Precautions for Individuals with Dysplastic Nevi

Cancer

According to the National Cancer Institute, doctors believe that dysplastic nevi are more likely than ordinary moles to develop into a type of skin cancer called melanoma. However, currently, most dermatologists do not believe that dysplastic nevi develop into melanomas. But individuals with multiple dysplastic nevi are at much higher risk for developing melanomas. Because of this, moles should be checked regularly by a doctor or nurse specialist, especially if they look unusual; grow larger; or change in color, or outline; or if any changes occur.

Today, most dermatologists believe that an individual with multiple dysplastic nevi do not need to have them all removed. The patient and doctor simply need to be exceedingly careful in identifying a melanoma growing among the dysplastic but benign lesions.

Self skin exam monthly is very important. Some dermatologist recommend that an individual with either histologic diagnosis of dysplastic nevus, or clinically apparent dysplastic nevi should be examined by an experienced dermatologist with dermatoscopy once a year (or more frequently).

A melanoma showing irregular borders and colour, diameter over 10 mm and asymmetry (ie A, B, C and D.)

To detect melanomas (and increase survival rates), it is recommended to learn what they look like (see “ABCDE” mnemonic below), to be aware of moles and check for changes (shape, size, color, itching or bleeding) and to show any suspicious moles to a doctor with an interest and skills in skin malignancy^.

A popular method for remembering the signs and symptoms of melanoma is the mnemonic “ABCDE”:

• Asymmetrical skin lesion.
• Border of the lesion is irregular.
• Color: melanomas usually have multiple colors.
• Diameter: moles greater than 6 mm are more likely to be melanomas than smaller moles.
• Evolution: The evolution (ie change) of a mole or lesion may be a hint that the lesion is becoming malignant.

The E is sometimes omitted, as in the ABCD guideline. A weakness in this system is the D. Many melanomas present themselves as lesions smaller than 6 mm in diameter; and likely all melanomas were melanomas on day 1 of growth, which is merely a dot a millimeter in size. An astute physician will examine all abnormal moles, including ones less than 6 mm in diameter. Unfortunately for the average person, many seborrheic keratosis, some lentigo senilis, and even warts breaks most if not all of the ABCD rules, and can not be distinguished from a melanoma without a trained eye or dermatoscopy.

A recent and novel method of melanoma detection is the “Ugly Duckling Sign” ^[6][7] It is simple, easy to teach, and highly effective in detecting melanoma. Simply, correlation of common characteristics of a person’s skin lesion is made. Lesions which greatly deviate from the common characteristics are labeled as an “Ugly Duckling”, and further professional exam is required. The “Little Red Riding Hood” sign, ^[8] suggests that individual with fair skin and light colored hair might have difficult to diagnose melanomas. Extra care and caution should be rendered when examining such individuals as they might have multiple melanomas and severely dysplastic nevi. A dermatoscope must be used to detect “ugly ducklings”, as many melanomas in these individuals resemble non-melanomas or are considered to be “wolves in sheep clothing”^[9]. These fair skinned individuals often have lightly pigmented or amelanotic melanomas which will not present with easy to observe color changes and variation in colors. The borders of these amelanotic melanomas are often indistinct, making visual identification without a dermatoscope (dermatoscopy) very difficult.

People with a personal or family history of skin cancer or of dysplastic nevus syndrome (multiple atypical moles) should see a dermatologist at least once a year to be sure they are not developing melanoma.

Biopsy

When an atypical mole has been identified, a skin biopsy takes place in order to best diagnose it. Local anesthetic is used to numb the area, then the mole is biopsied. The biopsy material is then sent to a laboratory to be evaluated by a pathologist. A skin biopsy can be a punch, shave, or complete excision. The complete excision is the preferred method, but a punch biopsy can suffice if cosmetic or practical concern (i.e. the patient does not want a scar) prevents it. A scoop or deep shave biopsy is often advocated, but should be avoided due to risk of causing a recurrent nevus, which can complicate future diagnosis of a melanoma.

