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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.
Ultrastructurally, advanced lesions of halo nevus show dermal macrophages containing portions
of nevus cells. While it is clear that an immunologic mechanism results in the demise of
melanocytes in halo nevi, the precipitating cause and the exact role of the lymphocytes remain
unknown. 5

Frequency

United States

The incidence of halo nevi in the population is estimated to be 1%. 6 Patients with Turner
syndrome have been reported to have an increased incidence of halo nevi.

Mortality/Morbidity

Halo nevi are benign. Morbidity is minimal and limited to cosmetic appearance.

Race

All races are susceptible to the development of these lesions. A familial tendency for halo nevi
has been reported.

Sex

No sexual predilection is reported.

Age

Halo nevi are found most commonly in children. The average age of onset is 15 years.

Clinical
History

Patients with halo nevi are usually asymptomatic. The central nevus may or may not involute
with time. Repigmentation often takes place over months or years; however, it does not always
occur. Occasionally, inflammation occurs with crusting in the depigmented zone of a halo
nevus. Most commonly, the chief complaint is that of a changing mole (or moles).

Physical

Halo nevi are usually single but may be multiple. They can develop anywhere on the body but
are seen most frequently on the trunk. Clinically, they appear as one or more uniformly colored,
evenly shaped, round or oval nevi centrally with even peripheral margins of hypopigmentation.
The central nevus may be tan, pink, or brown. The width of the halo is variable but is generally
of uniform radial distance from the central nevus.
Classic appearance of a halo nevus.

Classic appearance of a halo nevus.

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

Causes

The cause is unknown, 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
Workup
Other Tests

Performing an examination using a Wood lamp may aid in differentiating halo nevi from other
disorders.

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.

Histologic Findings

The histology of halo nevus is variable depending on the age of the lesion; however, in most
cases, a dense, somewhat bandlike lymphocytic infiltrate is present in the papillary and often
reticular dermis with nests of nevus cells located centrally. 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, particularly with older lesions or those in which the
infiltrate is quite dense. Mitotic figures usually are not seen, although occasional apoptotic cells
may be identified. Macrophages may be seen within the infiltrate, some of which are laden with
melanin, although, surprisingly, the number of melanophages is less than would be expected in
an inflamed melanocytic lesion.

At low magnification, a dome-shaped papular lesion reveals a dense infiltrate of


lymphocytes in the dermis (hematoxylin and eosin, original magnification X40).
At low magnification, 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, original magnification X40).
Higher magnification reveals nests of nevus cells with numerous lymphocytes surrounding
them and in the interstitium (hematoxylin and eosin, original magnification X40).

In more mature lesions, nevus cells may appear to be absent or decreased in number. Clinically,
a noninflammatory halo nevus may demonstrate a halo, but, histologically, virtually no
inflammatory infiltrate may be present. Conversely, some nevi may demonstrate marked
inflammation, but, clinically, no halo is visible. Therefore, clinical correlation is important in
rendering a diagnosis of halo nevus. The most important lesion to differentiate from halo nevus
is melanoma (see Table).

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
Treatment
Medical Care

Halo nevi are benign, and no treatment is necessary.

Consultations

The chief diagnostic consideration in patients with halo nevi is melanoma that is undergoing
regression, although making this distinction is not usually difficult. Primary melanoma is usually
solitary, whereas halo nevi are commonly multiple. Furthermore, children are affected more
commonly with halo nevi; adults are affected far more commonly by melanoma. 9

Melanomas with surrounding white or hypopigmented zones usually have been present for an
extended period of time, and the white areas represent zones of regression. Thus, the "halo" of a
regressing melanoma is irregular in shape and variable in radial width, as opposed to the evenly
distributed, circular zone of hypopigmentation in true halo nevi, which is distributed around the
central nevus. Furthermore, melanomas usually exhibit the characteristic clinical signs of
breadth, asymmetry, poor circumscription, and color irregularity with black foci that usually
allow the diagnosis to be rendered with relative ease.

In spite of clinically benign features, 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.
In those patients where a potential malignancy is in question, a dermatologist should be
consulted.

References
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2. Zeff RA, Freitag A, Grin CM, Grant-Kels JM. The immune response in halo nevi. J Am
Acad Dermatol . Oct 1997;37(4):620-4. [Medline] .
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hyperkeratotic halo naevus in children. Br J Dermatol . Feb 2005;152(2):357-60.
[Medline] .
4. Fishman HC. Letter: Malignant melanoma arising with two halo nevi. Arch Dermatol.
Mar 1976;112(3):407-8. [Medline] .
5. Jacobs JB, Edelstein LM, Snyder LM, Fortier N. Ultrastructural evidence for destruction
in the halo nevus. Cancer Res . Feb 1975;35(2):352-7. [Medline].
6. Herd RM, Hunter JA. Familial halo naevi. Clin Exp Dermatol . Mar 1998;23(2):68-9.
[Medline] .
7. Brazzelli V, Larizza D, Martinetti M, et al. Halo nevus, rather than vitiligo, is a typical
dermatologic finding of turner's syndrome: clinical, genetic, and immunogenetic study in
72 patients. J Am Acad Dermatol . Sep 2004;51(3):354-8. [Medline] .
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sunscreen application. J Am Acad Dermatol . Jun 2006;54(6):1106-7. [Medline].
9. Berg P, Lindelof B. Differences in malignant melanoma between children and
adolescents. P Berg, Lindelof B. A 35-year epidemiological study. Arch Dermatol
. Mar 1997;133(3):295-7. [Medline] .