CASE REPORT

Recurrent halo nevus: Dermoscopy and

confocal microscopy features
Ana Carolina Porto, MD,a Tatiana Pinto Blumetti, MD,a Raquel de Paula Ramos Castro, MD,a
Clovis Ant^onio Lopes Pinto, MD, PhD,b Adriana Silveira Pessoa Mendes, MD,a
Jo~ao Pedreira Duprat Neto, MD, PhD,a Gisele Gargantini Rezze, MD, PhD,c and
Juliana Casagrande Tavoloni Braga, MD, PhDa
S~
ao Paulo, Brazil
Key words: confocal microscopy; dermoscopy; halo nevus; melanoma; nevus; skin cancer.

INTRODUCTION
Abbreviations used:
Melanocytic nevi change throughout a person’s
life. Most melanocytic nevi are acquired during HN: halo nevi
RN: recurrent nevi
childhood and early adulthood; in later life, the RCM: reflectance confocal microscopy
prevalence of melanocytic nevi falls.1 Nevi
frequently form, but the exact mechanisms involved
in their generation remain unknown. Nevi usually
Recurrent nevi (RN) are benign and melano-
progressively fade or, less commonly, transition
cytic, and they usually develop after incomplete
through targetoid presentations (halo, cockade, or
surgical excision or trauma. RN are frequently
Meyerson nevi).2
referred to as pseudomelanomas because of their
In halo nevi (HN), a symmetrical hypopigmented
often challenging appearance on clinical and
rim can be observed surrounding a central nevus.
dermoscopy evaluation.8 RN and HN concomi-
The progressive involution of the central part of this
tantly affecting a single lesion has never been
variety of nevus might be seen over the course of
described before.
months to years, disappearing completely in 50%
of cases.3
HN are more commonly associated with benign CASE
melanocytic nevi, but rarely occur in nevi with We present the case of a 9-year-old boy, with
various degrees of atypia, in nonmelanocytic tumors, 2 years follow-up in our Cutaneous Oncology
in inflammatory lesions, and in melanoma.4 The risk Department for a changing nevus on the back.
for malignancy often leads to the clinical investiga- Dermoscopy revealed a regular globular reticular
tion and follow-up of doubtful lesions. Dermoscopic pattern surrounded by a hypopigmented rim. The
examination of HN typically shows a globular or lesion was showing progressive regression, and at
homogeneous pattern.5 Reflectance confocal micro- the last evaluation, it presented with a sudden and
scopy (RCM) of HN has been previously described in abrupt central repigmentation. On this occasion, a
2 studies and some atypical features, also seen in change in the dermoscopy pattern was observed,
atypical melanocytic lesions and malignant mela- with an atypic network in the center and asymmetric
noma, were observed in most patients evaluated. and irregular globules in the periphery.
These features included pagetoid cells, non-edged RCM of the pigmented area indicated a typical
papilla, junctional thickening, nucleated cells in the honeycomb pattern and dendritic cells in the
dermal papillae, and plump bright cells.6,7 These epidermis, non-edged papillae, an atypical mesh-
atypical findings might be due to local work pattern of dendritic cells and homogeneous
inflammation.7 nests (dense nests) at the dermo-epidermal

From the Cutaneous Oncology Departmenta and Pathology JAAD Case Reports 2017;3:256-8.
Departmentb AC Camargo Cancer Center, S~ao Paulo; and 2352-5126
DermaImage, S~ao Paulo.c Ó 2017 by the American Academy of Dermatology, Inc. Published
Funding sources: None. by Elsevier, Inc. This is an open access article under the CC BY-
Conflicts of interest: None declared. NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
Correspondence to: Ana Carolina Porto, MD, Rua Professor Ant^
onio 4.0/).
Prudente, 211, S~ao Paulo, SP, 01509-010, Brazil. E-mail: http://dx.doi.org/10.1016/j.jdcr.2017.02.020
[email protected].

256
JAAD CASE REPORTS Porto et al 257
VOLUME 3, NUMBER 3

Fig 1. Histopathologic analysis and immunohistochemical stainings of the recurrent halo

nevus. A, Panoramic view of the lesion. Lesion is characterized by a dense inflammatory
infiltrate obscuring the dermal-epidermal junction of the skin. B, Moderate atypical melanocytic
proliferation in the dermal-epidermal junction with nest formation and without pagetoid
migration; in the dermis, an intense lymphocytic infiltration with melanocytes nests and
numerous melanophages. C, Immunohistochemistry study revealing the intraepidermal
Langerhans cells, confirming that some of the dendritic cells seen on confocal microscopy
are Langerhans cells. D, S100 staining highlighting the melanocytic nests in the dermis
confirming the compound nature of the lesion, and an increased number of Langerhans cells in
the epidermis. (A and B, Hematoxylin-eosin stain; C, CD1a staining; D, S100 stain; original
magnifications: A, 340; B-D, 3400.)

junction, thick collagen bundles, and bright cells cutaneous melanoma is the scar pigmentation. In
within the dermis (Fig 1). In the surrounding melanoma, the pigmentation intersects the scar
hypopigmented area, a typical honeycomb limits, but in RN, pigmentation is limited to the
pattern within the epidermis was observed, as scar.8,10 In our case, the lesion was confined to the
well as faint bright-edged papillae at the dermo- scar but worrisome dermoscopic features and doubt-
epidermal junction and normal collagen in the ful RCM findings lead us to investigate histopathol-
papillary dermis (Fig 2). An excisional biopsy was ogy further.
carried out and histopathologic analysis revealed In conclusion, we presented the first report in
a compound melanocytic nevus with severe the literature of recurrent halo nevus, a combina-
atypia (Fig 1). tion of 2 relatively rare phenomena (HN and RN)
occurring in a single lesion. The sequential use of
DISCUSSION digital dermoscopy enabled us to register the
Even though RN are benign lesions, they often are natural course of a HN involution followed by a
challenging to diagnose because they might have recurrence. In addition, RCM revealed findings
clinical, dermoscopic, and histopathologic features from both phenomena in agreement with the
that resemble melanoma.9 subsequent histopathologic analysis, ensuring the
One crucial feature that has been reported to help reliability of this tool to evaluate challenging
differentiate RN from local recurrence of a primary melanocytic lesions.
258 Porto et al JAAD CASE REPORTS
MAY 2017

Fig 2. Dermoscopic images of recurrent halo nevus. A-C, Gradual regression of the halo nevus. A,
Dermoscopy shows a regular reticular and globular nevus surrounded by a symmetric halo. B,
After 6 months, a partial disappearance of the nevus was observed. C, After 1 year, an almost
complete regression of the nevus occurred. D and E, recurrent halo nevus. D, After a 2-year follow-
up, repigmentation in the center of the lesion occurred. Dermoscopy of the recurrent halo nevus
showed an atypical network in the center and asymmetric and irregular globules in the periphery.
E, Reflectance confocal microscopy (RCM) mosaic image (2.5 3 2.5 mm) of the recurrent nevus
shows an atypical meshwork pattern at the level of the dermo-epidermal junction. F, RCM mosaic
image (zoom in of the dashed square in E, 1 3 1 mm) shows homogeneous dense nests (red
asterisks), atypical meshwork patterns (yellow arrows), and dendritic cells (red arrows).

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