Some pathologists follow the traditional method of classifying a melanocytic nevus. It is either benign nevus or a dysplastic nevus (Clark’s nevus) or a melanoma. Some pathologist follow Dr. Ackerman’s philosophy - a nevus is either a benign nevus, or a melanoma.

Most dermatologists and dermatopathologists use a classification scheme devised by the NIH. In this classification, a nevus can be defined as benign, having atypia, or being a melanoma. A benign nevus is read as (or understood as) having no cytologic or architectural atypia. A dysplastic nevus is read as either having or not having architectural atypica, and having (mild, moderate, or severe) cytologic (melanocytic) atypia^[10]. Usually, cytologic atypia is of more important clinical concern than architectural atypia. Usually, moderate to severe cytologic atypia will require further excision to make sure that the margin is completely clear.

The most important aspect of the biopsy report is that the pathologist indicates if the margin is clear (negative or free of melanocytic nevus), or if further tissue (a second surgery) is required. If this is not mentioned, usually a dermatologist or clinician will require further surgery if moderate to severe cytologic atypia is present - and if residual nevus is present at the surgical margin.

Dysplastic nevus syndrome

“Dysplastic nevus syndrome” refers to dysplastic nevi with familial malignant melanoma, or risk factors for it. Dysplastic Nevus Syndrome is an autosomal dominant hereditary condition which causes the person to have a large quantity of nevi (moles), often 100 or more. There is a propensity for these nevi to become dysplastic in these individuals. Dysplastic nevi are a precursor to malignant melanoma, and these patients are therefore at a higher risk of developing this malignant form of skin cancer. A slight majority of melanomas do not form in an existing mole, but rather create a new growth on the skin. Nevertheless, those with more dysplastic nevi are at a higher risk of this type of melanoma occurrence. Such persons need to be checked regularly for any changes in their moles and to note any new ones. In 40-50% of cases, the disorder has been linked with germline mutations in the CDKN2A gene, which codes for p16 (a regulator of cell division).

Squamous Cell Carcinoma Treatments

Most squamous cell carcinomas may be treated by one of the following methods. More healthy tissue around the lesion is removed than for basal cell carcinomas because of the potential of squamous cell carcinomas to spread. Nearby lymph nodes are also examined carefully. The choice of treatment is influenced by:

* size, location, grade, and type of tumour
* whether the tumour is primary or is recurring
* person’s age and health
* people with organ transplants are at a high risk of aggressive squamous cell carcinoma, which is considered in their treatment plan
* availability of the treatment

Surgery (Wide Excision)

# used for:
- most small lesions that are less than 2 cm
- superficial or SCC that has not spread
- verrucous carcinomas (slow growing and less aggressive)
- tumours that have previously been treated with radiation therapy
- lesions on the eyelid, forehead, scalp, lip, penis, vulva and anus

Mohs Micrographic Surgery

* used for all types of squamous cell cancer
* commonly used for:
- areas that are at high risk of recurrence (eyelids, nose, ears, forehead, scalp), as well as areas that have - already recurred
- areas where it is important to keep function and appearance
- lesions that are larger than 2 cm, and lesions with poorly defined borders
- aggressive tumours, and invasive lesions that have spread to nerves, cartilage or bone
- tumours that have been left untreated for a long time
- lesions that had not been completely removed with prior surgery it involves a meticulous study of tissues removed by a  pathologist at the time of surgery

Radiation Therapy

* used after surgery for:
- elderly individuals
- ensuring cancer free margins
- treatment of involved lymph nodes
- squamous cell carcinoma that has recurred after surgery
- to relieve or control the symptoms of very large tumours
- for people who are unwilling or unable to undergo surgery
- tumours on the eyelid, cheek, earlobe and nose not used for verrucous carcinomas (slow growing and less aggressive)

Chemotherapy

* systemic chemotherapy is used for squamous cell cancer that has spread to other parts of the body
* drugs used most often in chemotherapy:
- cisplatin
- doxorubicin
- bleomycin

Curettage And Electrodesiccation (C & E)

used for
- small areas that are less than 2 cm
- lesions that haven’t spread
- squamous cell carcinoma with distinct margins in Actinic Keratosis should not be used for:

- larger lesions that are greater than 2 cm
- recurrent tumours
- aggressive squamous cell carcinoma
- lesions with poorly defined borders
- hairy areas like the underarms, scalp, and the pubic area
- areas where it is important to keep function and appearance uncommonly used

Wart Treatment by Type of Drug and Procedure

The new advance in treatment of genital warts has been imiquimod (Aldara). This encourages the patient’s autoimmune system to attack the wart. This is particularly helpful in the moist areas of the skin or mucosal surfaces.

