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he Morphologic Universe of Melanocytic Neviris Zalaudek, MD,* Manuela Manzo, MD,† Imma Savarese, MD,† Giovanni Docimo, MD,‡

erardo Ferrara, MD,§ and Giuseppe Argenziano, MD†

Different types of nevi do exist in relation to their epidemiology, morphology, evolution, andassociated melanoma risk. The introduction of dermoscopy opened a new dimension of themorphologic universe of nevi and allowed clinicians to observe colors and structures withinnevi that are otherwise not visible to the unaided eye. Because most of these colors andstructures correspond to well-defined histopathologic correlates, dermoscopy enablesclinicians to date to more precisely predict the histopathology diagnosis and therebyimprove on their clinical diagnostic accuracy. Besides the diagnostic impact, the in vivoobservation of thousands of nevi using dermoscopy and digital dermoscopic follow-up hasopened new understanding about the evolution of nevi and factors influencing the nevuspattern. In consequence, a new nevus classification has been proposed, subdividing neviinto 7 categories, which are as follows: (1) globular/cobblestone nevi, (2) reticular nevi, (3)starburst nevi, (4) homogeneous blue nevi, (5) nevi on special body sites, (6) nevi withspecial features, and (7) and unclassifiable melanocytic proliferations. This article providesan overview on the morphologic classification of nevi and the factors influencing the nevuspattern.Semin Cutan Med Surg 28:149-156 © 2009 Elsevier Inc. All rights reserved.

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he term “nevus family” indicates a heterogeneous groupof benign melanocytic proliferations that differ in epide-

iology, morphology, evolution, and associated melanomaisk. Based on the latter, currently 2 main categories, namelyongenital and acquired nevi, are distinguished. The formerre considered to have a certain risk for malignant transfor-ation, which seems to increase linearly with the clinical size

nd is definite only for large congenital nevi (�20 cm).1 Inontrast, acquired nevi, particularly when multiple or clini-ally atypical, are indicators for an increased risk for de novoevelopment of melanoma.2 Because in the past, with thexception of large (�20 cm) and intermediate (�15 mm)ongenital nevi, the clinical criteria were insufficient to dis-inguish between various types of nevi; our current classifi-ation, diagnosis, and understanding of evolution of nevi areargely based on histopathology.

This mixture of few clinical and mostly histopathologicriteria, particularly for diagnosing the spectrum of smallevi (�15 mm in size), has been proven to be problematic in

Division of Dermatology, Medical University of Graz, Graz, Austria.Department of Dermatology, Second University of Naples, Naples, Italy.Third Division of Surgery, Second University of Naples, Naples, Italy.Department of Oncology, Pathologic Anatomy Unit, Gaetano Rummo Gen-

eral Hospital, Benevento, Italy.ddress reprint requests to Iris Zalaudek, MD, Department of Dermatology,

Medical University of Graz, Auenbruggerplatz 8, 8036 Graz, Austria.

wE-mail: iris.zalaudek@meduni-graz.at

085-5629/09/$-see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1016/j.sder.2009.06.005

he daily routine. This is because clinicians are confrontedith histopathologic diagnosis that allows only limited con-

lusions about the clinical appearance of the nevus. Equally,athologists sometimes face difficulties in differentiatingmall congenital nevi from acquired nevi of the compound orermal type if a reliable history is missing.3 As a consequence,here is considerable confusion in terminology and classifi-ation of nevi, leading to the introduction of “congenital-like”evi or nevi with “congenital-like” features.4 The problem ofhis classification is perhaps best demonstrated by a practicalxample: It is virtually impossible for a clinician to under-tand the clinical aspect of a nevus defined as “a small con-enital-like nevus of the compound type,” which at the sameime expresses the pathologist’s uncertainty to classify theevus accurately into the spectrum of congenital or acquiredevi. Although histopathology at the current stage remainshe “gold” standard in the diagnosis of melanocytic prolifer-tions, it must be further acknowledged that histopathologictudies commonly rely on a significant selection bias, despitellowing the view just on a moment in the life of nevi. Thus,istopathology does not permit conclusions about the epide-iology or dynamics in the evolution of nevi. The introduc-

ion of dermoscopy opened a new morphologic dimensionnd allowed clinicians to observe colors and structuresithin nevi that are otherwise not visible to the unaided eye.ecause most of these colors and structures correspond to

