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).

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).

Using Lasers and IPL for Pigmentary Lesions

Lasers and intense pulsed light sources are frequently used for the treatment of pigmented lesions, and the appropriate selection of devices for different lesions is vital to achieving satisfactory clinical outcomes. In dark-skinned patients, the risk of post-inflammatory hyperpigmentation is of particular importance. In general, long-pulse laser and intense pulsed light sources can be effective with a low risk of post-inflammatory hyperpigmentation (PIH) when used for the treatment of lentigines. However, for dermal pigmentation and tattoo, Q-switched lasers are effective, with a lower risk of complications. In the removal of melanocytic nevi, a combined approach with a long-pulse pigmented laser and a Q-switched laser is particularly applicable.
Key Words: pigmented lesions, hyperpigmentation, lasers, intense pulsed light sources

The cutaneous application of lasers and intense pulsed light sources for the treatment of pigmented lesions can be divided into the following categories:

• a)  Tattoos
• b)  Epidermal pigmentation such as lentigines and café au lait patches
• c)  Dermal pigmentation such as nevus of Ota, acquired bilateral nevus of Ota, and melanocytic nevi

Tattoos

The use of lasers has been effective in the removal of some,  but not all, tattoos. Q-switched lasers have been found to be safe and effective in the treatment of tattoos. The response to laser treatment can vary greatly due to the wide range of tattoo ink. Previous in vitro quantitative chemical analysis of tattoo pigments found that the most common elements were aluminium, titanium, and carbon. Titanium overrepresentation was identified as the main reason for a poor response to laser treatment. Picosecond lasers were found to be more effective in achieving a greater degree of clearing. To improve the clinical outcome, more recent developments have included the external application of magnets to improve the removal of magnetite skin tattoos after Q-switched laser treatment, and the use of intradermal focusing of the Q-switched laser. In terms of complications, tattoos can darken after laser treatment due to the reduction of ferric oxide to ferrous oxide. This can be rectified with repeated Q-switched laser treatment and the use of a resurfacing laser. Less common complications include the development of allergic dermatitis or even anaphylactic shock after the laser surgery. Such reactions are thought to occur due to the release of allergic pigment into the extracellular space after laser exposure.

Epidermal Lesions

Lentigines

Lasers have been used for the treatment of lentigines, and although this is often effective for light-skinned patients with limited complications, for dark-skinned patients with a higher epidermal melanin content it can be associated with complications such as hyperpigmentation. Two years ago, our group performed an in vivo study of 34 patients and compared a Q-switched 532nm Neodymium:Yttrium-Aluminum-Garnet (QS 532nm Nd:YAG) laser to a long-pulse 532nm Nd:YAG laser. We found that the long pulse 532nm Nd:YAG laser (2msec pulse duration, 6.5-8J/cm2 fluence, 2mm spot size, with slate gray appearance as the clinical end-point) can result in a lower risk of PIH when used in the treatment of lentigines in Asians. We created controversy when we suggested that the photomechanical effect of QS lasers might not be desirable when used in such treatment. Intense pulsed light sources (IPL), which emit a broad band of visible light from a non-coherent filtered flashlamp, produce only photothermal effects. Recent studies that investigated the use of IPL to remove lentigines in Asians confirmed their effectiveness. Interestingly, no case of PIH was observed in two independent studies.

These observations confirm our hypothesis that the photomechanical effect of Q-switched laser for the treatment of lentigines in Asians is not desirable. The main concern regarding the use of the long-pulse laser for the treatment of cutaneous pigmented lesions is the potential of thermal diffusion from the epidermis to the dermis, which increases the risk of scar formation. To prevent such an occurrence, the pulse duration should be shorter than the thermal relaxation time of the epidermis basal layer, which was estimated to be in the range of 1.6-2.8ms if the epidermal basal layer thickness was 20mm.

It is now our routine approach to test patients with a long pulse 532nm Nd:YAG laser (2ms pulse duration, 6.5J/cm2 fluence, 2mm spot size), and if they respond well, we offer them full treatment. Those who do not wish to have down time, or those who develop post-inflammatory hyperpigmentation after the test, are offered IPL treatment, which requires several more treatment sessions to achieve the desired clinical outcome.

