OBSERVATION Dermoscopy Patterns of Halo Nevi Isabel Kolm, MD; Alessandro Di Stefani, MD; Rainer Hofmann-Wellenhof, MD; Regina Fink-Puches, MD; Ingrid H. Wolf, MD; Erika Richtig, MD; Josef Smolle, MD; Helmut Kerl, MD; H. Peter Soyer, MD; Iris Zalaudek, MD Background: Halo nevi (HN) are benign melanocytic globular and/or homogeneous patterns in more than 80% nevi surrounded by a depigmented area (halo). This study of HN. Follow-up of 33 HN revealed considerable size aims to evaluate the dermoscopic features of HN and their reduction of the nevus component, but this was not as- changes during digital dermoscopic follow-up and to in- sociated with significant structural changes. Of a total of vestigate the frequency of the halo phenomenon in a se- 475 melanomas, only 2 revealed an encircling halo, but ries of melanomas. both displayed clear-cut melanoma-specific patterns ac- cording to dermoscopy. Observations: In a retrospective study, digital dermo- scopic images of HN from patients who attended the Pig- Conclusions: Halo nevi exhibit the characteristic der- mented Skin Lesions Clinic of the Department of Der- moscopic features of benign melanocytic nevi, repre- matology, Medical University of Graz, between October sented by globular and/or homogeneous patterns that are 1, 1997, and March 31, 2004, were reviewed and classi- typically observed in children and young adults. Halo nevi fied by dermoscopic morphologic criteria. For HN that reveal considerable changes of area over time during digi- were followed up with digital dermoscopy, the percent- tal dermoscopic follow-up, albeit their structural pat- ages of changes in the size of the nevus and halo com- terns remain unchanged. For this reason and because ponents were calculated. In addition, digital dermo- melanoma with halolike depigmentation, despite being scopic images of histopathologically confirmed melanomas rare, additionally exhibits melanoma-specific dermo- obtained from the same database were reviewed for the scopic criteria, the role of digital dermoscopic fol- presence of an encircling halolike depigmentation. We low-up in the diagnosis of HN is insignificant. classified 138 HN in 87 patients (mean age, 22.4 years). The most common dermoscopic structures were the Arch Dermatol. 2006;142:1627-1632 ALO NEVI (HN), ALSO yet fully understood, but T lymphocytes termed Sutton nevi or leu- are considered to play a key role in the pro- koderma acquisitum cen- gressive destruction of nevus cells.7-11 Al- trifugum, are defined as be- though the halo phenomenon is most com- nign melanocytic nevi that mon in benign melanocytic nevi, reports are surrounded by a rim of depigmenta- of HN in individuals with a family and/or H 1-3 tion, resembling a halo. Halo nevi are personal history of melanoma and mela- common in children and young adults, with nomas with halo prompted concerns about a mean age at onset of 15 years.4 Affected the diagnosis and management of mela- individuals frequently have multiple HN, nocytic skin lesions that exhibit an encir- which are usually localized on the back and cling halo.12-15 4 Author Affiliations: may be clustered. The incidence of HN in Dermoscopy gained popularity be- Department of Dermatology, the population is estimated to be approxi- cause it permits a more accurate diagnosis Medical University of Graz, mately 1%.5 There is no predilection for sex, and management of melanocytic skin le- Graz, Austria (Drs Kolm, and all races are susceptible to the devel- sions compared with examination with the Hofmann-Wellenhof, opment of these lesions. A familial ten- naked eye.16-19 Although the dermoscopic Fink-Puches, Wolf, Richtig, dency for HN has been reported,5 and HN criteria of many benign melanocytic skin Smolle, Kerl, Soyer, and may be associated with atopic dermatitis or lesions and melanoma have been studied Zalaudek); and Department of with autoimmune disorders such as viti- extensively, the dermoscopic structures that Dermatology, University of ligo and Hashimoto thyroiditis.4-6 characterize HN have not yet been de- Rome Tor Vergata, Rome, Italy (Dr Di Stefani). Dr Zalaudek is For a period of months or even years, scribed in detail. We analyzed the dermo- currently with the Department HN tend to undergo 4 clinical stages char- scopic structures in HN and correlated the of Dermatology, Second acterized by a progressive involution with dermoscopic findings with changes in the University of Naples, Naples, subsequent total regression of the central size of the nevus and halo components of Italy. nevus. The underlying pathogenesis is not HN over time. Moreover, we investigated (REPRINTED) ARCH DERMATOL/ VOL 142, DEC 2006 WWW.ARCHDERMATOL.COM 1627 ©2006 American Medical Association. All rights reserved. Downloaded From: http://archderm.jamanetwork.com/ by a UQ Library User on 11/12/2015 100 Table 1. Demographics of Patients With Halo Nevi 90 Revealing a History of Concomitant Disease 80 Patient No./ Sex/Age, y Concomitant Disease 60 1/F/45 Personal history of melanoma 2/F/58 Personal history of melanoma 40 3/M/14 Family history of melanoma (grandfather) No. of Halo Nevi 4/F/24 Family history of melanoma (mother) 5/F/35 Dysplastic nevus syndrome 20 16 17 9 6/M/33 Dysplastic nevus syndrome 2 4 7/F/28 History of autoimmune Hashimoto thyroiditis 0 Legs Head and Arms Abdomen Chest Back 8/F/10 History of familial halo nevi (sister and mother) Neck 9/F/8 Vitiligo Body Site 10/M/28 Vitiligo 11/F/20 Atopic dermatitis Figure 1. Geometric body site–related distribution of halo nevi (N=138). 