Moles in children: the norm, observation, removal

Moles in children are benign accumulations of melanocytes in the skin that most often appear in early childhood and adolescence, while some are noticeable from birth. Most moles are harmless, but certain types and behavioral characteristics require monitoring and sometimes treatment. This article explains the types of moles in children, their appearance, their differences, and when to see a dermatologist. [1]

In newborns, birthmarks are called congenital melanocytic nevi. They are common, vary in size and color, and may be accompanied by increased hair growth on the surface. Very large congenital nevi are rare, but they do increase the risk of complications, so closer monitoring is recommended for such children. [2]

During preschool and school age, new moles appear regularly: their number and appearance are influenced by heredity and sun exposure. Moles that appear in childhood often remain the most noticeable throughout life. External changes to a mole are most often normal in a growing child, but sudden or unusual changes should be evaluated by a specialist. [3]

Although rare, melanoma can develop in children. Its symptoms don't always match those seen in adults, so pediatricians use expanded criteria for suspicion, and when in doubt, dermatoscopy and, if necessary, biopsy are recommended. Early diagnosis determines the outcome. [4]

ICD-10 and ICD-11 codes

For medical documentation, moles in children are coded as "melanocytic nevi" according to ICD-10, with specific localization. Congenital nevi may also have a specific code in the congenital anomalies section. ICD-11 provides codes for congenital melanocytic nevus, including the giant form. Basic correspondences are provided below. [5]

Table 1. Codes for melanocytic nevi in children

Classifier	Code	Name
ICD-10	D22.*	Melanocytic nevi specifying body region (eg, eyelids, ear, facial skin, scalp and neck, extremities, unspecified)
ICD-10	Q82.5	Congenital non-neoplastic nevus: used for a number of congenital spots, the code should be selected taking into account the clinical situation and the institution's coding recommendations
ICD-11	2F20.2	Congenital melanocytic nevus: includes subtypes including giant congenital melanocytic nevus 2F20.20
Comment: The specific choice of code is made by the attending physician, taking into account the clinical picture and national coding rules. [6]

Epidemiology

Congenital melanocytic nevi occur in approximately 1% of newborns. Medium-sized forms occur in approximately 1 in 1,000 newborns, while giant forms occur in approximately 1 in 20,000 newborns. Giant congenital nevi are more often associated with associated "satellite" nevi and have an increased risk of complications. [7]

During childhood and adolescence, the number of acquired moles increases, especially in fair-skinned children and those with high sun exposure. The greatest severity of "neovogenesis" is observed between the ages of 2 and 10 years, and then some moles may regress or fade in adulthood. [8]

Giant congenital melanocytic nevus is a rare condition. Its prevalence is estimated at 1 in 20,000 newborns, and some observational series suggest an even lower incidence. These children represent a high-risk group for neurological complications and require routine specialist monitoring. [9]

Malignant skin tumors in children are rare. For reference, the incidence of melanoma in adolescents aged 15-19 in the United States is approximately 5-10 cases per 1,000,000 per year, and is higher in girls than in boys. Rates vary by age, gender, and geography. [10]

Table 2. Epidemiological landmarks

Indicator	Grade
Congenital melanocytic nevi in newborns	~1%
Medium-sized congenital nevi	~1 in 1,000
Giant congenital nevi	~1 in 20,000
Melanoma in adolescents 15-19 years old	~5-10 per 1,000,000 per year
For source of estimates, see cited guidelines and reviews. [11]

Reasons

A mole is a clonal proliferation of melanocytes. Congenital nevi often have somatic mutations in the NRAS gene, which arise early in embryonic development. Acquired nevi are characterized by mutations in BRAF and, less commonly, NRAS, reflecting the different mechanisms of formation in different subtypes. [12]

The appearance and number of moles is influenced by solar radiation. Children living in regions with high sun exposure tend to have more nevi. A fair skin phototype and heredity are also associated with a higher number of moles, as demonstrated in clinical observations and dermatoepidemiological studies. [13]

Specific subtypes in children, such as Spitz nevus, have molecular features distinct from those of "common" moles. Some are characterized by HRAS mutations and increased copy number of chromosome 11p, as well as rare kinase gene fusions. This helps explain the clinical and histological characteristics of children. [14]