Café au Lait Patch

The use of lasers in the treatment of the café au lait patch has yielded variable results, and although some early studies indicated complete removal without recurrence, such findings have not always been repeated. Previous studies showed that 510nm pulsed dye lasers and copper vapor lasers can be used successfully, with no recurrence, at least one year after treatment. These reports were confirmed by others. Grossman, et al. used a QS Ruby laser and a frequency double Q-switched Nd:YAG laser, and found that the degree of clearance varied across lesions. Moreover, the categorization of the patches into the two histological sub-types that they identified did not help to predict the extent of the clinical response. We looked at the use of normal-mode ruby laser (NMRL) and compared it to QS Ruby laser in the clearing of café au lait patches in 33 patients. Our preliminary data indicated that there was a lower risk of recurrence when the NMRL was used (42.4% of recurrence, as compared to 81.8% recrrence in those who were treated with QS Ruby laser) 3 months after a single treatment. By affecting the follicular melanocytes, the long-pulse laser may reduce the recurrence rate. Further histological study is necessary to confirm this hypothesis.

Dermal Lesions

Nevus of Ota

Q-switched Alexandrite (QS Alex), QS Ruby, and QS 1064nm Nd:YAG have been used for the treatment of nevus of Ota with excellent results and minimal risk of complications. The clinical efficacy of the QS Ruby was confirmed when Watanabe and Takahashi⁶ studied 114 nevus of Ota patients and found that a good-to-excellent degree of lightening was achieved after three or more treatment sessions. The side-effects were few, with transient hyperpigmentation after the first treatment being the most common. Studies comparing the use of QS Alex and QS Nd:YAG lasers found that most patients better tolerated the former. However, QS Nd:YAG laser appeared to be more effective than QS Alex in the lightening of nevus of Ota after three or more laser treatment sessions. In terms of complications, hypopigmentation was common, especially among those treated with QS Ruby. The original pigmentation could also recur in patients after complete laser-induced clearing, which is an important issue, especially for pediatric patients. The risk of such recurrence is estimated to be between 0.6% and 1.2%. However, the use of QS Ruby laser for the treatment of nevus of Ota in children can achieve an excellent result in fewer sessions and at a lower complication rate than later treatment.  Hence, the advantages and disadvantages of treating nevus of Ota early in childhood should be thoroughly discussed with the patient’s relatives.

Acquired Bilateral Nevus of Ota-like Macules (ABNOM) or Hori’s Macules

Acquired bilateral nevus of Ota-like macules (ABNOM), or Hori’s macules, are a pigmentary disorder that is clinically characterized by speckled or confluent brownish-blue or slate gray pigmentation over the face, and histologically characterized by diffuse upper dermal melanocytosis. Unlike nevus of Ota, the pigmentation occurs in a symmetrical bilateral fashion, has a late onset in adulthood, and does not involve the mucosa.

One hundred forty patients with ABNOM were treated with a Q-switched Ruby laser (7-10J/cm2 fluence at a repetition rate of 1Hz, 2-4mm spot size). Complete clearance was obtained in 131 patients, and hyperpigmentation was observed in 7%. Hypopigmentation persisted in 2.1% of the patients, and there was no recurrence after 6 months to 4.3 years of follow up (mean was 2.5 years). QS Nd:YAG laser was also used to treat ABNOM, and the rate of PIH was estimated to be between 50% and 73%.⁸ Our group showed that QS Alex laser is effective in the treatment of ABNOM. Post-operative pigmentary changes were frequent, and the use of topical bleaching agents was necessary to achieve a satisfactory result. The risk of transient hypopigmentation was high, and it affected up to 50% of the patients. More recently, a combination approach with a scanned carbon dioxide laser followed by a Q-switched Ruby laser has been found to be effective.

Melanocytic nevi are common, and often removed for cosmetic reasons. Various pigmented lasers have been used in their removal. A previous study using a QS Ruby laser found that an average clearance of 76% occurred after eight treatment sessions.10 However, recurrence can be a problem depending upon the depth of the nests of melanocytes. The use of a normal mode ruby laser (NMRL) for the treatment of melanocytic nevi is based upon the principle that with longer pulse durations, a greater degree of clearance is achieved when nests of cells are destroyed. A combined approach with a QS Ruby laser followed immediately, or 2 weeks later, with an NMRL has more recently been used with the intention of removing the superficial pigment first with the QS Ruby laser, thereby enhancing the penetration of the NMRL. A previous study found that although 52% of the nevi showed a visible reduction in pigment, no lesion had complete histological clearance. The short- and long-term histological findings of congenital nevi that have been treated with the NMRL indicated that subtle microscopic scars of up to 1mm in diameter are frequent. It has been proposed that such scars cover the underlying nevus cells, which leads to cosmetic improvement. Better cosmetic results were produced by first using an NMRL to remove the epidermis, immediately followed by multiple passes of a QS Ruby laser.¹¹ This approach effectively removes the epidermis, and in doing so enables a greater degree of penetration by the QS Ruby, of which multiple passes further enhance the clinical efficacy. A similar approach using a long-pulse pigmented laser immediately followed by multiple passes of a Q-switched pigmented laser can obtain similar results.