ell-defined histopathologic correlates, it does not come as a

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urprise that dermoscopy enables clinicians to more preciselyredict the histopathology diagnosis and thereby improve onheir clinical diagnostic accuracy.5,6 Besides the diagnosticmpact, the in vivo observation of thousands of nevi usingermoscopy and digital dermoscopic follow-up has allowednew understanding about the epidemiology, morphology,

nd evolution of nevi and led recently to a new proposal ofevus classification.7

ermoscopiclassification of Nevi

he most significant difference between the new and tradi-ional classification of nevi is that the new classification noonger classifies small nevi into “congenital” or “acquired.”nstead, nevi are summarized into 4 main categories based onommon epidemiologic and morphologic features, irrespec-ive of their history. These 4 main features are the globular,eticular, starburst, and homogeneous blue pattern, ofhich each corresponds to specific histopathologic sub-

trates5 (Table 1).

able 1 Dermoscopic Structures, Colors, and Their Pathologi

Pattern Description

eticularnetwork

Network of brownish interconnectedlines over a background of tandiffuse pigmentation

lobularcobblestone

Numerous, variously sized, round tooval structures with various shadesof brown and gray-black � large,closely aggregated, somehowangulated globule-like structuresresembling a cobblestone

tarburst Bulbous and often kinked or fingerlikeprojections seen at the edge of alesion. They may arise from networkstructures but more commonly donot. They range in color from tan toblack.

omogeneousblue

Structureless blue pigmentation in theabsence of pigment network orother distinctive local features

Color Pathologic Correlate

lack Melanin in keratinocytes ormelanocytes

rown Melanin in keratinocytes ormelanocytes

ray Melanin in either keratinocytes,melanocytes, or melanophages

lue Melanin either free or withinmelanocytes or within

melanophages

More importantly, in this simplified classification, smallcongenital” nevi, “congenital-like” nevi, and “acquired” nevif the compound and dermal type are considered together 1ategory of “globular” nevi based on their common dermo-copic-histopathologic features, namely, variably large glob-les corresponding to predominantly dermal nests of mela-ocytes (Fig. 1). In light of the remarkable clinical andistopathologic difficulties to reliably differentiate small “trueongenital” nevi from “congenital-like” or “acquired” nevi ofhe compound and dermal type, the advantage of this newlassification is obvious.

Reticular pattern correspond either to small junctionalests of melanocytes or to single melanocytes at the basal

ayer (ie, junctional or lentiginous nevi) (Fig. 2), whereas theroup of “starburst” nevi summarizes pigmented Spitz/Reedevi (SN/RN) in 1 group based on their striking dermoscopiceatures of starburst pattern (ie, regular peripheral streaks)8

Fig. 3). The fourth category includes blue nevi typified der-oscopically by homogenous structureless blue pigmenta-

ion in the absence of any additional dermoscopic structures9

Fig. 4). The previously introduced homogeneous brown

relates Associated with Melanocytic Skin Lesions

Pathologic CorrelateDiagnostic

Significance

rly elongated, notedly pigmentedridges with increasednocytes in the basal layer ands of melanocytes at the tips ofrete ridges

Junctional nevusLentiginous nevus

le large nests of melanocytes atdermo-epidermal junction or inpapillary dermis

Congenital nevusCompound nevusDermal nevus

emarcated junctional nests ofnocytesngitudinal shape of the streakss one to assume that thetional melanocytic nests formd-like structures parallel to thesurface

Pigmented Spitznevus

Reed nevus

e infiltrate of dendriticnocytes and melanophages in

papillary and/or reticular dermis

Blue nevus

tomic Level in the SkinDiagnostic

Significance

atum corneum Nevus with epidermalinvolvement

al layer or upper dermis Nevus with epidermalinvolvement

per dermis Nevus with epidermaland dermalinvolvement

per to deep dermis Nevus with dermalinvolvement

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Nevus classification 151

attern is not considered an own category because recenttudies demonstrated that it reveals overlapping histopatho-ogic correlations with the globular and reticular pattern.10

urthermore, it has yet to be determined whether nevi with aixed pattern (reticular and globular or reticular and homo-

eneous) represent a specific entity or belong to the group oflobular or reticular nevi.

Figure 2 Lentiginous (A) and junctional nevi (B) are d

Figure 1 Dermoscopy images of (A) small congenital nevcongenital-like nevus with a history of development w30-year-old patient, and (D) dermal nevus in a 50-yearglobular/cobblestone pattern underlining a common his

magnification, �10).

