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).

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

Dysplastic Nevi Prevention Guidelines

Anyone who has an increased risk of developing melanoma must be particularly vigilant. Do any of these risk factors apply to you: light eyes, hair, and/or skin; freckles; many moles; personal or family history of melanoma or nonmelanoma skin cancer; sun sensitivity; inability to tan; repeated and intermittent sunburns; a very large mole present at birth, or dysplastic nevi?

The best advice is “Know your skin.” Each family member should become aware of all moles on his/her total skin surface to minimize the risk of melanoma progressing to life-threatening stages.

Anyone, especially someone with an increased risk of developing melanoma, should:

* Examine the skin completely each month, using a good light source (to illuminate the areas being examined), a full-length mirror and a hand-held mirror. Ask a family member or friend to help in examining hard-to-see parts of the body. A hair dryer is useful when checking the scalp. Also, examine the bottom of the feet and between the toes.
* Seek prompt medical attention if any of the warning signs of melanoma described earlier are found.
* Have a head-to-toe skin examination by a physician annually or more often. If moles are changing, as they may during adolescence, they should be checked at more frequent intervals. Inform your doctor about any moles that have suspicious signs, symptoms, or changes.

SUGGESTIONS FOR PEOPLE WITH DYSPLASTIC NEVI

If your doctor suspects dysplastic nevi, one or more moles may be biopsied — removed in a minor surgical procedure for microscopic examination. It is not necessary to remove all dysplastic nevi. However, if moles show significant change or signs of melanoma, or if new moles appear after age 40, they may be considered for removal by your physician.

When the diagnosis of dysplastic nevus is confirmed microscopically, it is advisable to:

* write down a complete family history of unusual moles, melanomas or other cancers. Discuss it with your doctor.
* have regular complete skin examinations at intervals suggested by your doctor, and advise family members to do the same.
* supplement regular medical checkups with monthly selfexamination of the skin.
* reduce sun exposure. Excessive exposure may stimulate formation of new moles or even cause melanomas.
* check with your doctor about having a set of full-body photographs taken, especially if family members have dysplastic nevi or melanoma and/or you have many moles. Changes can be more easily spotted in this way.
* have any unusual or changing skin growth examined promptly by your doctor.
* check with your physician to see if an eye examination is recommended, since moles and melanomas may also arise in the eyes.
* be concerned, but don’t worry excessively.

With regular self-examination, professional examination, and common sense, you greatly reduce your chances that a melanoma will grow to a threatening size before it can be detected and removed.

PREVENTING SKIN CANCER

While skin cancers are almost always curable when detected and treated early, the surest line of defense is to prevent them in the first place. Here are some sun safety habits that should be part of everyone’s daily health care:

* Seek the shade, especially between 10 A.M. and 4 P.M.
* Do not burn.
* Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses.
* Use a broad-spectrum sunscreen with an SPF of 15 or higher every day.
* Apply 1 ounce (2 tablespoons) of sunscreen to your entire body 30 minutes before going outside. Reapply every two hours.
* Keep newborns out of the sun. Sunscreens should be used on babies over the age of six months.
* Avoid tanning parlors and tanning devices.
* Examine your skin head-to-toe every month.
* See your doctor every year for a professional skin exam.

A PUBLICATION OF THE SKIN CANCER FOUNDATION
For more information or to order this article as a brochure, contact:
The Skin Cancer Foundation
149 Madison Ave., Suite 901,
New York, NY 10016

What is Dysplastic Nevus?

A dysplastic nevus, (or naevus; pl. nevi or naevi) is an atypical melanocytic nevus; a mole whose appearance is different from that of common moles. Dysplastic nevi are generally larger than ordinary moles and have irregular and indistinct borders. Their color frequently is not uniform and ranges from pink to dark brown; they usually are flat, but parts may be raised above the skin surface. Dysplastic nevi can be found anywhere, but are most common on the trunk in men, and on the calves in women. In 1992, the NIH recommended that the term “dysplastic nevus” be avoided in favor of more descriptive language.

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.

The controversy over the malignant potential of dysplastic nevi is highlighted by the publications and opinions of Dr. Clark and Dr. Ackerman. Essentially, Dr. Clark proposed that the melanocytic nevus evolve into a melanoma in stages - benign to dysplastic, then dysplastic to melanoma. Dr. Ackerman refuted this theory, by proposing that you either have a benign nevus, or a melanoma. There is no transition stage; and the melanoma is a melanoma on day one of its development. 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” 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, 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”. 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.

FAQ on Sunscreens and Sunburns

1. “How Much Sunscreen Should I Apply?”

The average user of sunscreen tends to use significantly less sunscreen than the amount required to achieve the SPF listed on the container.

2. “How Often Should I Apply Sunscreen When I’m Out In The Sun?’”

