Skin Lesions in Children: Evaluation of Clinicopathological Findings
Begum CALIM-GURBUZ1, Burcin PEHLIVANOGLU2, Tuce SOYLEMEZ-AKKURT1, Ozan ERDEM3, Anvar AHMEDOV4
1Department of Pathology, 1Basaksehir Cam and Sakura City Hospital, ISTANBUL, TURKEY
2Dokuz Eylul University Faculty of Medicine, IZMIR, TURKEY
3Department of Dermatology, Reconstructive and Aesthetic Surgery, Basaksehir Cam and Sakura City Hospital, ISTANBUL, TURKEY
Department of Plastic, Reconstructive and Aesthetic Surgery, Basaksehir Cam and Sakura City Hospital, ISTANBUL, TURKEY
Keywords: Children, Skin, Neoplastic, Inflammatory, Lesion
Pediatric skin diseases may show various manifestations, occasionally affecting the patients quality of life. Histopathological
examination may be required for the diagnosis. The aim of this study was to evaluate the spectrum of clinicopathological features in pediatric
Material and Method: A total of 368 biopsies of 359 consecutive patients were included. The clinicopathological findings were retrospectively
evaluated. Non-neoplastic (inflammatory) lesions (ILs) (n=186) were grouped per their origin, while neoplastic/proliferative lesions (NPLs)
(n=182) were grouped based on their pattern. The clinical and histopathological characteristics were statistically analyzed.
Results: 51% were male and the median age was 10.4±4.9 years (range 0-17). ILs mainly involved the head and neck, and NPLs were mostly
located in the lower extremity (p<0.001). The most common NPLs were benign nevus (18%, n=33) and pilomatrixoma (15%, n=27), while
the most frequent IL was spongiotic/psoriasiform dermatitis (38%). Skin appendage/connective tissue tumors were the largest among NPLs
(p=0.02). NPLs were more frequently seen in children >12 years old compared to ILs (p=0.03). The discordance rate between clinical and
histopathological diagnoses was higher for NPLs (27% vs. 15%).
Conclusion: Although the spectrum of skin lesions is broad in pediatric patients, most are benign in nature. The higher frequency of melanocytic
and/or cystic lesions among children >12 years old may be attributed to increased self-care during puberty. Neoplastic/proliferative lesions of
childhood seem to be less commonly recognized by clinicians, and a multidisciplinary approach remains the optimal method, considering the
relatively high rate of discordance between the clinical and histopathological diagnoses.
The frequency of skin diseases in pediatric patients is
affected by hereditary and environmental factors 1
clinical presentation varies from localized subtle changes to
generalized lesions affecting the patients quality of life 2
Some diagnoses require histopathological verification, and
the correlation of clinical and histopathological findings is
critical for diagnosis in certain diseases 3
Both inflammatory and neoplastic skin disorders may
occur in children. In fact, pediatric skin diseases have been
reported to increase 4. However, there is limited data
available on the epidemiological and clinicopathological
evaluation of pediatric skin diseases.
In this study, we aimed to assess the clinicopathological
features of neoplastic and non-neoplastic skin diseases in
The study protocol has been approved by the institutional
ethics committee (Approval date/no: 08.09.2021/192).
A total of 368 consecutive biopsies of 359 pediatric patients
(i.e., < 18 years of age) that were evaluated between June
2020 and August 2021 in the Department of Pathology
were included in the study. Clinicopathological data were
retrospectively evaluated. Data on the age, sex, type and
site of biopsy, size of the lesion, and preliminary clinical
diagnosis were retrieved from hospital records, while histopathological
diagnoses were retrieved from pathology
reports. Patients with inadequate biopsy samples and/or
samples with nonspecific findings were excluded.