Besides these 4 main morphologic categories, the dermo-copic classification further distinguishes between 3 sub-roups, which are nevi of special body sites (including facial,cral, subungual, and mucosal nevi), nevi with special featureshalo nevus, Meyerson nevus, traumatized targetoid hemosider-tic nevus, cockade nevus, combined nevus, and recurrent ne-us), and unclassifiable melanocytic proliferations.

opically characterized by a reticular pattern (original

a documented history of being present since birth, (B)e patient was 6 years old, (C) compound nevus in atient. All types are dermoscopically characterized by atic background (original magnification, �10).

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Nevi located on the face, palms and soles, subungual, orucosal sites exhibit peculiar dermoscopic features that are

elated to the specific anatomic structure of the skin of theseocations. Such nevi are therefore also referred to as nevi ofpecial body sites and show a pseudonetwork pattern, paral-el-furrow pattern, regular band-like pattern, and often mixed-lobular pattern, respectively6,7 (Table 2).

Notably, the nevi with special features and unclassifiableelanocytic proliferations are not considered as separate en-

ities as melanocytic lesions from all previous categories mayall into these categories.

Nevi with special features differ from the 4 main categoriesnasmuch as they exhibit peculiar clinical features (white,ed-eczematous, or purple halo and/or targetoid appearance)r a special clinical history (biopsy or trauma)11,12 (Table 2).Importantly, lesions from all previous categories may show

onflicting diagnostic criteria from a clinico-dermoscopicnd/or a histopathologic point of view, which are encoun-ered in the group of unclassifiable melanocytic proliferationssynonyms: atypical melanocytic proliferations or gray zoneesions). Examples for such gray zone lesions are atypicalpitz tumors, melanocytic tumors with extensive regression,

igure 3 Dermoscopy of starburst nevus showing regular streaks athe periphery (original magnification, �10).

igure 4 Dermoscopy of blue nevus shows homogeneous blue pat-ern in the absence of any discernible morphologic patterns (original

magnification, �10).

everely dysplastic nevi, melanocytic tumors of uncertainalignant potential, or superficial atypical melanocytic pro-

iferation of uncertain significance.Last, the new dermoscopic classification is designed for the

able 2 Dermoscopic Pattern of Nevi Located on Specialody Sites and Nevi with Special Features

Nevi atSpecial Body

Sites Dermoscopy

cral Parallel pigmented lines within thefurrows or perpendicular to thefurrows

ail Small pigmented band composed byparallel lines of uniform color andwidth

enital Mixed pattern composed of prominentnetwork structures and/or gray-blueglobules and/or homogeneous blue-gray pigmentation

ace Pseudo-network pattern intermingledby hairs

Nevi withSpecial

Features Dermoscopy

alo nevus The central nevus often exhibits aglobular or homogeneous pattern,which is surrounded by a variablerim of a white scar-likedepigmentation. In fully regressedhalo nevi, the central nevuscomponent lacking entirely and areddish papule eventually revealingvisible vessels from the dermalvascular plexus may be seen

eyerson nevus The central nevus component appearsoften blurred and as an unspecificpattern due to overlying superficialserocrusts

rritated,hemosiderotictargetoid nevus

The central nevus component showstypical features of globular nevuswith vascular-hemorrhagic (red topurple or black) changessuperimposed on the nevusTypically the purple ecchymotic rimsurrounds the nevus

ockade nevus This nevus shows a central pigmentedpapular component of gray-browncolor surrounded by a depigmentedinner rim and outer rim composedof globules or network

ombined nevus Its stereotypical appearance is that ofa central homogeneous bluestructureless area surrounded by aglobular or reticular pattern

ecurrent nevus Round scar exhibiting a centralirregular pattern composed ofatypical network, streaks, andglobules

anagement and diagnosis of the most common types of

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Nevus classification 153

evi, which are small nevi (�15 mm in size), but does notnclude large- to intermediate-sized (ie, nevi larger than 15

m or more) congenital melanocytic nevi. The latter areonsidered to represent “true congenital nevi” as also con-rmed in most cases by the patient’s history. For these le-ions, dermoscopy is only of limited diagnostic value andlinical size or history of changes remain the most importantriteria for their diagnosis and management.

