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Temporal Changes in Size and Dermoscopic Patterns of New and Existing Nevi in Adolescents

Open ArchivePublished:February 22, 2019DOI:https://doi.org/10.1016/j.jid.2018.12.034
      To the Editor
      Cross-sectional studies have shown significant differences in the size and patterns of nevi by age (
      • Zalaudek I.
      • Grinschgl S.
      • Argenziano G.
      • Marghoob A.A.
      • Blum A.
      • Richtig E.
      • et al.
      Age-related prevalence of dermoscopy patterns in acquired melanocytic naevi.
      ,
      • Zalaudek I.
      • Schmid K.
      • Marghoob A.A.
      • Scope A.
      • Manzo M.
      • Moscarella E.
      • et al.
      Frequency of dermoscopic nevus subtypes by age and body site a cross-sectional study.
      ), which may have important implications in the clinical evaluation of skin lesions and in understanding melanocytic growth of benign and malignant lesions. The principal dermoscopic nevus pattern in childhood is globular, whereas a reticular pattern predominates in adulthood (
      • Zalaudek I.
      • Grinschgl S.
      • Argenziano G.
      • Marghoob A.A.
      • Blum A.
      • Richtig E.
      • et al.
      Age-related prevalence of dermoscopy patterns in acquired melanocytic naevi.
      ,
      • Zalaudek I.
      • Hofmann-Wellenhof R.
      • Soyer H.P.
      • Ferrara G.
      • Argenziano G.
      Naevogenesis: new thoughts based on dermoscopy.
      ,
      • Zalaudek I.
      • Schmid K.
      • Marghoob A.A.
      • Scope A.
      • Manzo M.
      • Moscarella E.
      • et al.
      Frequency of dermoscopic nevus subtypes by age and body site a cross-sectional study.
      ). Multiple factors may contribute to the observed age-related shift in dermoscopic pattern, but few temporal studies have monitored individual nevi over time. The objective of the present study was to document temporal changes in dermoscopic pattern and size of nevi during childhood and adolescence.
      The Study of Nevi in Children (SONIC) was approved by the Institutional Review Boards at Boston and Harvard Universities. Recruitment and methodology were detailed previously (
      • Oliveria S.A.
      • Yagerman S.E.
      • Jaimes N.
      • Goodwin A.I.
      • Dusza S.W.
      • Halpern A.C.
      • et al.
      Clinical and dermoscopic characteristics of new naevi in adults: results from a cohort study.
      ,
      • Oliveria S.A.
      • Scope A.
      • Satagopan J.M.
      • Geller A.C.
      • Dusza S.W.
      • Weinstock M.A.
      • et al.
      Factors associated with nevus volatility in early adolescence.
      ). Three cohorts of participants originated from schools in Framingham, Massachusetts. We performed longitudinal follow-up of selected nevi on the back and legs of participants. Assessments, including skin examination, nevus photography, and questionnaires, were completed in the 8th or 9th grade (baseline) and again in the 11th grade (follow-up). One of the three cohorts (n = 366) had undergone a previous assessment of back nevi in the fifth grade. Photography methodology, definitions for anatomical sites, nevus selection methodology, nevus surface area calculations, and dermoscopic pattern classification have been published previously (Supplementary Materials online) (
      • Fonseca M.
      • Marchetti M.A.
      • Chung E.
      • Dusza S.W.
      • Burnett M.E.
      • Marghoob A.A.
      • et al.
      Cross-sectional analysis of the dermoscopic patterns and structures of melanocytic naevi on the back and legs of adolescents.
      ,
      • Geller A.C.
      • Oliveria S.A.
      • Bishop M.
      • Buckminster M.
      • Brooks K.R.
      • Halpern A.C.
      Study of health outcomes in school children:key challenges and lessons learned from the Framingham schools' natural history of nevi study.
      ,
      • Oliveria S.A.
      • Yagerman S.E.
      • Jaimes N.
      • Goodwin A.I.
      • Dusza S.W.
      • Halpern A.C.
      • et al.
      Clinical and dermoscopic characteristics of new naevi in adults: results from a cohort study.
      ,
      • Oliveria S.A.
      • Scope A.
      • Satagopan J.M.
