Most melanocytic lesions in children are considered ‘nonproblematic’ and are managed conservatively because of their invariable benignity. Congenital melanocytic nevi (CMN) and Spitz nevi are the most problematic pigmented lesions in childhood. Regarding CMN, the biggest risk of melanoma development occurs with increased nevus size, being particularly high in giant CMN, in children younger than 10 years. On the other hand, awareness should be related to new, rapidly growing lesions (the clinical hallmark of Spitz/Reed nevi and melanoma). The aim of this review is to present clinical and dermoscopic features of a large spectrum of pediatric melanocytic lesions with special attention to problematic lesions that may occur in childhood.