Preliminary data of this manuscript have been presented as oral communication at the 1st Congress of the International Dermoscopy Society, Naples, Italy - April 6-8, 2006, and published as abstracts of the Congress on Dermatology 2006;212:265-320.

INTRODUCTION
Spitz naevus (SN) is an uncommon, benign melanocytic neoplasm that shares many clinical and histological features with melanoma (1). SN presents clinical ambiguity that makes the diagnosis and management of the patient difficult. There is no consensus concerning management of Spitz naevi (SNi) (2-4). Much more is still to be learnt about its evolution, modifications seen clinically and by dermoscopy (5). Today, when a diagnosis of SN is made, the most common therapy is surgery. Infact, a study performed by a questionnaire (6) showed that 93% of responding dermatologists recommend biopsies of suspected SNi: 43% recommend total biopsies and 55% recommend partial biopsies. 70% of general dermatologists recommend excision with a 1- to 2-mm margin of normal-appearing skin around a SN.
The use of dermoscopy in the clinical practise allowed more specific diagnoses avoiding surgical excision of numerous benign lesions so leading to better management (7).
A seven-groups based dermoscopic classification of melanocytic nevi has been reported in a recent study by Argenziano et al. (8). This classification focused to allow a better collaboration between dermatologist and pathologist in the diagnosis of pigmented lesions, give us the possibility to present a study that underlines the modifications of SNi with starburst pattern in the paediatric age. We present our experience in the management of SN by rigorous dermoscopic long-term follow-up of 8 SNi in patients younger than 12 year-old. The specific aim of this paper is not to review exhaustively the evolution of knowledge and thinking about SN but rather to better understand the long-term modifications of nevi with starburst pattern so avoiding surgical excision of these nevi in the paediatric age.


OBJECTIVES AND RESULTS
This study was carried out to ascertain how SN can change during long-term follow-up. We followed 8 cases of SNi with starburst pattern in patients younger than 12 years of age (6 males, 2 females). They were evaluated, every six months, for at least 6-months until a 7-years period during the last ten years. In seven of these patients follow-up ended before 12 years of age.
Dermoscopy was performed using Heine Delta 10 dermoscope after covering the lesion with immersion oil. In addition, a stereomicroscope (Wild M650, Heerbrugg, Switzerland) was used for observing some of the difficult lesions at 10-fold magnification. Contact-dermatoscopic photography was performed by Heine dermaphot with optical system for Minolta X-300 S, modified for contact dermatoscopic use. Results are showed in table 1.
All the lesions presented streaks with radial and regular distribution at the periphery. Almost all lesions were characterized by symmetric silhouette and prominent blue-gray pigmentation. A thin blue-whitish veil (named reticular depigmentation) was observed in two of patients. It has been reported that these dermoscopic aspects allow to enhance from 56% to 93% the diagnostic accurance of pigmented SNi (9). At dermoscopic evaluation, in all our patients a transition from starburst to reticular pattern was observed. This transition was observed at first follow-up in three cases, in the second year of follow-up in five cases. In particolar, in four patients, pigmented network presented a central increase (figure 1-4). In the patient n° 3, who received a six-years follow-up, a further transition from reticular pattern to regression was observed. In the other four patients transition to a regular and prominent network was observed (figures 5-8).

DISCUSSION

Dermoscopy allows today to make confident diagnosis of SNi (10). These nevi are observed both in paediatric and adult age. The very rare appearance in older age could hypotesize a tendence to regression in the life (11). The classical clinical variant initially described by Sophie Spitz (12) presents a pink colour and it appears with less frequence in the histopathologic studies, perhaps because these lesions are rarely excised in paediatric age. In most of cases (71%) the colour varies from brown to black and usually they are simmetric lesions that are especially located on face, legs and arms (13). The most frequent is starburst pattern. In the less pigmented lesions a pointed vascular pattern and reticular depigmentation were observed.
Nevi with starburst pattern correspond to group 3 nevi (starburst, Spitz/Reed, naevus) of the recent classification presented by Argenziano et al. (8). In our study we present results of a long-term follow-up of 8 SNi with starburst pattern in patients under 12 years of age. As showed in table 1, all our patients presented a dermoscopic transition from starburst to reticular pattern. This transition was observed at first follow-up in three cases, in the second year of follow-up in five cases. It is interesting to considerate that our SNi with starburst pattern present in the time the modifications from group 3 to group 2 described in the study of Argenziano et al. (8).
We would like to emphasize the uncertainty and difficulty in the diagnosis and correct management of SN. There is no consensus about the benign nature of SN, but their natural history is not fully understood and the histopathological differentiation is often as difficult as the management. We are agree with Kreusch et al. (14) and Pizzichetta et al. (15) on the possibility of various dermoscopic appearances of SNi during their evolutionary phases which include not only a globular or a starburst pattern. There are two extremes of management: SN can be always periodically controlled, or should be always excised. In a recent article about the management of SNi, 93% of dermatologists consulted recommended biopsies of suspected SNi (6). Other authors recommends that all Spitz tumors should be fully resected in order to facilitate complete histopathological examination and also to diminish the risk of recurrence.
All patients should be managed on an individual basis and efforts should be made to avoid both overly aggressive and suboptimal management strategies (16). Only through rigorous clinical and dermoscopic characterization of a such number of SNi and long-term follow-up of patients, we will be able to have truly objective informations about these lesions. Future data would allow us to finally formulate optimal guidelines for the care of patients with these lesions.
In conclusion, we should hypothesize a proposal of management for dermoscopically starburst-type nevi in children under 12 years of age: it is based on every 6 months follow-up for the first 2 or 3 years; then a year follow-up.
Nevertheless, further studies about follow-up of these nevi also in patients more than 12 years of age, are necessary to extend this proposal at adult age.