Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2022;12(4):e2022172 1 Atypical Spitz Nevus: Dermoscopic, Confocal Microscopic and Histopathological Correlation Rita Bouceiro Mendes1, Camila Scharf2, Eugenia Veronica Di Brizzi2, Andrea Ronchi3, Giuseppe Argenziano2, Elvira Moscarella2 1 Dermatology Unit, North Lisbon University Hospital Centre, Lisbon, Portugal. 2 Dermatology Unit, University of Campania L. Vanvitelli, Naples, Italy. 3 Pathology Unit, University of Campania L. Vanvitelli, Naples, Italy. Citation: Bouceiro Mendes R, Scharf C, Di Brizzi EV, Ronchi A, Argenziano G, Moscarella E. Atypical Spitz nevus: dermoscopic, confocal microscopic and histopathological correlation. Dermatol Pract Concept. 2022;12(4):e2022172. DOI: https://doi.org/10.5826/ dpc.1204a172 Accepted: January 14, 2022; Published: October 2022 Copyright: ©2022 Bouceiro Mendes et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Rita Bouceiro Mendes, North Lisbon University Hospital Centre, Dermatology Department, Piso 5, Av. Prof. Egas Moniz, 1649-035 Lisboa. Phone: 00351 969928106, E-mail: rita.bouceiro.mendes@gmail.com Case presentation A 12-year-old girl was observed for a new asymmetric pink and black papule on her back. Dermoscopy revealed a multicom- ponent pattern with pink pigmentation, and blue-white veil. By reflectance confocal microscopy (RCM) overall asymmetry was noted. Irregular honeycomb pattern of the epidermis and compact dermal nests, matching the pink pigmentation area were evident while, in the blue-white veil dermoscopic area, multiple superficial dendritic cells and an irregular meshwork pattern at the dermal-epidermal junction were seen. Consid- ering these findings, surgical excision was performed. Histo- pathological examination disclosed an asymmetric compound proliferation of melanocytic epithelioid cells. Its junctional element was predominantly nested, whereas the dermal as- pect was highly cellular with fascicles of slightly pleomorphic epithelioid cells throughout the entire dermis. These findings favored the diagnosis of atypical Spitz nevus. Teaching point Atypical Spitz nevi represent an intermediate category of melanocytic lesions whose differentiation from melanoma is difficult because of overlapping features [1]. RCM represents a noninvasive diagnostic add-on, but RCM features of atypi- cal Spitz tumors are not well characterized [1,2]. Confocal features that may help to differentiate Spitz nevi from melanoma have already been identified [2]; how- ever, a study from Guida et al stated that RCM was not useful in lesions with multicomponent or unspecific dermo- scopic patterns since many “malignant” features were shared between both entities [1]. We are able to overcome this gap if we consider the patient age when evaluating a spitzoid le- sion. Besides that, this case illustrates the RCM features of an atypical Spitz nevus with an impressive dermoscopic and histopathological correlation. 2 Image Letter | Dermatol Pract Concept. 2022;12(4):e2022172 References 1. Guida S, Pellacani G, Cesinaro AM, et al. Spitz naevi and mela- nomas with similar dermoscopic patterns: can confocal micros- copy differentiate? The Br J Dermatol. 2016;174(3):610-616. DOI: 10.1111/bjd.14286. PMID: 26554394. 2. Pellacani G, Longo C, Ferrara G, et al. Spitz nevi: In vivo confo- cal microscopic features, dermatoscopic aspects, histopathologic correlates, and diagnostic significance. J Am Acad Dermatol. 2009;60(2):236-247. DOI: 10.1016/j.jaad.2008.07.061. PMID: 19091443. Figure 1. Spitz nevus. (A) Clinical picture: asymmetric 1cm diameter papule with uneven pink and black color. (B) Dermoscopy picture: multicomponent pattern with irregular brown and pink pigmentation, and blue-white veil. (C) Confocal microscopy picture: C1 - epidermal honeycombed structures and thin dermal papillae; C2 - irregular meshwork pattern at the dermal-epidermal junction and associated areas of totally disarranged papillary contours owing to multiple bright fusiform cells with dendrites (white asterisks). (D) Histopathological pictures: D1 - Overall asymmetric polypoid-like melanocytic compound proliferation with an important deep component. The junctional element of the lesion is predominantly nested while the dermal aspect is highly cellular (white asterisk) (H&E, x25). D2 - Higher magnification showing the cellular dermal component of slightly pleomorphic epithelioid cells organized in fasciles. These cells immunostaining for HMB-45 was positive throughout the entire dermis (H&E, x100).