      • Geller A.C.
      • Dusza S.W.
      • Weinstock M.A.
      • et al.
      Factors associated with nevus volatility in early adolescence.
      ). Notably, a complex nevus dermoscopic pattern included nevi with both network and globules, nevi with a distinct peripheral rim of globules, and nevi with a starburst pattern.
      Baseline assessment in the eighth or ninth grade was performed in 569 participants (consent rate for study participation of 32%). Of these, 395 (69%) participants, of which 60% were male and 89% were Caucasian, underwent repeat evaluation in 11th grade (see Supplementary Table S1 online). A total of 1,375 nevi on the back (n = 1,054 [77%]) or legs (n = 321 [23%]) were serially imaged with dermoscopy (Table 1), of which, 69% (n = 944) demonstrated no change in dermoscopic classification. We observed that 60% of complex, 37% of homogenous, 31% of globular, and 22% of reticular nevi demonstrated dermoscopic pattern change at follow-up. Moreover, 21 of 22 (95%) nevi with peripheral globules lost their rim of globules, and were most frequently classified as homogeneous (n = 9) or reticular (n = 6) at follow-up. There was minimal shift in dermoscopic pattern from reticular to globular (1% [n = 8]) or globular to reticular (4% [n = 8]). The net change in the proportion of dermoscopic patterns was +1.2% for complex, –5.8% for homogenous, +1.5% for globular, and +3.1% for reticular. Four percent of nevi disappeared during the study. No differences in rate of nevus disappearance were found by dermoscopic pattern (χ2 = 5.03, P = 0.17).
      Table 1Dermoscopic pattern changes of nevi at baseline and follow-up (n = 395 students)
      Follow-up (11th Grade)
      Baseline (8th or 9th Grade)ComplexHomogenousGlobularReticularDisappearTotal
      Complex2312910256
      Homogenous103585412331576
      Globular152912886186
      Reticular2177843516557
      Total69476199576551,375
      From 366 participants imaged in fifth grade, 189 new back nevi were imaged in eighth grade; of these, 44% were reticular, 21% were globular, 19% were homogenous, and 16% were complex. New back nevi (n = 218) were imaged in 112 of 395 participants imaged at 11th grade follow-up: 44% were reticular, 23% were homogenous, 17% were complex, and 16% were globular. New leg nevi (n = 88) were also imaged in 44 of 395 participants in 11th grade: 54% were reticular, 43% were homogenous, 2% were complex, and none were globular.
      The mean ± standard deviation surface area for nevi at baseline (8th/9th grade) and follow-up (11th grade) was 6.59 ± 6.89 mm2 and 7.70 ± 8.79 mm2, respectively. The mean ± standard deviation percent increase in surface area for back nevi was 7.33% ± 0.57% per year, leg nevi was 4.67% ± 0.84% per year, and all nevi was 6.75% ± 0.48% per year. Nevi with a complex pattern demonstrated the most growth (+15.3% ± 3.8% per year), followed by globular (+8.44% ± 1.1% per year), reticular (+6.51% ± 0.72% per year), and homogenous (+5.59% ± 0.76% per year). The subgroup of complex nevi with peripheral globules showed the largest growth (+25.6% ± 9.6% per year) (see Supplementary Table S2 online).
      A convenience sample of 353 nevi (293 back and 60 leg nevi) from 263 students was used to assess nevus growth, while accounting for constitutional changes in the perilesional body surface area (i.e., overall growth of the participant), using high-resolution 3-dimensional stereophotogrammetry-based imaging as described previously (
      • Chung E.
      • Marchetti M.A.
      • Scope A.
      • Dusza S.W.
      • Fonseca M.
      • DaSilva D.
      • et al.
      Towards three-dimensional temporal monitoring of naevi: a comparison of methodologies for assessing longitudinal changes in skin surface area around naevi.
      ). Because the mean area of all nevi increased by 8.3% ± 0.8% per year and perilesional surface area increased by 6.2% ± 0.2% per year, the calculated mean nevus-growth surface area increase was 2.1% ± 0.8% per year (see Supplementary Table S3 online).
      Over 2–3 years of monitoring in late adolescence, the majority of nevi on the back and legs retained their dermoscopic pattern; this is consistent with previous data documenting the dermoscopic stability of individual back nevi in younger children (