Salicylic acid
Salicylic acid can be applied either in the form of plasters or as liquid on to the warts. This will break down the thickened skin on the surface. It is more effective if the area is covered. These are useful for warts on the hands, knees and feet. They do turn the skin white. They can be used in combination with paring of the warts. Treatment with these at nighttime and covering with duct tape can be effective although slow.

Podophyllin

Podophyllin has a long history of use. It is useful mostly in genital warts. It should be applied very carefully on the warts, trying to prevent spread on to normal skin. It should be washed off after a few hours. There is irritation usually for a few days. Repeat treatments are usually required. A more purified form of podophyllin called podophyllotoxin is available for patient use. It can be used once or twice daily for a few days in succession. This produces some irritation. It has the advantage of not being as irritating as podophyllin and can be applied by the patients themselves.

Vitamin Acid

Vitamin acid (Tretinoin) is a vitamin A preparation. It is used in the treatment of acne and photo damage. Vitamin A products tend to regulate the surface of the skin, generally trying to keep the epidermis behaving normally. It may also cause some inflammation. In some individuals it can help reduce or even eliminate warts.

Cantharone

Cantharone (cantharidin) is derived from an insect. It can be very helpful in children but the application is painful. Inflammation and
blistering usually occurs later in the day, after application. Multiple treatments may be required. There are two concentrations. The
stronger version combines Cantharone with podophyllin and salicylic acid. Very occasionally the blistering reaction can be quite severe
and associated with swelling and pain. It is often very effective even in resistant warts.

Cryotherapy

Cryotherapy is the use of liquid nitrogen. This can be applied either with a Q-Tip or it can be sprayed on to the skin. It causes destruction by freezing water inside the cells. This damages the cell causing death. It is painful to apply and there is blistering associated with this. Multiple treatments may be required. Thawing and freezing again makes this therapy more effective. It can be a problem in dark skin in that it can either increase or decrease pigmentation, which can be permanent. This treatment can be used in combination with other therapies.

Electrodesiccation

Electrodesiccation is the use of an electric needle to burn warts. It usually requires a local anesthetic. It does have a potential risk of scarring. Very large warts can sometimes be scraped off before they are cauterized.

CO2 Laser

The CO2 laser has been used for many years. It essentially vaporizes water in the skin and causes destruction. It leaves a hole in the skin which will heal. There is often scarring with this technique. Other lasers such as the pulse dye laser are easier to use. The yellow light is absorbed by blood in the vessels that feed the warts. This is a similar laser used in the treatment of red birthmarks. The pulse dye laser at a high power setting can be effective particularly if multiple pulses are used in succession.

Aldara

Aldara is an immune response modulator. It boosts the patient’s immune response to viruses. It can also encourage the production of a lasting immune memory. It has been available in Canada since 1999. It works best in the genital area as penetration into the skin is easier. When it is used elsewhere it often has to be covered to help with penetration into the skin. It has been shown to work well particularly in women. It is applied three times weekly. There will be some inflammation associated with this. The results may be enhanced by combining this with liquid nitrogen. This drug has added a very significant tool in treating genital warts.

Understanding Basic Types of Moles

It is necessary to clarify that not all moles are the same. There are a few classifications. But the most important for you is to be able to
discern the common mole from the moles that are more risky to cause skin cancer.

Moles are overgrowths of the skin’s pigment cells called melanocytes. Usually the moles are round spots on the skin colored in medium to dark brown. The greater part of moles is flat with constant color and regular in shape. A number of moles are raised with lighter colors. The people often had mistaken the new moles with the freckles. Sporadically the moles may develop a white halo around them.