Immunosuppression and certain medications have been associated with changes in the number of nevi. For example, "flares" of nevi have been reported in people treated with BRAF inhibitors. These examples highlight the role of signaling pathways in the development of pigmented skin lesions. [15]

Risk factors

Factors associated with a higher number of moles include fair skin, red or blond hair, family history, and living in areas with high sun exposure. The more moles a person has, the higher the relative risk of melanoma in the future, especially if they have multiple atypical moles. [16]

Sunburns in childhood and adolescence increase the risk of melanoma in adulthood. Therefore, preventing sunburn in children is a strategically important measure to reduce long-term risks. Advice on photoprotection should be part of standard pediatric practice. [17]

Giant congenital melanocytic nevi and multiple congenital nevi are associated with an increased risk of neurocutaneous melanosis - the accumulation of melanocytes in the membranes of the brain and spinal cord - and a higher risk of melanoma compared to the general childhood population.[18]

In Spitz nevi, clinical uncertainty may lead to excessive biopsies, but current approaches include watchful waiting under the supervision of a dermatologist in typical cases in young children and excision in cases of equivocal features.[19]

Table 3. Risk factors and estimated strength of association

Factor	What is known
Light skin phototype	More nevi, higher risk of melanoma
Numerous moles	A marker of increased risk of melanoma in adults
Giant congenital nevus	The risk of neurocutaneous melanosis and melanoma is higher than average.
Frequent sunburns in childhood	Increased long-term risk of melanoma
Immunosuppression	Increased number of nevi and risk of skin cancer
Estimates are based on dermatological society guidelines and reviews.[20]

Pathogenesis

Congenital nevi are formed as a result of early embryonic mutations in melanocyte precursor cells, most often in the NRAS gene. This leads to diffuse migration of melanocytes throughout the skin and sometimes into the central nervous system. In large congenital nevi, it is this migration that explains the risk of neurocutaneous melanosis. [21]

Acquired nevi typically arise from a BRAF mutation in individual cells of the epidermis and dermal-epidermal junction, triggering localized clonal proliferation. As the nevus matures, it may migrate deeper into the dermis and become more prominent, and in adulthood, it may stabilize and eventually regress. [22]

Specific pediatric nevi subtypes have distinct molecular signatures. Spitz nevus is characterized by HRAS mutations and some chimeric genes, which are rarely found in classic adult-type melanomas. These features are reflected in the dermatoscopic appearance and morphology. [23]

Not only mutations but also the skin microenvironment play a role in determining overall "risk." Ultraviolet radiation causes DNA damage and local inflammation, which can contribute to the appearance of new nevi and changes in existing ones, especially in children with sensitive skin. [24]

Symptoms

Common birthmarks in children are smooth, uniformly colored spots or slightly raised growths in brown tones, usually round or oval in shape. Congenital birthmarks may be darker, have a rough surface, and increased hair growth. Normally, as the child grows, the birthmark may enlarge slightly and change shape. [25]

Warning signs include the rapid appearance of a raised nodule within a congenital nevus, marked asymmetry, severely irregular edges, uneven coloration, bleeding, ulceration, or persistent itching. In children, melanoma may be unpigmented and appear as a "pink pimple" or "bleeding papule."[26]

Spitz nevus most often occurs in preschool children and appears as a pinkish-reddish, dome-shaped nodule. Typically, it is benign and can stabilize, but due to its resemblance to aggressive tumors, it requires observation and sometimes removal for an accurate diagnosis. [27]

Giant congenital nevi may exhibit neurological symptoms associated with neurocutaneous melanosis, including headaches, vomiting, seizures, and behavioral changes. The appearance of such symptoms warrants urgent examination. [28]

Classification, forms and stages

Clinically, a distinction is made between congenital and acquired nevi. Congenital nevi are classified by their expected adult size: small, medium, and giant. Size is an important prognostic indicator that helps determine monitoring tactics and the need for instrumental diagnostics. [29]

Common childhood subtypes include Spitz nevus, blue nevus, nevus with Meyerson phenomenon, lentiginous nevi, and combined nevi. Each subtype has characteristic dermatoscopic features that help differentiate them from each other and from malignant processes. [30]