he Concept of theredominant Nevus Pattern

t has been shown that most individuals with multiple orlinically atypical nevi harbor a predominant nevus patternmong all their nevi (defined as the pattern seen in more than0% of all nevi).10,13 The diagnosis of the predominant nevusattern relies not only on the prevailing structural morphol-gy of the nevi, but additionally considers colors and pig-ent distribution. Colors in dermoscopy are quite important

ecause they allow estimations about the localization of pig-ented cells in the different compartments of the skin.5 Black

nd brown represent pigmentation in the epidermis or at theermo-epidermal junction. Accordingly, they are mostlyeen in nevi with significant epidermal components. Gray orlue represents pigmentation in the upper or mid dermis andre therefore observable in nevi with dermal involvementTable 2). With regard to the pigment distribution, the fol-owing 6 types can be distinguished: uniform, multifocal,entral (central area of hyper- or hypopigmentation), or ec-entric (eccentric foci of hyper- or hypopigmentation) pig-ent distribution.10,14

The importance of identifying the predominant nevus typen the management of persons with multiple nevi has beenepeatedly addressed in the literature as it aids the identifica-ion of “atypical” lesions with deviant patterns, which mayequire closer examination.10 There is mounting evidencehat both the prevalent nevus pattern and the patterns ofingle nevi are influenced by age, skin type, history of mela-oma, ultraviolet (UV) exposure, and pregnancy as well aseveal time-related dynamic changes.15

Figure 5 (A) Nevi in individuals with a fair skin type reveawhile in dark skin types, nevi exhibit a dark brown co

cation, �10).

actors Influencinghe Nevus Patterngehe prevalent nevus pattern is significantly influenced by thege of a person. In prepubertal children most nevi exhibit alobular pattern, while nevi developing during puberty (untilhe second decade of life) often reveal a central reticular-omogeneous pattern surrounded by rim of small brownlobules (sign of nevus growth).16-18 In contrast, nevi witheticular or mixed patterns are the most frequent types indults, although a few globular nevi (typically located on thehest or head/neck areas) can be seen throughout all ages.esides the age-related morphologic pattern, epidemiologictudies suggest that the number of nevi steadily increase fromuberty until midlife (fourth to fifth decade of life), while

ater a decline in number of nevi can be observed.19,20

Age also plays a critical role in the dermoscopic or his-opathologic diagnosis of SN/RN and nevi on special bodyites. It is well known that the former are rare after the thirdecade of life.21 Similarly, subungual lesions or mucosal nevire much more common in children or young adults butarely observed after the fifth decade of life.22-24 The newevelopment of a pigmented melanocytic lesion after this agehould therefore always raise the suspect for melanoma. Sim-larly, a facial nevus with a pseudo network pattern and aistopathologic diagnosis of junctional nevus after the fifthecade of life should be carefully reviewed to rule out lentigoaligna melanoma in its early phase.25

kin Typehe prevalent nevus pattern in an individual is also influ-nced by the individuals’ skin photo type (ST).26 Individualsith ST I typically harbor nevi with a light-brown color,

eticular pattern (which is however sometimes less evident orisible) and a central hypopigmentation, while individualsith a ST IV mostly exhibit nevi with a dark-brown color

eticular pattern and a central hyperpigmentation (so-calledlack or hypermelanotic nevi) (Fig. 5). The latter corre-ponds to pigmented parakeratosis and appears as central

lly a light brown color and a central hypopigmentation,d a central hyperpigmentation (B) (original magnifi-

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lack lamella covering the underlying network. This mayometimes cause diagnostic difficulties. However, the centrallack lamella can be easily removed by a tape or plaster,llowing the visualization of the typical network (reticularattern) and the diagnosis of black nevus with increasedonfidence. Although globular nevi are the most commonypes of nevi in children, a recent study found a higher prev-lence of small reticular nevi in children with a dark ST.11

evi in ST II and III are often characterized by a reticularattern and a multifocal hyper-hypo-pigmentation. It shoulde noted that a fair ST does not necessarily rule out thedditional presence of nevi with different pigmentation typesnd vice versa, but a single lesion revealing deviating patternsrom the others (ugly duckling sign) may require closer ob-ervation.13

elanoma-associatedattern and Melanoma Riskarious studies report consistently on a higher frequency ofevus-associated melanomas on axial body sites with respecto the lower extremities. Notably, the associated nevus com-onent often shows significant dermal involvement by histo-athology (ie, congenital-like pattern). Based on the dermo-copic-pathologic correlation of globular nevi and the morerequent location of this type on the upper axial body siteshan on extremities, it is legitimate to conclude that a certainroportion of melanoma arises in nevi dermoscopically char-cterized by variations of a globular pattern (Fig. 6). Becausehe risk of malignant transformation is considerably low,articularly for small congenital or congenital-like nevi,ystematic excision of these common nevi is certainly notndicated.11,15

