BACKGROUND: Dermoscopy improves the recognition of melanoma and Spitz nevus but occasionally melanoma may exhibit a symmetric pattern mimicking Spitz nevus.OBJECTIVE: We sought to investigate the likelihood of finding melanoma when excising a symmetric Spitzoid-looking lesion in patients aged 12 years or older.METHODS: This study included patients aged 12 years or older with symmetric, Spitzoid-looking lesions that were diagnosed histopathologically as Spitz nevus or melanoma. Demographic, clinical, and dermoscopic variables were included in the analysis. We used χ(2) for nonparametric comparisons. Crude odds ratios and 95% confidence intervals were calculated by univariate logistic regression.RESULTS: Of 384 included lesions, 333 (86.7%) were histopathologically diagnosed as Spitz nevus and 51 (13.3%) as melanoma. The risk of melanoma significantly increased with increasing age, being 50% or higher after the age of 50 years.LIMITATIONS: Limitations are retrospective design, exclusion of patients younger than 12 years, lack of detailed histopathologic data, and limited sample size.CONCLUSION: Our results confirm the observation that melanoma may be dermoscopically indistinguishable from Spitz nevi, strongly suggesting that the only safe strategy not to miss melanoma is to excise all Spitzoid-looking lesions in patients aged 12 years or older.