      • Scope A.
      • Marghoob A.A.
      • Dusza S.W.
      • Satagopan J.M.
      • Agero A.L.C.
      • Benvenuto-Andrade C.
      • et al.
      Dermoscopic patterns of naevi in fifth grade children of the Framingham school system.
      ). For nevi that did exhibit a change, we observed the greatest net shift in dermoscopic pattern to the reticular type, a trend also seen in our same cohort from fifth to eighth grade (
      • Scope A.
      • Dusza S.W.
      • Marghoob A.A.
      • Satagopan J.M.
      • Tavoloni J.B.C.
      • Psaty E.L.
      • et al.
      Clinical and dermoscopic stability and volatility of melanocytic nevi in a population-based cohort of children in Framingham school system.
      ). In addition, nevi with reticular and globular patterns infrequently changed from one pattern to the other. A notable exception was nevi with a peripheral rim of globules, which are known to ultimately stop enlarging, lose their peripheral globules, and retain the dermoscopic pattern present at their center (
      • Bajaj S.
      • Dusza S.W.
      • Marchetti M.A.
      • Wu X.
      • Fonseca M.
      • Kose K.
      • et al.
      Growth-curve modeling of nevi with a peripheral globular pattern.
      ). Of new nevi found at follow-up in the 8th grade and 11th grade, we found that as our cohort aged, fewer new nevi were globular, while new reticular nevi were most prevalent; this, along with the net shift toward a reticular pattern in changing existing nevi, appear to be contributing factors to the observation of reticular patterned nevi becoming the most common pattern in adulthood. A study examining the dermoscopic patterns of new nevi in adults is consistent with our findings (
      • Oliveria S.A.
      • Yagerman S.E.
      • Jaimes N.
      • Goodwin A.I.
      • Dusza S.W.
      • Halpern A.C.
      • et al.
      Clinical and dermoscopic characteristics of new naevi in adults: results from a cohort study.
      ).
      Significant changes in nevus surface area were observed. Size change is a sensitive but nonspecific marker of malignancy. A better understanding of normal nevus growth patterns may allow physicians to better differentiate abnormal growth and reduce unnecessary biopsies. For example, nevi with a peripheral rim of globules exhibited marked size changes. Additionally, up to 75% of surface area changes in nevi could be attributed to regional body growth. We suspect that accelerated growth in adolescence likely influences the observed growth of nevi during this age range. Hence, the ability to recognize disproportionate nevus size change may have clinical utility for identifying suspicious lesions (
      • Korotkov K.
      • Quintana J.
      • Puig S.
      • Malvehy J.
      • Garcia R.
      A new total body scanning system for automatic change detection in multiple pigmented skin lesions.
      ).
      A predominance of males and Caucasians among participants limits the generalizability of our study. Imaging was also restricted to select nevi of the back and legs. Finally, participant dropout risks unrecognized selection bias. Further studies in larger cohorts with longer follow-up are needed to validate our observations.

      ORCIDs

      Conflict of Interest

      ACH declares consulting, advisory, or speaking compensation for Caliber ID, HealthCert-Consulting, and INC. The remaining authors state no conflict of interest.

      Acknowledgments

      The Study of Nevi in Children was conducted in Framingham, MA. Statistical analysis and manuscript preparation were carried out in New York, NY. This study was funded in part through Cancer Center Support Grant P30-CA008748 from the National Institutes of Health / National Cancer Institute and supported by award number R01-AR049342 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health as well as grant P41-GM103545 from the National Institute of General Medical Sciences of the National Institutes of Health.

      Supplementary Material

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