Common Mole

In fact the moles could come into view everywhere on the body. Their color is usually brown, because is caused by the pigment melanin. Usually the common mole appears at the first part of life, when the system is growing but it is not impossible some moles to appear after the age of 20. The sun is one of the direct factors that have a strong influence on the moles. The people who are often exposed at sun light tend to have more moles that the others.

The common moles could change during the adolescence and the pregnancy, because of the big hormonal changes in the system. There is no typical way of change of one common mole. Usually one mole exists about forty to fifty years. Usually at the beginning of its life cycle the mole is flat and thin something like a freckle. Sometimes the color of the new mole is brown to black or even pink.

According to the size and shape the moles become bigger and rise over the surrounding skin with the time. Usually this is attended with the lightening of their color. It is not unusual some moles to rise over the skin and to develop a small stalk. The older moles tend to have some hairs on it that makes it odious sometimes. Some moles do not ever change.

The question which excites a lot of people is: Is it possible the common mole to disappear by its own? In fact the answer is yes. Some moles at the end of their life cycle tend to loose their color and to fade away. The raised moles also could fall of if they are raised vastly over the skin and have a thin stalk, but remember you must not try to wrench it away yourself. Look for a professional medical pracictioner to remove your mole for you.

As you can see there is no typical course of mole development. Because of that it is very important to know well your moles and to keep the history of their growth. According to the risk of skin cancer the early mark of any changes in the mole could be the decisive factor for the success of the melanoma treatment.

In order to make the process of the moles observation easier and at the same time enough efficient and useful for your dermatologist, our organization develops a list of common descriptions and characteristics of the moles that will help you to check your moles regularly and correctly. Be sure that you know the common types of moles.

Types of Moles

Each person has at least a few skin moles. They usually come out by the time an individual is 20 and at the beginning looks like freckles. Of course there are a lot of people who were born with skin moles. Usually every 1 of 20 babies has one or more moles at its birth.  A skin mole’s shade and form don’t usually change. A mole typically lasts about forty or even fifty years before start to become lighter. Some skin moles fade away completely, and some never fade at all. Sometimes a number of moles extend stalks that raise them above the skin’s surface it is possible these moles to drop off.

A skin mole is a spot on the skin with darker color. Generally it is part of skin pigmentation and could appear anywhere at the body. Most often we are talking about benign moles that are just a couple colored cells of the skin. Sometimes the facial moles could be even charming. On the other hand, from time to time moles can cause a serious health risk and can become Cancerous moles.

There are several skin mole types depending on its placement on our body:

Facial moles – or all moles on the face. It could appear all over the face and the head.

Body moles – are the moles at the other parts of the body with no specific location.

Genital Moles – Very often a lot of people feel ashamed of its genital moles. It is not surprising that most often the mole can cause
more psychological than health problems to its owner.

Moles in Children – It is normal the kids to have some moles at their bodies and it is important their parents to know what to check and how to examine the moles of the children

Black Moles
This variant of a benign mole (the common mole) is also referred to as a mole of midlife. It typically is seen in darker-skinned persons

between the ages of sixteen and thirty years. Of course this rule has a lot of exceptions. Usually the black mole is little, up to 5 mm.

Bleeding Moles
In common cases the mole which is bleeding or ooze is a reason to go to dermatologist. But even in this case the bleeding could be caused by irritation of the mole on the underwear or just a cut during shaving.

Body Moles
Moles may come out from the birth of an individual or may appear later during the whole life. It may begin from maturity and could still
grow when the person become forty or fifty years old. There is no specific place where the moles tend to occur more often

Changing Moles
The changes in the mole have to be brought to the attention of your dermatologist. It is normal the mole to grow with us and to change through the years but any unusual change in the color, fast growth, bleeding or oozing, inching or pain could indicate that the mole is turning into a melanoma.

The average person seldom has only “beauty marks”. In fact, in our present society the moles are often seen as a hindrance for their owner. There are a lot of people who feel depressed by their moles, especially if we are talking about the facial moles. If such a mole has strong influence upon the overall appearance and the general condition of the person may be it will be better for him or her to remove it.