Conclusion

For epidermal pigmented lesions, long-pulse pigmented laser or IPL can be effective with a lower risk of post-inflammatory hyperpigmentation, especially when used on dark-skinned patients. Q-switched laser is necessary to remove dermal pigment and tattoo in order to avoid the risk of scarring. A combination approach can be used for the removal of melanocytic nevi.

H.H.L. Chan, MD, FRCP¹, and T. Kono, MD^2
1Division of Dermatology, Department of Medicine, the University of Hong Kong, China
²Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medical University, Tokyo, Japan

Skin Biopsies and Skin Lesions

Skin biopsy is a biopsy technique in which a skin lesion is removed and sent to the pathologist to render a microscopic diagnosis. It is usually done under local anesthetic in a physician’s office, and results are often available in 4 to 10 days. It is commonly performed by dermatologists.

Skin biopsies are also done by family physicians, internists, surgeons, and other specialties. However, performed incorrectly, and without appropriate clinical information, a pathologist’s interpretation of a skin biopsy can be severely limited. There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy. The choice of the different skin biopsies is dependent on the suspected diagnosis of the skin lesion.

Like most biopsies, patient consent and anesthesia (usually lidocaine injected into the skin) are prerequisites.

Different types of skin biopsies

Shave biopsy

This is done with either a small scalpel blade, a curved razor blade, or a broken piece of “safety” razor. The technique is very much user skill dependent, as some surgeons can remove a small fragment of skin with minimal blemish using any one of the above tools, while others have great difficulty securing the devices. Ideally, the razor will shave only a small fragment of protruding tumor and leaving the skin relatively flat after the procedure. Hemostasis is obtained using light electrocautery, Monsel solution, or aluminum chloride. This is the ideal method of diagnosis for basal cell
cancer.

It can be used to diagnose squamous cell carcinoma and melanoma-in-situ, however, the doctor’s understanding of the growth of these last two cancers should be considered before one uses the shave method. The punch or incisional method is better for the latter two cancers as a false negative is less likely to occur (i.e. calling a squamous cell cancer an actinic keratosis or keratinous debris). Hemostasis for the shave technique can be difficult if one relied on electrocautery alone. A small “shave” biopsy often ends up being a large burn defect when the surgeon tries to control the bleeding with electrocautery alone. Pressure dressing or chemical astringent can help in hemostasis in patients taking anticoagulants.

Punch biopsy

This is done with a round shaped knife ranging in size from 1mm to 8 mm. Some punch biopsies are shaped like an ellipse, although one can accomplish the same desired shape with a standard scalpel. The 1 mm and 1.5 mm punch are ideal for locations where cosmetic appearance is difficult to accomplish with the shave method. Minimal bleeding is noted with the 1 mm punch, and often the wound is left to heal without stitching for the smaller punch biopsies. Disadvantage of the 1 mm punch is that the tissue obtained is almost impossible to see at times due to small size, and the 1.5 mm biopsy is preferred in most cases. The common punch size use to diagnose most inflammatory skin condition is the 3.5 or 4 mm punch. Ideally, the punch biopsy include the full thickness skin and subcutanous fat in the diagnosis of skin disease

Incisional biopsy

When a cut is made through the entire dermis down to the subcutanous fat. A punch biopsy is essentially an incisional biopsy, except it is round rather than elliptical as in most incisional biopsies done with a scalpel. Incisional biopsies can include the whole lesion (excisional), part of a lesion, or part of the affected skin plus part of the normal skin (to show the interface between normal and abnormal skin). Incisional biopsy often yield better diagnosis for deep pannicular skin diseases and more subcutanous tissue can be obtained than a punch biopsy. Long and thin deep incisional biopsy are excellent on the lower extremities as they allow a large amount of tissue to be harvested with minimal tension on the surgical wound. Advantage of the incisional biopsy over the punch method is that hemostasis can be done more easily due to better visualization. Dog ear defects are rarely seen in incisional biopsies with length at least twice as long as the width.