In pediatrics, a special diagnostic group of “atypical” or “questionable” Spitz-like lesions is also distinguished, for which more active management is indicated: close observation, consultation with a dermato-oncologist and, if necessary, complete excision with histology. [31]

Table 4. Classification of childhood nevi (simplified)

Group	Examples	Key Features
Congenital melanocytic nevi	Small, medium, giant	From birth, size is the main prognostic sign
Acquired melanocytic nevi	Common nevi	Appear in childhood and adolescence
Specific pediatric subtypes	Spitz nevus, blue nevus, combined	Characteristic clinical picture and dermatoscopy
Questionable Spitz-like lesions	Atypical group	Require active monitoring and, in part, excision.
Based on pediatric dermatology guidelines and reviews.[32]

Complications and consequences

The main potential complication is melanoma. The absolute risk is low in most children, but it increases with giant congenital nevi and multiple congenital nevi. Modern reviews estimate the overall risk of melanoma for congenital nevi of any size to be approximately 0.7-1.15%, and higher for large ones. [33]

Neurocutaneous melanosis occurs predominantly in large and multiple congenital nevi and may be asymptomatic or present with symptoms of intracranial hypertension and epileptic seizures. If suspected, imaging of the brain and sometimes the spinal cord is indicated. [34]

Cosmetic and psychosocial consequences are significant, especially for large nevi in exposed areas. Timely information to the family about monitoring and treatment options, as well as psychological support, reduce anxiety and improve the child's quality of life. [35]

Inappropriate treatment, including the destruction of typical childhood lesions by cauterization, curettage, cryotherapy, or laser without histological examination, can complicate subsequent diagnosis and mask early malignant changes. For Spitz nevus, specialized societies explicitly warn against such approaches. [36]

When to see a doctor

A child should be routinely examined by a dermatologist if they have a large congenital nevus, multiple congenital nevi, or any new, rapidly growing nodule on a mole. A family history of melanoma or multiple "non-standard" moles is an additional reason for observation. [37]

An urgent evaluation should be sought if bleeding, ulceration, rapid growth, marked asymmetry, multicolored lesions, or increased itching or pain occur. In children, particular attention should be paid to "pink" or "red" nodules, which may be pigmentless. [38]

In giant congenital nevi, warning signs include headaches, repeated vomiting, seizures, sudden changes in behavior and gait - these signs require urgent brain imaging to rule out neurocutaneous melanosis. [39]

Table 5. Red Flags for Immediate Action

Sign	Why is it important?
Rapid nodular growth on the background of a mole	May indicate tumor transformation
Bleeding, ulcer	Sign of injury or malignancy
Sharp asymmetry, jagged edges, mosaic coloring	Classic warning signs
New "pink bump"	In children, melanoma can be pigmentless.
Neurological symptoms in large congenital nevi	Risk of neurocutaneous melanosis
Supporting sources include clinical studies and guidelines. [40]

Diagnostics

Diagnosis begins with a thorough clinical examination of the entire skin, assessing the number and distribution of moles and comparing them with previous photographs, if any. The doctor collects information about family history, sunburn, and the rate of change of the specific lesion. [41]

Non-invasive imaging techniques are then used. Dermoscopy helps differentiate typical childhood nevi from suspicious lesions. In questionable cases, reflectance confocal microscopy is additionally used, allowing for increased accuracy without the need for immediate biopsy. [42]

For giant and multiple congenital nevi in infants, magnetic resonance imaging of the brain is often considered, ideally in the first months of life, to promptly detect neurocutaneous melanosis. The decision is made individually, taking into account the clinical presentation and anesthesia risks. [43]

If signs of malignancy persist or worsen, excision of the lesion is performed within healthy tissue, with a minimal margin for a complete histological examination. Shave and partial biopsies in children are avoided whenever possible if melanoma is suspected. [44]

A practical list of methods with explanations

• Clinical examination of the skin: counting and mapping of moles, photo recording for dynamics. [45]
• Dermatoscopy: clarification of structure, vascular pattern and pigment architecture. [46]
• Reflectance confocal microscopy: increasing specificity in controversial childhood lesions and reducing unnecessary biopsies. [47]
• Magnetic resonance imaging of the brain: in large and multiple congenital nevi to exclude neurocutaneous melanosis. [48]
• Complete excision with histology: the gold standard for confirming the diagnosis when neoplastic transformation is suspected. [49]