Statistical analysis was performed using IBM SPSS Statistics
for Windows, Version 22.0 (Chicago, IL). Descriptive
statistical methods (mean, median, standard deviation,
frequency, percentage, maximum-minimum) were used
to evaluate the data. The Pearson chi-square test, the Fisher
exact test, and the Freeman-Halton tests were used to
analyze the relationship between clinical and pathological
parameters. The histopathological diagnoses were evaluated
and separated into two groups: neoplastic/proliferative
lesions (NPLs) and non-neoplastic/inflammatory lesions
(ILs). For statistical analyses, NPLs were grouped per their
origin as follows: 1) tumors of the surface epithelium (verruca
vulgaris, epidermal nevi, etc.), 2) melanocytic lesions,
3) tumors of the skin appendage/connective tissue (pilomatrixoma,
dermatofibroma, etc.), 4) cutaneous cysts (epidermoid/
trichilemmal cysts), 5) vascular lesions (lobular
capillary, capillary, cavernous hemangioma, etc.), and 6)
lymphoproliferative/related disorders. ILs were grouped
based on their pattern as spongiotic/psoriasiform dermatitis,
interphase dermatitis, superficial/deep perivascular
dermatitis, vasculopathic reaction pattern, connective tissue
diseases, dermal granulomatous/necrobiotic reaction
pattern, and panniculitis. Patients were divided into three
groups based on their age: 0-6 years, 7-12 years, and >12
years old. The preliminary clinical diagnoses and the final
histopathological diagnoses were compared as compatible
or incompatible in all biopsies. p <0.05 was considered
as statistically significant.
A total of 359 patients with single or multiple biopsy samples
were evaluated. Nine patients had multiple biopsies
from different sites with different diagnoses. We therefore
noted them separately and there were 368 biopsies in total.
186 biopsies were in ILs, while 182 biopsies were in the
The mean age was 10.4±4.9 years (range 0-17 years). 51% of
the cases (182 patients) were male, while 49% (177 patients) were female. The most common location was the lower
extremity (31%, 114 patients). The other sites were the head
and neck (26%), trunk (24%), and upper extremity (19%).
Half of the biopsies were incisional (skin punch biopsy),
while the other half was composed of excision materials.
The number of patients with ILs was slightly higher than
the cases with NPLs (51% (n=185) and 49% (n=174),
respectively). There was no statistically significant difference
between gender and NPLs/ILs distribution (p>0.05).
NPLs were significantly more common in patients older
than 12 years old (p=0.03) (Table I).
NPLs were significantly more common in the head and
neck, while the lower extremity was the most common
site for ILs (p<0.001). The mean diameter of NPLs was 2.3
cm, the largest ones being connective tissue/skin appendage
tumors (p=0.02). The most frequent NPLs were benign
nevus (18%, n=33) and pilomatrixoma (15%, n=27) (Figure
1). Juvenile xanthogranuloma occurred only in children <6
years old (Table II). The most common pattern of ILs was
spongiotic/psoriasiform dermatitis (38%, n=71), followed
by superficial/deep perivascular dermatitis (29%, n=55)
(Figure 2, TableIII).
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|Figure 1: The most common NPLs in our series. A) Benign nevus, as the most common NPL; papillomatous compound nevus on the leg
in a 17-year-old girl (40x). B) Pilomatrixoma, as the second most common NPL; composed of basaloid and ghost cells on the neck in a
6-year-old girl (40x). C) Juvenile xanthogranuloma on the neck of a 2-year-old child. Dermal infiltrate of foamy histiocytes with Touton
type giant cells (40x), and D) Hemangioma, as the most clinically recognizable lesion in NPLs. Polypoid lobular capillary hemangioma
on the neck of a 6-year-old girl (40x).
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|Table II: The most common NPL diagnoses and distribution according to age groups.
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|Figure 2: Inflammatory lesions (ILs). A) Spongiotic/psoriasiform dermatitis, as the most common IL; psoriasis vulgaris in a 16-year-old
boy (100x). B) Lichen nitidus, as an interphase dermatitis, in a 5-year-old boy shows a ball and claw appearance at the dermoepidermal
junction (100x). C) Perivascular lymphohistiocytic infiltrate in a 7-year-old girl (100x). D) Granuloma annulare in a 4-year-old girl, with
degenerated collagen surrounded by lymphocytes, histiocytes, and multinucleate giant cells (100x).
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|Table III: The most common IL diagnoses and distribution according to age groups.
The concordance of the clinical and pathological diagnoses
was 73% in NPLs and 85% in ILs. The rate of clinicopathological
discordance in NPLs was significantly higher than
in ILs (p=0.03).