12/F/9 Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) the frequency of halo phenomenon in melanomas to evalu- ate the occurrence of this peculiar type of regression. Forty-six patients (52.9%) were women and 41 (47.1%) were men, with a mean age for all patients of 22.4 years (range, 5-69 years). METHODS From data included in the patient registration forms, we recorded concomitant diseases (Table 1). In 6 pa- For this retrospective study, dermoscopic images of HN were tients, generally accepted risk factors for melanoma were selected from a database that contained 29 383 digital images of pigmented skin lesions from 6079 patients who attended the recorded. These patients were older (mean age, 34.8 years; Pigmented Skin Lesions Clinic of the Department of Derma- range, 14-58 years) with respect to the mean age of 23.2 tology, Medical University of Graz, between October 1, 1997, years in our study population. However, in none of these and March 31, 2004. The digital dermoscopic images were re- patients was the time at onset of HN related to mela- corded with a digital epiluminescence microscopic system (Mole noma development and/or melanoma progression. Max II; Derma Medical Systems, Vienna, Austria) and stored In 58 nevi (42.0%), we observed a combination of ho- at 30-fold magnification in JPEG format, with a resolution of mogeneous and globular patterns in different areas of the 640ϫ480 pixels at 24-bit color depth. The diagnosis of HN was lesion. The homogeneous-globular pattern was fol- made by experienced dermatologists (I.K., A.D.S., and R.H.- lowed in frequency by the homogeneous pattern (32 nevi; W.) and was based on clinical and dermoscopic examination. 23.2%) and the globular pattern (24 nevi; 17.4%) The HN were classified according to the primary dermoscopic structural patterns (reticular, globular, or homogeneous).18 (Figure 2 and Figure 3). Variations on the reticular When 2 different dermoscopic structural patterns were pre- patterns were recorded in only 9 nevi, and no single ne- sent, the HN were classified as reticular-globular, homogeneous- vus in the study showed a combination of all 3 patterns globular, or homogeneous-reticular. The HN that showed al- (reticular, globular, and homogeneous). Three nevi most total disappearance of the nevus were classified as regressed. showed complete regression of the nevus component, If a nevus could not be classified because of poor quality of the characterized by a light brown to pink central area that digital dermoscopic image, it was labeled as “not classifiable.” exhibited dotted vessels as the only dermoscopic fea- When available, follow-up digital images of a given nevus ture (Figure 4). were measured and compared with the earlier digital images. From a total of 138 HN, we were able to follow changes Because of the retrospective study design, we were unable to in 33 HN (23.9%) from 16 patients. The mean fol- clarify the exact time of onset of HN in an individual patient. However, given that the approximate waiting time for consul- low-up period for these nevi was 26 months (range, 4-61 tation at our specialized clinic is 2 months, we assumed that months). We observed a reduction in the nevus area in the baseline visit for treatment of HN was sought within the all HN, with a mean reduction of 2.2% per month. For first 3 months of onset. Measurement was performed on- 12 HN a follow-up image was available within 6 months screen (semiautomatically) with the Mole Max “Expertizer” pro- after the initial baseline visit, and these nevi showed a gram (Derma Medical Systems), and the percentage of change mean reduction in the nevus area of 5.2% per month dur- in the area per month was calculated for both the nevus and ing the first 6 months (Table 2). halo components. In addition, we reviewed the dermoscopic Halo size decreased over time in 17 (51.5%) of the 33 images of histopathologically confirmed melanomas obtained cases for which follow-up images were available from the same database for the presence of an encircling halo. (Figure 5), with a mean reduction in the halo area of 0.85% per month.