Differential diagnosis

In children, multiple brown spots differentiate congenital nevi from simple lentigines and "café au lait" spots, which are not nevi and have a different meaning in diagnosing hereditary syndromes. Blue nevi are distinguished by their bluish tint and the deep location of the pigment. [50]

Spitz nevus must be distinguished from Spitz-like melanoma, so in doubtful cases, consultation with a specialist and often excision are indicated. Juvenile xanthogranuloma, pyogenic granuloma, and hemangioma, which can mimic a "pink nodule," are also considered. [51]

An important practical task is to detect childhood melanoma, which is often pigmentless and masquerades as benign vascular or inflammatory lesions. Expanded pediatric criteria for detection, dermatoscopy, and histology are helpful here. [52]

Table 6. What children confuse with what: brief differences

State	What is similar?	What helps to distinguish
Congenital nevus	Café au lait stains	Relief, hairs, structure under a dermatoscope
Spitz nevus	Pyogenic granuloma, hemangioma	Dermoscopy, dynamics, in case of doubt - excision
Blue nevus	Nodular pigmented lesions	Bluish color, deep pigment
Childhood melanoma	A pink pimple without pigment	Rapid growth, bleeding, histology
The summary features are based on guidelines and clinical reviews.[53]

Treatment

The management of most childhood birthmarks is based on observation. Typical small congenital nevi and common acquired nevi in children without warning signs do not require treatment. Photoprotection, self- and parental monitoring of changes, and periodic examinations are recommended. [54]

In young children, Spitz nevus with a typical course is often managed observationally with regular dermatoscopy. If the diagnosis is in doubt, due to rapid growth, bleeding, or marked asymmetry, complete excision with histological examination is performed. Superficial "cauterization" without histological confirmation is not recommended. [55]

Small congenital nevi are often left until adolescence and removed for cosmetic reasons or if changes occur. From an oncological standpoint, they have a low risk, so delaying removal is usually safe and allows for a procedure with better anesthetic tolerability. [56]

Medium-sized and especially giant congenital nevi are considered on a case-by-case basis. Options include staged surgical excisions, skin expanders, dermabrasion, and some laser techniques to improve appearance. The impact of such interventions on the long-term risk of melanoma remains a matter of debate, so the decision is made with the family after a detailed discussion of the risks and benefits. [57]

If melanoma is suspected, treatment begins with complete excision of the lesion with minimal margins for diagnosis and staging. Further steps are determined by the stage and generally follow current oncology guidelines for cutaneous melanoma, adapted for childhood. [58]

Reflectance confocal microscopy is increasingly being used to select children who can safely avoid biopsy and to clarify indications for excision. This method does not replace histology, but it helps make more informed decisions. [59]

For multiple or giant congenital nevi, neuroimaging at an early age, a follow-up plan with a neurologist and dermatologist, and individual timing of possible interventions are discussed. It is important to consider the impact of anesthesia in infants and weigh the need for examination and intervention. [60]

Photoprotection is a mandatory component of treatment and prevention of progression: shade, clothing, hats, glasses, and regular application of high-protection sunscreens, reapplying after prolonged sun exposure. This is especially important for children with a large number of moles. [61]

It is useful for families to have "baseline" photographs of their child, capturing large and unusual moles for comparison over time. This approach improves the accuracy of self- and parental monitoring and helps the physician assess changes objectively. [62]

Table 7. Management options and when they are indicated

Approach	When appropriate	Comments
Observation with dermatoscopy	Typical small congenital and common acquired nevi	Teaching families photo control
Complete excision	Doubt about the diagnosis, warning signs, cosmetics at the family's discretion	Complete rather than partial removal is preferred.
Staged excisions, expanders	Medium and large congenital nevi	Teamwork between a dermatologist and a surgeon
Laser and grinding techniques	Selective based on cosmetic indications	Effect on cancer risk has not been proven
Neuroimaging	Large and multiple congenital nevi	Exclusion of neurocutaneous melanosis
The summary is based on guidelines and clinical reviews.[63]