Excisional biopsy

This is essentially the same as incisional biopsy, except the entire lesion or tumor is included. This is the ideal method of diagnosis of small melanomas (when performed as an excision). Ideally, an entire melanoma should be submitted for diagnosis if it can be done safely and cosmetically. This “excisional” biopsy is often done with a narrow margin to make sure the deepest thickness of the melanoma is given before prognosis is decided. However, as many melanoma-in-situs are large and on the face, a physician will often chose to do multiple small punch biopsies before committing to a large excision for diagnostic purpose alone. Many prefer the small punch method for initial diagnostic value before resorting to the excisional biopsy. An initial small punch biopsy of a melanoma might say “severe cellular atypia, recommend wider excision”. At this point, the clinician can be confident that an excisional biopsy can be performed without risking committing a “false positive” clinical diagnosis.

Curettage biopsy

This can be done on the surface of tumors or on small epidermal lesions with minimal to no topical anesthetic using a round curette blade. Diagnosis of basal cell cancer can be made with some limitation, as morphology of the tumor is often disrupted. The pathologist must be informed about the type of anesthetic used, as topical anesthetic can cause artifact in the epidermal cells. Liquid nitrogen or cryotherapy can be used as a topical anesthetic, however, freezing artifact can severely hamper the dianosis of malignant skin cancers.

Fine needle aspirate

Needle aspiration biopsy[1] is done with the rapid stabbing motion of the hand guiding a needle tipped syringe and the rapid sucking motion applied to the syringe. It is a method used to diagnose tumor deep in the skin or lymphnodes under the skin. The cellular aspirate is mounted on a glass slide and immediate diagnosis can be made with proper staining or submitted to a laboratory for final diagnosis. A fine needle aspirate can be done with simply a small bore needle and a small syringe (1 cc) that can generate rapid changes in suction pressure. Fine needle aspirate can be used to distinguish a cystic lesion from a lipoma. Both the surgeon and the pathologist must be familiar with the method of procuring, fixing, and reading of the slide. Many center have dedicated team used in the harvest of fine needle aspirate.

Saucerization biopsy

Also known as “scoop”, “scallop”, or “shave” excisional biopsy[2], or “shave” excision. A trend has occurred in dermatology over the last 10 years with the advocacy of a deep shave excision of a pigmented lesion [3] [4] [5] An author published the result of this method and advocated it as better than standard excision and less time consuming. The added economic benefit is that many surgeons bill the procedure as an excision, rather than a shave biopsy. This saves the added time for hemostasis, instruments, and suture cost. The great disadvantage, seen years later is the numerous scallop scars, and a very difficult to deal with lesions called a “recurrent melanocytic nevus”, see recurrent nevus. What has happened is that many “shave” excisions do not adequately penetrate the dermis or subcutanous fat enough to include the entire melanocytic lesion. Residual melanocytes regrow into the scar. The combination of scarring, inflammation, blood vessels, and atypical pigmented streaks seen in these recurrent nevus gives the perfect
dermatoscopic picture of a melanoma[6][7][8][9]. When a second physician re-examines the patient, he or she has no choice but to recommend the reexcision of the scar.

If one does not have access to the original pathology report, it is impossible to tell a recurring nevus from a severely dysplastic nevus or a melanoma. As the procedure is widely practiced, it is not unusual to see a patient with dozens of scallop scars, with as many as 20% of the scar showing residual pigmentation. The second issue with the shave excision is fat herniation, iatrogenic anetoderma, and hypertrophic scarring. As the deep shave excision either completely removes the full thickness of the dermis or greatly diminishes the dermal thickness, subcutanous fat can
herniate outward or pucker the skin out in an unattractive way. In areas prone to friction, this can result in pain, itching, or hypertrophic scarring.

The Pathology Report

A pathology report is highly dependent on the quality of the biopsy that is submitted. It is not unusual to miss the diagnosis of a skin tumor or a skin biopsy due to a poorly performed or inappropriately performed skin biopsy. The clinical information provided to the pathologist will also affect the final diagnosis. An example would be a rapidly growing dome shaped tumor of the sun exposed skin. Despite doing a large wedge incision, a pathologist might call the biopsy keratin debris with characteristics of actinic keratosis. But provided with an accurate clinical information, he/she might consider the diagnosis of a well differentiated squamous cell carcinoma or keratoacanthoma. It is not infrequent for two, three or more biopsies to be performed by different doctors for the same skin condition, before the correct diagnosis is made on the final biopsy.