By contrast, a high number of nevi have been shown to berisk factor mostly for the de novo development of mela-oma. In light of this, a recent study is of particular interest inhich the authors identified significant differences in dermo-

igure 6 Dermoscopic image of a nevus-associated melanoma. Theat component shows an atypical network pattern and correspondso the melanoma, while the central elevated area showing globularattern corresponds to the nevus component (superficial spreadingelanoma arising in a globular nevus-dermal type, tumor thickness

Bccording Breslow �1 mm) (original magnification, �10).

copic patterns of nevi between individuals with a personalistory of melanoma and a healthy control group.27 Accord-

ng to this study, patients with melanoma more frequentlyxhibited nevi dermoscopically characterized by a mixed pat-ern with a prevailing globular component (reticular-globu-ar pattern or homogeneous-globular pattern) compared to a

ore uniform pattern often showing superficial black dots inealthy individuals. Consequently, individuals harboringevi with complex patterns may be considered at higher riskf melanoma development and subsequently may require aloser surveillance than individuals with nevi revealing a uni-orm pattern. Based on personal observations, patients withlinically so-called “dysplastic nevus syndrome” often revealevi of larger size (�5 mm) that dermoscopically exhibit aentral globular or structureless pattern associated with anften atypical-appearing network, but further studies areeeded to confirm these preliminary observations (Fig. 7).Per definition, starburst nevi are benign nevi that do not

equire further treatment. However, because melanoma mayimic such nevi clinically, dermoscopically, and also his-

opathologically, excision of lesions with Spitzoid features isenerally recommended.8,11

Blue nevi are rarely a precursor of melanoma, althoughases of malignant transformation of cellular blue nevus,hich is a peculiar histopathologic variant of blue nevus,ave been reported. The latter is clinically characterized by a

arge size (often �10 mm) and a certain predilection for thecalp. Therefore, excision of large blue nevi or blue neviocated on difficult-to-examine body sites, such as the scalp,s generally recommended.9,11

V ExposureV exposure may cause significant but reversible changes ofermoscopic features of nevi, including significant darkeningf pigmentation, fading of the pigment network, increase inize, erythema, and new development of irregular dots, glob-les, or blotches.28,29 Such changes may be associated with aigher (more suspicious) dermoscopy score using dermo-copic algorithms.6 Because they are reversible after 1-3onths after discontinuation of UV exposure, examination ofevi recently exposed to UV should be generally avoided orcheduled between 1 and 3 months after discontinuation ofV exposure.

regnancyimilar to UV-induced changes, pregnancy causes transienthanges of dermoscopic patterns of nevi, such as progressiveightening or darkening, progressive reduction of thicknessnd prominence of reticular pattern, new appearance of dotsr globules, increase in size (irrespectively of location butost prominent at the abdomen), and increased vasculariza-

ion.30,31 The latter is particularly visible in raised globularevi. These changes linearly increase with time of pregnancynd are most evident at third trimester and time of deliveryut are reversible approximately 3-6 months after delivery.

ecause changes at the end of pregnancy may be also corre-

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Nevus classification 155

ated with a higher dermoscopy score, re-examination of nevi-6 months after delivery is generally recommended.

ime-related Dynamic Changeshe age-related difference of nevus pattern between childrenglobular nevi) and adults (reticular nevi) and the presence ofsually few nevi with globular pattern throughout all ages has

ed to the concept that globular nevi represent dermal prolifer-tions that develop during early childhood and persist through-ut lifetime showing only little changes and acquire the stereo-ypical appearance of dermal nevi in elderly persons.32

In contrast, reticular nevi develop as epidermal prolif-rations in response to UV exposure or hormonal growthactors. These nevi reveal a dynamic life (increasing andecreasing nevus number). In line with this is the presencef evolving nevi dermoscopically characterized by a retic-lar-homogeneous pattern surrounded by a peripheralim of brown globules in young adolescence33 (Fig. 8). Theeripheral rim of brown globules is a well-recognized signf nevus growth. Such nevi show a symmetric enlargementuring digital dermoscopic follow up until the disappear-nce of peripheral globules indicate stabilization ofrowth. At this stage, the nevus reveals a reticular patterns the only dermoscopic feature. As a consequence, theost common pattern of nevi in adults is the reticular pat-

ern. The decline in number of acquired melanocytic nevifter the fifth decade of life can be explained by a progressivenvolution, regression, or apoptosis of reticular nevi untilheir final disappearance.

