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A Pink Nodule on a Boy's Left Cheek

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 4-year-old boy presented with a pink nodule on his left cheek. The lesion started as a hyperpigmented macule 3 years ago and since then had been gradually increasing in size and developing into a pink nodule. The lesion was pruritic at times and sometimes bled with minor trauma. The boy was otherwise healthy, with an unremarkable medical history and with no history of trauma or exposure to radiation. On physical examination, there was a 1-cm well-circumscribed, symmetrical, pinkish, dome-shaped nodule with central erosions on the left cheek (Figure 1). Hair, nails, and mucosae were of normal appearance, and the remainder of the examination was unremarkable.

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Epithelioid Spitz nevus

A. Obtain a biopsy for hematoxylin-eosin stain

The key to the correct diagnosis is the early onset of a pink, symmetrical, solitary, smooth, and dome-shaped nodule on the cheek of a young boy. The differential diagnosis includes Spitz nevus, pyogenic granuloma, sporotrichosis, and amelanotic malignant melanoma. A biopsy for fungal culture is needed to diagnose sporotrichosis, but sporotrichosis typically has a granulomatous appearance and erosions or ulcerations with purulent drainage can be seen on the surface. Cryotherapy and pulsed dye laser therapy can be used in pyogenic granulomas, but pyogenic granulomas predominantly occur in the second decade of life, mostly in young adult females.1 Amelanotic malignant melanomas rarely occur in young children and are usually ulcerated and asymmetrical. There are different types of Spitz nevi, which cannot be completely differentiated clinically; therefore, a skin biopsy for hematoxylin-eosin stain is needed to confirm the diagnosis.

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Article Information

Corresponding Author: Dong-Lai Ma, MD, PhD, Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, PR China (mdonglai@sohu.com).

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank the patient’s father for providing permission to share the patient’s information.

References
1.
Aldulaimi  S, Saenz  A.  A bleeding oral mass in a pregnant woman.  JAMA. 2017;318(3):293-294.PubMedGoogle ScholarCrossref
2.
Dika  E, Ravaioli  GM, Fanti  PA, Neri  I, Patrizi  A.  Spitz nevi and other spitzoid neoplasms in children: overview of incidence data and diagnostic criteria.  Pediatr Dermatol. 2017;34(1):25-32.PubMedGoogle ScholarCrossref
3.
Koga  M, Koga  K, Kiryu  H, Nakayama  J.  Congenital Spitz nevus on the foot.  J Dermatol. 2014;41(3):282-283.PubMedGoogle ScholarCrossref
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Requena  C, Requena  L, Kutzner  H, Sánchez Yus  E.  Spitz nevus: a clinicopathological study of 349 cases.  Am J Dermatopathol. 2009;31(2):107-116.PubMedGoogle ScholarCrossref
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Stefanaki  C, Stefanaki  K, Chardalias  L, Soura  E, Stratigos  A.  Differential diagnosis of Spitzoid melanocytic neoplasms.  J Eur Acad Dermatol Venereol. 2016;30(8):1269-1277.PubMedGoogle ScholarCrossref
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Hiscott  P, Seitz  B, Naumann  GO.  Epithelioid cell Spitz nevus of the eyelid.  Am J Ophthalmol. 1998;126(5):735-737.PubMedGoogle ScholarCrossref
7.
Brunetti  B, Nino  M, Sammarco  E, Scalvenzi  M.  Spitz naevus: a proposal for management.  J Eur Acad Dermatol Venereol. 2005;19(3):391-393.PubMedGoogle ScholarCrossref
8.
Metzger  AT, Kane  AA, Bayliss  SJ.  Differences in treatment of Spitz nevi and atypical Spitz tumors in pediatric patients among dermatologists and plastic surgeons.  JAMA Dermatol. 2013;149(11):1348-1350.PubMedGoogle ScholarCrossref
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