The method, depth, and quality of clinical data will all affect the yield of a skin biopsy. For this reason, doctors specializing in skin diseases are invaluable in the diagnosis of skin cancers and difficult skin diseases. Specific stains (PAS, DIF, etc), and certain type of sectioning (vertical and horizontal) are often requested by an astute physician to
make sure that the pathologist will have all the necessary information to make a good histological diagnosis.

References

1. ^ http://www.virtualcancercentre.com/investigations.asp?sid=3
2. ^ Saucerization biopsy of pigmented lesions . Clinics in Dermatology , Volume 23 , Issue 6 , Pages 631 - 635 J . Ho , R . Brodell , S . Helms
3. ^ http://escholarship.umassmed.edu/ssp/46/
4. ^ http://www.clinmedres.org/cgi/content/full/6/2/86
5. ^ http://www.aafp.org/afp/20021101/letters.html
6. ^ http://www.springerlink.com/content/u353473367570111/
7. ^ http://www.pathology-skin-rjreed.com/html/recurrent_nevus__c20t3_.htm
8. ^ http://dermoscopic.blogspot.com/2007/11/recurrent-nevus.html
9. ^ http://www.pathology-skin-rjreed.com/congenital_nevust_c7bt2_.HTM

The Warning Signs of Melanoma

The A, B, C, D, Es of Melanoma.  Moles, brown spots and growths on the skin are usually harmless — but not always. Anyone who has more than 100 moles is at greater risk for melanoma. The first signs can appear in one or more atypical moles. That’s why it’s so important to get to know your skin very well and to recognize any changes in the moles on your body. Look for the ABCDEs of melanoma, and if you see one or more, make an appointment with a physician immediately.

Melanoma - What You Need to Know

Hearing the words “It’s cancer” can be overwhelming. Often, people are too stunned to be able to ask physicians for the information they need. When discussing your diagnosis and treatment options with your physician, it can be helpful to have questions prepared ahead of time, so that you don’t forget anything important. Take a pen and paper to write down the answers, or a portable tape recorder so that you can play back the answers later. Studies have shown that people who are more informed about their cancer have a more positive attitude and respond better to treatment.

Questions to Ask Your Physician

• How advanced is my melanoma? What stage is it in?
• What are my chances of recovery?
• What treatments are available?
• Will I be given a choice of options?
• If I need surgery, will there be a scar?
• Which treatment do you think is best for me? Why?
• What are the side effects? Can they be treated, too?
• Will my health insurance or Medicare/Medicaid cover the cost?
• Will I be able to work and lead a normal life during treatment?
• What tests will be performed to show that the melanoma is cured?
• What are the chance of it coming back?
• Is there anything I can do to prevent a recurrence?

	Asymmetry If you draw a line through this mole, the two halves will not match.
	Border The borders of an early melanoma tend to be uneven. The edges may be scalloped or notched.
	Color Having a variety of colors is another warning signal. A number of different shades of brown, tan or black could appear. A melanoma may also become red, blue or some other color.
	Diameter Melanomas usually are larger in diameter than the size of the eraser on your pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected.
	Evolving Any change — in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching or crusting — points to danger.

Prompt action is your best protection. The pictures below show atypical normal moles and melanomas.

	Benign	Malignant
Symmetrical			Asymmetrical
Borders are even			Borders are uneven
One shade			Two or more shades
Smaller than 1/4 inch			Larger than 1/4

How are skin tags treated?

There are several effective medical ways to remove a skin tag, including removing with scissors, freezing (using liquid nitrogen), and burning (using medical electric cautery at the physician’s office).

Usually small tags may be removed easily without anesthesia while larger growths may require some local anesthesia (injected lidocaine) prior to removal. Application of a topical anesthesia cream prior to the procedure may be desirable in areas where there are a large number of tags.

Dermatologists (skin doctors), family physicians, and internal medicine physicians are the doctors who treat tags most often. Occasionally, an eye specialist (ophthalmologist) is needed to remove tags very close to the eyelid margin.

There are also home remedies and self-treatments, including tying off the small tag stalk with a piece of thread or dental floss and allowing the tag to fall off over several days.

The advantage of scissor removal is that the growth is immediately removed and there are instant results. The potential disadvantage of any kind of scissor or minor surgical procedure to remove tags is minor bleeding.

Possible risks with freezing or burning include temporary skin discoloration, need for repeat treatment(s), and failure for the tag to fall off.