Of peculiar interest are the typically rapid time-relatedhanges of starburst nevi.34-36 Notably, the starburst pattern

Figure 7 Clinical and dermoscopic image of a patient wioften larger than common nevi and reveal by dermosconeous areas and peripheral often atypical network patte

epresents only an intermediate pattern in the evolution of p

pitz nevi that at initial growth commonly exhibit a globularattern. In contrast to the uniform appearance of globularevi, the globules of SN/RN are much more irregular in sizend color and less densely distributed. After a variable time ofonths, the globular pattern develops into the classic star-

urst pattern and subsequently into a homogeneous-reticularattern. The latter indicates a stabilization of growth. In thishase, the Spitz/Reed nevus may be indistinguishable fromommon reticular nevi. However, there is upcoming evi-ence that SN/RN seem also to involute, which explains thepidemiologic data that SN/RN are rare after the third decadef life.21

Finally, blue nevi, once developed, are highly stable le-ions that persist throughout lifetime. This stability of blue

erous clinically atypical nevi. These nevi are clinicallyixed pattern composed by central globules or homoge-ginal magnification, �10).

igure 8 Typical example of evolving reticular nevus showing at the

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evi is an important criterion in their diagnosis because blueolor alone is a highly unspecific feature that may occur alson nodular melanoma, melanoma metastases, or pigmentedasal cell carcinoma.6,9 Therefore, the diagnosis of blue nevihould be based on the combination of the dermoscopic pat-ern and a “convincing subjective” lacking history of changes.he combination of blue color with a history of changeshould always lead to rule out nodular melanoma, basal cellarcinoma, or melanoma metastases. In situations in which aeliable history is difficult to obtain, excision must be alwayseighted over watch and wait.

onclusionifferent types of nevi do exist in relation to their epidemi-logy, morphology, evolution, and melanoma risk. Thenowledge of the dermoscopic patterns of nevi and the fac-ors influencing the nevus pattern improves the diagnosis,lassification, and management of the heterogeneous spec-rum of benign melanocytic proliferations.

eferences1. Krengel S, Hauschild A, Schafer T: Melanoma risk in congenital mela-

nocytic naevi: A systematic review. Br J Dermatol 155:1-8, 20062. Bauer J, Garbe C: Acquired melanocytic nevi as risk factor for mela-

noma development. A comprehensive review of epidemiological data.Pigment Cell Res 16:297-306, 2003

3. Cribier BJ, Santinelli F, Grosshans E: Lack of clinical-pathological cor-relation in the diagnosis of congenital naevi. Br J Dermatol 141:1004-1009, 1999

4. Kopf AW, Levine LJ, Rigel DS, et al: Prevalence of congenital nevus-likenevi, nevi spili, and cafe au Lait spots. Arch Dermatol 121:766-769, 1985

5. Zalaudek I, Leinweber B, Hofmann-Wellenhof R, et al: The impact ofdermoscopic-pathologic correlates in the diagnosis and management ofpigmented skin tumors. Exp Rev Dermatol 4:579-587, 2006

6. Argenziano G, Soyer HP, Chimenti S, et al: Dermoscopy of pigmentedskin lesions: Results of a Consensus Meeting via the internet. J Am AcadDermatol 48:679-693, 2003

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8. Ferrara G, Argenziano G, Soyer HP, et al: The spectrum of Spitz nevi: Aclinicopathologic study of 83 cases. Arch Dermatol 141:1381-1387, 2005

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4. Arevalo A, Altamura D, Avramidis M, et al: The significance of eccentric

and central hyperpigmentation, multifocal hyperpigmentation or hy-

popigmentation, and the multicomponent pattern in melanocyticlesions lacking specific dermoscopic features of melanoma. ArchDermatol 144:1440-1444, 2008

5. Zalaudek I, Docimo G, Argenziano G: Using dermoscopic criteria andpatient-related factors for the management of pigmented melanocyticnevi. Arch Dermatol 2009 (in press)

6. Zalaudek I, Grinschgl S, Argenziano G, et al: Age-related prevalence ofdermoscopy patterns in acquired melanocytic naevi. Br J Dermatol154:299-304, 2006

7. Oliveria SA, Geller AC, Dusza SW, et al: The Framingham school nevusstudy: A pilot study. Arch Dermatol 140:545-551, 2004

8. Scope A, Marghoob AA, Dusza SW, et al: Dermoscopic patterns of naeviin fifth grade children of the Framingham school system. Br J Dermatol158:1041-1049, 2008

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