Prevention

Sun protection during childhood reduces the risk of sunburn and the long-term effects of UV radiation. This includes seeking shade during peak sun exposure hours, clothing, hats, eyewear, and proper use of high-protection sunscreens with regular reapplying. [64]

Children with a large number of moles, fair skin, and a family history of melanoma are recommended to have monthly skin examinations with the participation of their parents and regular preventive visits to a dermatologist according to an individualized plan. [65]

It is important to avoid self-treatment of moles and "cosmetic removal" without consulting a doctor. Any destruction of the pigmented lesion without histological examination can complicate subsequent diagnosis. This is especially critical for Spitz nevi. [66]

Psychological support for the family and information about realistic risks help to make informed decisions about monitoring and interventions, reducing anxiety and avoiding unnecessary procedures. [67]

Forecast

For the vast majority of children, the prognosis is favorable: common and small congenital nevi do not affect life expectancy and often remain stable or barely noticeable. Regular monitoring and photoprotection help maintain safety. [68]

In giant congenital nevi, the prognosis is determined by the risk of neurocutaneous melanosis and melanoma, as well as cosmetic and psychosocial consequences. Early multidisciplinary management improves outcomes and quality of life. [69]

If a child is diagnosed with melanoma, early staging and complete excision significantly increase the chances of a cure. Treatment strategies are based on modern oncology guidelines, adapted for pediatric patients. [70]

Long-term management focuses on family education, regular skin examinations, the use of photoprotection, and prompt referral when warning signs appear. This approach has proven effective in real-world practice. [71]

FAQ

Should all congenital moles in children be removed prophylactically?
No. Most small congenital nevi are harmless and can be monitored. The decision to remove them is made individually, taking into account the size, location, dynamics, and family preferences. [72]

Is it true that melanoma in children can be pigmentless and difficult to recognize?
Yes, apathetic variants are more common in children, so extended criteria for detection and noninvasive imaging are used. When in doubt, histology is the deciding factor. [73]

When should magnetic resonance imaging be performed for large congenital nevi?
This decision is made on an individual basis. Early imaging is often recommended in infants with giant and multiple congenital nevi to rule out neurocutaneous melanosis. [74]

Is laser removal of childhood moles dangerous?
For typical childhood lesions, especially Spitz nevus, laser and cauterization without histological examination are not recommended, as they complicate diagnosis and may conceal early signs of malignancy. [75]

What is the most important minimum preventative measure for a child with multiple moles?
Shade during peak sun hours, clothing and hats, eyewear, regular application of high-protection sunscreens, family self-examination training, and scheduled visits to a dermatologist. [76]

Additional tables for practice

Table 8. Observation plan (guideline, individualized by the physician)

Situation	Frequency of inspections	Additionally
Typical small congenital and common acquired nevi	Once every 12 months	Photographic recording of large and unusual
Spitz nevus without warning signs	Once every 3-6 months in the first year, then less often	Dermoscopy at every visit
Medium and large congenital nevi	Individually, often 2-4 times a year	Discussion of correction plans
Giant congenital nevi	Individually, interdisciplinary	Neuroimaging as indicated
Based on clinical guidelines and expert community opinion. [77]

Table 9. Extended criteria of suspicion for children (ABCD for children in practical interpretation)

Sign	The essence
Without pigment	A pink or red lump instead of a dark spot
Bleeding or lumpy	The appearance of a "bump" is easily injured
Monochromaticity	Uniform coloring does not eliminate the risk in children
Emergence from scratch	A new, rapidly growing entity of any size
The criteria are proposed in pediatric dermatology and complement the “adult” rules. [78]

Table 10. What can and cannot be done with children's birthmarks

Action	Recommendation
Self-examination with photographic documentation	It's helpful to teach your family a simple algorithm.
Routine dermatological examinations	Required for large, multiple, unusual moles
Laser, cauterization, "freezing" without histology	Undesirable, may interfere with diagnosis
Complete excision when in doubt	Preferably, it gives an accurate diagnosis
Sun protection	Essential in a child's daily life
Summary of practical rules based on recommendations from specialized societies. [79]