than would be expected in an inflamed melanocytic lesion. original magnification X40). some of which are laden with melanin. a dense. in most cases. although occasional apoptotic cells may be identified. Mitotic figures usually are not seen. The lesion usually demonstrates a dome-shaped architecture similar to that seen in noninflamed nevi. Identifying residual nevus cells may be difficult in some cases. . surprisingly. although. Macrophages may be seen within the infiltrate. At low magnification. a dome-shaped papular lesion reveals a dense infiltrate of lymphocytes in the dermis (hematoxylin and eosin. .Workup Other Tests Performing an examination using a Wood lamp may aid in differentiating halo nevi from other disorders. Histologic Findings The histology of halo nevus is variable depending on the age of the lesion. Procedures Lesions that are not uniform in shape and color or that have a papular component that is not centrally located should be considered for biopsy to exclude the presence of melanocytic atypia. somewhat bandlike lymphocytic infiltrate is present in the papillary and often reticular dermis with nests of nevus cells located centrally. particularly with older lesions or those in which the infiltrate is quite dense.

original magnification X40). a dome-shaped papular lesion reveals a dense infiltrate of lymphocytes in the dermis (hematoxylin and eosin. original magnification X40). Higher magnification reveals nests of nevus cells with numerous lymphocytes surrounding them and in the interstitium (hematoxylin and eosin.At low magnification. .

but. Table. Distinguishing Features of Halo Nevus and Melanoma Halo Nevus Melanoma Nevus cells in nests Single atypical melanocytes at all levels of the epidermis and aggregates of atypical melanocytes in the dermis Lesion symmetrical Lesion asymmetrical Maturation of nevus cells Lack of maturation Mitotic figures rare or absent Mitotic figures present Lymphocytic infiltrate present Lymphocytic infiltrate tends to be at be concentrated at diffusely throughout lesion periphery . The most important lesion to differentiate from halo nevus is melanoma (see Table). some nevi may demonstrate marked inflammation. virtually no inflammatory infiltrate may be present. Clinically. but. histologically. clinically. clinical correlation is important in rendering a diagnosis of halo nevus. Therefore. nevus cells may appear to be absent or decreased in number. a noninflammatory halo nevus may demonstrate a halo. In more mature lesions.Higher magnification reveals nests of nevus cells with numerous lymphocytes surrounding them and in the interstitium (hematoxylin and eosin. Conversely. original magnification X40). no halo is visible.

[Medline]. Fishman HC. Consultations The chief diagnostic consideration in patients with halo nevi is melanoma that is undergoing regression. Herd RM. 5. J Am Acad Dermatol .51(3):354-8. Freitag A. and color irregularity with black foci that usually allow the diagnosis to be rendered with relative ease. [Medline] . and the white areas represent zones of regression. and no treatment is necessary. Mar 1976. whereas halo nevi are commonly multiple. a dermatologist should be consulted. Edelstein LM. Grin CM. melanomas usually exhibit the characteristic clinical signs of breadth. Furthermore.35(2):352-7. Oct 1997. Thus. asymmetry. Grant-Kels JM. Patrizi A. Brazzelli V. [Medline] . 7. Furthermore. 6. Clin Exp Dermatol . [Medline] . [Medline] . Zeff RA. adults are affected far more commonly by melanoma. The immune response in halo nevi. Neri I. Misciali C. Sep 2004. Feb 2005.37(4):620-4. children are affected more commonly with halo nevi.23(2):68-9. References 1. Hunter JA. In spite of clinically benign features. Ultrastructural evidence for destruction in the halo nevus. [Medline] . rather than vitiligo. Dec 1994.152(2):357-60. genetic. the presence of a new "halo nevus" in an older adult should be regarded with a high index of suspicion for melanoma and may warrant performing a biopsy. 9 Melanomas with surrounding white or hypopigmented zones usually have been present for an extended period of time. Halo nevus.Treatment Medical Care Halo nevi are benign. Arch Dermatol. et al. as opposed to the evenly distributed. Snyder LM. Unusual inflammatory and hyperkeratotic halo naevus in children. 3. Br J Dermatol . Fortier N.112(3):407-8. which is distributed around the central nevus. Feb 1975. J Am Acad Dermatol . Sabattini E. poor circumscription. Larizza D. Cancer Res . Hautarzt . and immunogenetic study in 72 patients. 4.45(12):882-3. is a typical dermatologic finding of turner's syndrome: clinical. 2. Primary melanoma is usually solitary. although making this distinction is not usually difficult. Jacobs JB. Rizzoli L. Happle R. Martinetti M. In those patients where a potential malignancy is in question. [Grunewald nevus]. Mar 1998. the "halo" of a regressing melanoma is irregular in shape and variable in radial width. . circular zone of hypopigmentation in true halo nevi. [Medline] . Familial halo naevi. Letter: Malignant melanoma arising with two halo nevi.

8.133(3):295-7. Jun 2006. Berg P. Artifactual "pseudo-halo nevi" secondary to sunscreen application. 9. [Medline] . Zalaudek I. J Am Acad Dermatol .54(6):1106-7. P Berg. Moscarella E. Arch Dermatol . Mar 1997. Lindelof B. Argenziano G. Differences in malignant melanoma between children and adolescents. A 35-year epidemiological study. [Medline]. . Lindelof B.