Growing Red Papule on a 13-Year-Old's Face: Should We Worry?

Correct answer: E. Spitz nevus

Treatment and management. The histologic findings in the pathology report found no evidence of malignancy and were consistent with a compound congenital Spitz nevus, thereby confirming the diagnosis. As this is a benign melanocytic proliferation, and margins were clear of melanocytic features, no further treatment was required. 

Outcome and follow-up. We counseled the patient on the importance of regular self-skin checks, which involve inspection of the entire skin surface in a well-lit environment to identify new or changing moles, using mirrors or assistance from another individual for difficult-to-see areas. At the patient’s 3-week follow-up by phone, his mother reported that the small linear scar from his excision was healing well.

Discussion. Spitz nevi (SN) are benign melanocytic proliferations that typically occur within the first 2 decades of life, with 50-75% of cases affecting individuals under the age of 20.¹ These nevi typically present as solitary, dome-shaped, well-demarcated papules with pigmentation ranging from pink to dark brown and are most often found on the head and extremities.² While SN may exhibit a period of rapid growth, they are usually less than 1 cm in diameter.² Previously termed juvenile melanoma due to their clinical and histological resemblance to melanoma, SN were recognized as benign in 1948 when Sophie Spitz described their biologic behavior.³ Dermoscopic patterns typically observed in SN include the starburst, negative network, homogenous, and non-specific patterns.⁴ However, significant morphologic overlap exists between SN and melanoma. A study examining these similarities found that both lesions can exhibit architectural disarray and cytologic atypia.⁴

Melanoma is a life-threatening malignancy of melanocytic cells, responsible for 90% of skin cancer-related deaths.⁵ While patients under age 20 represent only 0.4% of diagnoses and 0.1% of deaths, approximately 500 new cases occur annually in this age group in the United States.⁶ About 25% of these pediatric melanoma (PM) cases are linked to underlying predisposing conditions.⁶ Diagnosis in pediatric patients can be challenging, as a subset of cases do not meet the classic ABCDE criteria (asymmetry, border irregularity, color variation, diameter >6 mm, and evolution). Instead, PM may present with features outlined by a modified ABCDE mnemonic: amelanotic, bleeding or Bump, color uniformity, de novo and any diameter, and evolution.⁶ 

Based on the largest dermoscopy study in PM, lesions can be subcategorized as spitzoid or nonspitzoid by dermoscopic features.⁷ Nonspitzoid melanomas most often showed multicomponent or nevus-like patterns, similar to adult melanoma. Spitzoid melanomas that are amelanotic showed atypical vessels and shiny white lines, and pigmented spitzoid melanomas displayed an asymmetric starburst pattern.⁷ Nonspitzoid melanomas were more common in adolescents, on the back, in association with a preexisting nevus and in patients with melanoma risk factors, while spitzoid melanomas were associated with younger age, extremity involvement, nodular or polypoid morphology, frequent amelanosis, and de novo presentation.⁷ In this case, the patient’s young age and absence of known predisposing conditions make melanoma less likely. However, given the wide spectrum of clinical and dermoscopic features in PM, we required a histopathological evaluation for a definitive diagnosis. 

We also considered hemangioma, a benign proliferation of endothelial cells and the most common soft-tissue tumor in infancy and childhood.⁸ Hemangiomas typically present on the head and neck and can be classified as infantile or congenital.⁸ Infantile hemangiomas appear within the first 8 weeks of life, initially as discoloration or telangiectasias, followed by a rapid growth phase (6-12 months), forming a raised, bright-red, rubbery lesion that regresses by 5-9 years of age.⁸ Congenital hemangiomas, which are present at birth, often appear as pink or purple plaque-like lesions with telangiectasias and may involute within the first year of life or persist without regression.⁸ While congenital hemangiomas do not usually exhibit growth after birth, they can expand proportionally with the child.⁸ Given this patient’s recent history of lesion growth and the more papular morphology, hemangioma was less likely. 

Pilomatrixoma is a benign neoplasm of the hair follicle matrix that typically arises in the first 2 decades of life and is associated with Wnt pathway mutations.⁹ Clinically, it presents as a slow-growing, solitary, firm subcutaneous nodule with bluish or reddish discoloration, typically on the head and neck.⁹ Multiple lesions may be associated with syndromes, including Gardner syndrome and myotonic dystrophy.⁹ Dermoscopy may show irregular white structures, red homogeneous areas, hairpin, linear-irregular, and dotted vessels, with ulceration and gray-blue structureless areas.⁹ Ultrasound can aid recognition, and histopathology demonstrates basophilic cells, ghost cells, and calcification.⁹ Pilomatrixoma was unlikely due to the lesion’s soft texture and absence of a tent or teeter-totter sign, with histopathology excluding this diagnosis.

Lastly, a pyogenic granuloma is a benign proliferation of capillaries that often arises following skin trauma, certain medications, or during pregnancy.¹⁰ Despite the name, it is neither infectious nor granulomatous. Pyogenic granulomas typically occur on the head and neck in children and young adults, classically presenting as a rapidly growing, friable, red papule that bleeds easily with minor trauma.¹¹ However, this diagnosis was less likely, as the patient’s lesion was present for many years without any history of bleeding, a hallmark of pyogenic granulomas.

Conclusion. This case highlights the challenges of diagnosing melanoma in children and adolescents, particularly given its rare and atypical presentations. While PM is uncommon, it remains a significant concern and should always be considered, especially with an evolving lesion, which is a key warning sign. PM may present as amelanotic, itchy, raised, or bleeding, and can be completely uniform in color.⁶ New lesions, particularly those with a change in size, shape, or appearance, are also critical indicators.⁶ Given these subtle and diverse signs, healthcare providers must remain vigilant and promptly excise suspicious lesions for accurate diagnosis. Early detection and timely intervention are critical in improving outcomes for these pediatric patients. Fortunately, despite the recent growth, the biopsy results provided reassurance for the 13-year-old in this case. 

AUTHORS:
Emily Cleary, BS,¹ Michelle Gallagher, DO²

AFFILIATIONS:
¹Michigan State University College of Osteopathic Medicine, East Lansing, MI
²Assistant Professor, Department of Pediatrics, Michigan State University College of Osteopathic Medicine, East Lansing, MI

CITATION:
Cleary E, Gallagher M. Growing red papule on a 13-year-old's face: should we worry? Consultant. Published online January 27, 2026. DOI: 10.25270/con.2026.01.0000010

Received September 15, 2025. Accepted December 29, 2025.

DISCLOSURES:
The authors report no relevant financial relationships.

ACKNOWLEDGEMENTS:
None.

CORRESPONDENCE:
Emily Cleary, BS. Michigan State University College of Osteopathic Medicine. 965 Wilson Road, East Lansing, MI 48824 (email: clearyem@msu.edu)

References

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