Mole

Dear Lisa,

I have a 2 year old who seems healthy but has recently been itching his outer thigh area in about a quarter sized patch. Initially I thought it was just dry skin however as I looked more closely there is a patch of hair growing there. It is fine and fair colored but it is only in the one spot...no where else. As I feel it I can feel a little bump under the skin. It feels the way it does after he has had immunizations but he hasn't had shots for almost a year. I would appreciate any insight you have. I feel very worried. He has no other symptoms. Thank you.

“I feel worried”

Dear “I feel worried”,

Without physically examining your child, it is impossible to tell you exactly what this skin patch is. Through my years of practice, I have had many parents telephone me describing a rash or skin condition. When the child came into the office for an exam, in most cases the findings were totally different from what I expected.

Rashes are very difficult to describe, the appearance varies depending upon the type of skin and any medications that may have been used. Therefore, the best way to diagnose a skin condition is to have an examination by a Physician. A Dermatologist, the type of doctor that specializes in skin conditions, will be able to tell you what your son’s patch is.

Having said that, I can tell you that the description you gave sounds like a mole. A Nevus or mole is a growth on the skin that children develop. Some parents are under the impression that the only way a child gets a mole is to be born with it. Yes, it is true that some infants are born with moles, but many children develop moles as they grow older. It is very common for parents of young children to report the sudden appearance of a new mole. Many times it seems that they grow overnight!

The typical brown flat appearing moles that most people are familiar with are called Congenital Melanocytic Nevi. A congenital Melanocytic Nevus is black or brown in color and flat or nodular in appearance. When a mole first develops, it can start out as a lighter tan color and darken or enlarge over time. Congenital Melanocytic Nevi happen to be present in 1% to 2% of all newborns. (1) This type of mole is benign in nature and the chance of melanoma is quite rare. (1)

The greatest concern that parents have about moles is the chance that they may become cancerous. This is a legitimate concern because some moles do have a risk of becoming malignant. A Nevus spilus is an example of a type of pediatric mole that can turn cancerous. This well demarcated lesion has an unevenly pigmented background with multiple 2 to 4 mm brown specks dispersed throughout the lesion. This type of mole is found in 2 out of every 1000 newborns. This type of lesion needs to be followed closely by a health care professional because of the possibility that it can lead to Melanoma. (2)

Another common type of mole found in the pediatric population is the Café au Lait spot. They are recognized in normal infants as “birth marks”. Café au Lait spots are exactly what they sound like; flat, light tan moles that look like coffee was splashed on the child’s skin.

It is normal for a child to have less than 5 Café au Lait spots on their body, with three being the average amount found. Children with Café au Lait spots need to be monitored by their Physician for the development of new lesions. The appearance of more than 5 Café au Lait spots is associated with fibromas, neurofibromatosis or Recklinghausen disease. (3,4) The presence of multiple Café au Lait spots can also represent other disorders. Children with more than 5 Café au Lait spots need to be followed by a Neurologist. (3,4)

Neurofibromatosis is a neurocutaneous disorder that occurs in 1 out of every 3000 births.(3)Children with neurofibromatosis have Café au Lait spots that are frequently present at birth and increase in size, number and pigmentation with age.(3) Other findings include neurofibromas, freckling in the axilla or groin area, learning disabilities, bone lesions and eye lesions. Although Neurofibromatosis is inherited, 50% of the cases that develop are attributed to a new mutation and can be found in a child with no family history of the disorder. (5)

You did mention that your child has been itching his new patch. He may be itching the area because it feels different. On the other hand, there is a particular type of mole that presents with itchiness, blushing and in some cases blistering. This type of mole is called a Mastocytoma.

A Mastocytoma is a 1 to 5 cm nodule that later turns into a rubbery pink, yellow or tan plaque. They often present on the trunk, but also may occur on the palm, sole, eyelid or vulva. Many times these types of moles resolve before adulthood, with more than half of the cases spontaneously disappearing by the age of 10.(6)

A child that develops a new mole should be evaluated by their Physician. Moles in children should be diagnosed, mapped out, measured, recorded in the medical record and followed on a regular basis by a health care professional. In some cases a consultation with a Dermatologist or a skin biopsy is necessary in order to identify the type of mole.

You did not mention if there is a family history of any skin conditions, if your child has any other health problems, skin conditions, moles or if he was using any medication. All of this information is very important to know when determining the cause of a pediatric skin condition. Along with a physical examination, a complete history needs to be obtained in order to make an accurate diagnosis.

It would be essential to know if any topical medications have been applied to the area or to other parts of the body. This is a concern if your child had used immunomodulators such as pimecrolimus and tacrolimus (Elidel, Protopic). These medications may be prescribed for children with eczema.
The FDA committee urged a black box warning on these products after questions arose about their safety in some patients. (7)

There were some children who developed skin cancer during or shortly after using this medication. In some cases the skin cancer developed at the site of application. In addition, laboratory studies showed an increased rate of skin cancer in animals when tacrolimus application is followed by sun exposure.(8)

If your child has used these medications in the past, it would be very important to show your child’s rash to his physician without delay.

References:
(1)Eichenfield L, Larralde M. Congenital melanocytic nevi. Pediatric Dermatology. Edinburgh: Mosby;2003:216-217.
(2)Dermclinic. Consultant for Pediatricians. 2006. Feb:74-75.
(3)Leung A, Lane W, Robson M. A Young Girl with Café’au Lait Spots. Consultant for Pediatricians. 2006. April:229-232.
(4)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:266.
(5)Young H, Hyman S, North K. Neurofibromatosis 1: Clinical review and exceptions to the rules. J Child Neurol. 2002. 17:613-621.
(6)Ganz J, Kim F. Infant with an “Atypical Mole”. Consultant for Pediatricians. 2006. August:511-512.
(7)Rosenthal M. Pediatricians treating more patients with atopic dermatitis. Infectious Diseases in Children. 2006. April:511-512.
(8)Connelly E, Eichenfield L. Treatment Pearls for Managing Atopic Dermatitis. Pediatric Skin Care. 2004. Spring:16-18.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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