There is no evidence that removing tags causes more tags to grow. Rather, there are some people that may be more prone to developing skin tags and may have new growths periodically. Some patients even require periodic removal of tags at annual or quarterly intervals.

Do skin tags need to be sent for pathology?

Most typical small skin tags may be removed without sending tissue for microscopic examination. However, there are some larger or atypical growths that may be removed and sent to a pathologist for examination under a microscope to make sure that the tissue is really a tag and nothing more. Additionally, skin bumps that have bled or rapidly changed may also need pathologic examination. While extremely rare, there are a few reports of skin cancers found in skin tags.

What else could it be?

While classic skin tags are typically very characteristic in appearance and occur in specific locations such as the underarms, necks, under breasts, eyelids and groin folds, there are tags that may occur in less obvious locations.

Other skin growths that may look similar to a skin tag but are not tags include moles (dermal nevus), nerve and fiber-type moles (neurofibromas), warts, and “barnacles” or “Rice Krispies” (seborrheic keratosis).

Warts tend to be rougher, with a “warty” irregular surface whereas skin tags are usually smooth. Warts tend to be flat whereas tags are more like bumps hanging from thin stalk. While warts are almost entirely caused by human papilloma virus (HPV), tags are only sometimes associated with HPV.

Groin and genital lesions resembling skin tags may actually be genital warts or condyloma. A biopsy would help diagnose which of these growths are not skin tags. Very rarely, a basal cell skin or squamous cancer or melanoma may mimic a skin tag, but this is very uncommon.

Is there another medical name for a skin tag?

Medical terms your physician or dermatologist may use to describe a skin tag include fibroepithelial polyp, acrochordon, cutaneous papilloma, and soft fibroma. All of these terms describe skin tags and are benign (noncancerous), painless skin growths. Some people refer to these as “skin tabs” or warts. However, a skin tag is best known as a skin tag.

Skin Tag At A Glance

• A skin tag is a common but harmless skin growth.
• Skin tags are frequently found on the eyelids, neck, chest, armpits, and groin.
• Treatments include freezing, tying off with a thread or suture, or cutting off.

Acne Treatments

Acne treatment consists of reducing sebum production, removing dead skin cells, and killing bacteria. Treatment methods differ depending on how serious the acne is. Topical drugs are applied directly to the affected areas of the skin. They are available in the form of creams, gels, lotions, or pads. They are used primarily to treat mild forms of acne in which there is little or no inflammation.

One group of topical drugs used for acne includes antibiotics. These drugs kill the bacteria that contribute to the disease. Another group of drugs is called comedolytics (pronounced KO-mee-do-LIE-tiks). These drugs loosen hard plugs and open pores. Still another group of drugs works by increasing the rate at which new skin cells form. These drugs prevent the formation of new comedos.

Topical drugs are applied once or twice a day after washing with mild soap. Treatment may have to continue anywhere from a few weeks to a few months to a few years. Side effects such as mild redness, peeling, irritation, dryness, and an increased sensitivity to sunlight may occur.

Oral Drugs

Oral drugs are taken by mouth. Doctors sometimes prescribe oral antibiotics for moderate cases of acne. These antibiotics prevent the formation of new comedos and reduce inflammation. They are usually taken once a day
for two to four months. Side effects may include allergic reactions, stomach upset, vaginal yeast infections, dizziness, and tooth discoloration.

A drug that is used for severe cases of acne is isotretinoin (pronounced i-so-TRET-uh-no-un, trade name Accutane). This drug reduces the production of sebum and the stickiness of skin cells. It is used when cysts and nodules are present. The drug may be used alone or with other topical or oral antibiotics.
Isotretinoin treatment usually lasts for four or five months. It is effective in about 60 percent of all patients. If the acne reappears, another course of treatments may be necessary. Some side effects that may accompany the use of isotretinoin include nosebleeds, dry skin, a temporary worsening of the acne, vision disorders, and increased production of liver enzymes, blood fats, and cholesterol. It may also cause birth defects and cannot, therefore, be used by pregnant women.

Women who do not respond to any of these treatments may be given another type of oral drug, an anti-androgen. Anti-androgens reduce the production of androgen and therefore reduce the formation of comedos. Certain types of oral contraceptives are also effective as anti-androgens.

The most serious forms of acne require other types of drugs, including oral corticosteroids, or anti-inflammatory drugs. These drugs are often used for the treatment of a form of acne known as acne fulminans, which occurs mostly among adolescent males. They are also used with acne that produces numerous deep, inflamed nodules that heal with scarring.