Our study demonstrated that most pediatric skin lesions
are benign in nature, and the most common NPLs are melanocytic
nevus and pilomatrixoma. A broad spectrum of
skin lesions may be encountered in pediatric patients, and
this spectrum is affected by the geographic region (Table
making a high frequency of melanocytic nevi
. Exposure to UV radiation and changes
in a pre-existing nevus is the primary concern for the parents
. Therefore, clinicians prefer to rule out the possible
development of melanoma. Another reason for the relatively
common excision of melanocytic nevus is cosmetic concerns. In fact, cosmetic disturbance is the main reason
for the doctors visit for many skin lesions. Acquired skin
disorders in puberty have a robust impact on self-esteem
compared to congenital skin disorders 13,14
. The higher
frequency of melanocytic and/or cystic lesions among children
>12 years old may also be attributed to increased selfcare
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|Table IV: The clinical and pathological data of the pediatric skin lesions from prior studies of different regions.
Curiously, certain skin lesions exclusively occur in early
childhood. Juvenile xanthogranuloma, a non-Langerhans
cell histiocytosis of the first years of life, is one of them 15.
Juvenile xanthogranuloma was diagnosed in only children
that are younger than six years old in our series, consistent
with the literature 16. Although it is usually a self-limiting
benign lesion, some patients may manifest with a systemic
disease that may require chemotherapy, or it may be associated with hereditary syndromes such as neurofibromatosis,
etc. 17,18. Of note, the main challenge in the differential
diagnosis of juvenile xanthogranuloma is Langerhans cell
histiocytosis. These two histiocytic disorders may be distinguished
based on their immunohistochemical profiles.
The most common location for NPLs was the head and neck
in the present study. Similarly, Yang et al. found that the
majority of the neoplastic lesions in pediatric patients were
located in the scalp area 19. The authors also observed
that congenital malformations, like nevus sebaceous, tend
to occur in the scalp. Still, they might undergo a growth
phase during late childhood due to the enlargement of
sebaceous lobules. In our study, all sebaceous lesions were
located on the scalp, but we did not observe any significant
difference between age groups.
The frequency of inflammatory skin diseases was slightly
higher (51%) in our study group, and spongiotic/psoriasiform
dermatitis was the most common group, frequently
including atopic/allergic dermatitis and psoriasis. This
frequency seems to be higher than some of the previously
reported data. Theiler et al. from Switzerland reported the
rate of neoplastic lesions (benign tumor/hamartoma/cyst)
as 79% and dermatitis as 18% in pediatric patients 7. In
Katsarou et al.s study from Greece, the rate of dermatitis/
eczema was 34.7%, and rate of nevi was 5.6% in children
9. On the other hand, Afsar have found the rate of allergic
skin diseases in childhood as 49.9% in their study from
Turkey 8. In another study from Turkey, eczema was
found at a rate of 14%, which was lower than in the studies from the same geographical region 20. Those differences
may be attributable to populational immunologic differences,
i.e., individuals from certain areas of the world may
be more prone to allergic skin reactions and/or dermatitis.
Eczema is the leading health issue for children in developed
countries, while infections constitute a significant problem
in developing countries 10,21. Moreover, in developed
countries, multidisciplinary management and clinical follow-
up of neoplastic skin lesions have become more critical
nowadays 22. We think that being a large research hospital
in a multicultural setting of a metropolis has also resulted
in a similar frequency of NPLs and ILs in our study, as
we receive excisional and incisional biopsies both from the
Dermatology and Plastic Surgery Departments.
We observed that recognition of the NPLs seems to be more
difficult for clinicians compared to ILs. This suggests that
NPLs of childhood may have overlapping features clinically.
The rates of clinicopathological compatibility were consistent
with the literature both for NPLs and ILs 23,24. In
prior studies about neoplastic skin disorders, the concordance
rates were between 44% and 96.5% 25. On the other
hand, Haugstved et al. found the rate of clinicopathological
accuracy in non-neoplastic lesions as 57.5% 26. Although
the concordance rates seem to differ widely among different
clinical settings, they may be improved by a multidisciplinary
approach and tight cooperation between the
clinicians and the pathologists.
In conclusion, our study provides insight into both neoplastic
and non-neoplastic skin lesions in children by
histopathological confirmation. Although clinical and histopathological concordance is relatively high for specific
types of lesions such as hemangiomas, a multidisciplinary
approach is of utmost importance for the optimal management
of skin lesions in children.
Conflict of Interest>br>
The authors declare that there is no conflict of interest.
This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
Concept: BCG, Design: BCG, BP, Data collection or processing:
BCG, BP, TSA, Analysis or Interpretation: BCG, BP, TSA OE,
AA, Literature search: BCG, BP, Writing: BCG, BP, TSA, OE, AA,
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