Many experts recommend that frequent application during sun exposure is required. However, a group of children were tested by spreading on 1 application of sunscreen to one side of their bodies, and four applications to the other.

They then spent 6 hours in the sun. One application provided the same level of protection as four applications, confirming the adequacy of a single daily application of a sunscreen in that situation.

3. “How Long Before Sun Exposure Should I Apply Sunscreen To My Skin?”

As molecules of sunscreen are present in their active state in the sunscreen, sunscreens work immediately upon application. The only reason for application early is to allow absorption into the skin so that the sunscreen is less likely to be washed off, should the person be entering the water. Even so, modern sunscreens are quite resistant to removal from the skin.

4. “Sun Protection Factor (SPF) - What Is It?”

SPF is the ratio of the minimal ultraviolet dose required to produce redness with and without a sunscreen. For example, if it took ½ hour for your skin to become sunburned without any sunscreen, then for a sunscreen that has a 15 SPF rating, you could stay in the sun for 15 times longer (or 7.5 hours) before you get sunburned. This is provided, of course, that you’ve applied the sunscreen properly so that you’re getting the prescribed protection.

5. “Reactions To Sunscreens?”

Sunscreens can be both an irritant and an allergen, though allergic reactions are rare. Irritant reactions, however, abound. One classic error in sunscreen application is to put a large amount of sunscreen on the forehead. Perspiration and gravity can cause the sunscreen to migrate down your forehead into your eyes, causing a stinging sensation. Some people attribute this to an allergic reaction and discontinue use. It’s also important to wash your hands after applying sunscreen, since rubbing your sunscreen covered finger near your eyes can induce an irritant reaction.

6. “Why Is It Important To Use Sunscreens During Childhood?”

It appears that a great deal of time can elapse between actual sun damage and the development of skin cancer or other skin problems like photoaging. Therefore, it is important to protect your skin from an early age when you are out in the sun.

7. “Sunscreens And The Elderly?”

Many elderly people can become quite obsessed by sun avoidance, and their quality of life can suffer. Sometimes, if they are diagnosed with an actinic keratosis or basal cell carcinoma, they can become anxious and almost leap from shadow to shadow. However, few of them are likely to develop new skin cancers from present sun exposure. As long as they are prudent about avoiding excessive sun exposure and protecting their skin to prevent sunburn, they can continue to enjoy time outdoors.

8. “Can Sunscreens Prevent Cancer?”

There is clear evidence that sunscreens are helpful in preventing actinic keratoses, which are warty lesions that can occur on sun-exposed skin of the face or hands. Research has shown that these lesions can develop into a cancer called squamous cell carcinoma, and that this is linked to a cumulative exposure to the sun.

However, there is surprisingly little evidence that sunscreens have much effect in preventing another kind of skin cancer called basal cell carcinoma, or for malignant melanoma. For malignant melanoma and for basal cell carcinoma, the character and timing, that is, the type of sunlight and your age at the time of the exposure to the sun appears to be more important than the cumulative dose.

Adapted from an article by David I. McLean, MD, and Richard Gallagher, MA.

Protecting Your Skin From The Sun

Higher altitude means increased levels of harmful UV exposure compared to sea level areas. UV exposure increases 8-10 percent with every 1,000 feet above sea level.  At an altitude of 9-10,000 feet, UV may be 45-50 percent more intense than at sea level. In addition, snow reflects about 80 percent of the UV light from the sun, meaning that you are often hit by the same rays twice. This only contributes to the problem, further increasing the risk for skin cancer.

The combination of higher altitude and ultraviolet (UV) rays reflected by the snow puts skiers and snowboarders at an increased risk of sun damage and ultimately, skin cancer. More than 90 percent of all skin cancers are caused by sun exposure. It’s easy to associate winter with frostbite and windburn, but most people are unaware that UV rays can be even more damaging on the slopes than on the beach,it’s important to take proper precautions while on the slopes.

Both snow and strong wind can wear away sunscreen and reduce its effectiveness, so you have to take extra precautions. To protect your skin from the bitter cold, heavy winds and winter sun, follow these important sun protection tips:
•    Use a broad-spectrum sunscreen with an SPF of 15 or higher whenever you spend time outdoors. Apply 30 minutes before hitting the slopes.Be aware that the sun’s reflection off the snow is strong even on cloudy days.
•    Apply sunscreen liberally and evenly to all exposed skin - most skiers and snowboarders do not use enough sunscreen and therefore do not get the maximum protection.
•    Use a more moisturizing sunscreen. Winter conditions can be particularly harsh on the skin.
•    Be sure to cover often-missed spots: lips, ears, around eyes, neck, underside of chin, scalp and hands.
•    Always wear a lip balm with an SPF 15 or higher. Lips are even more sensitive than most parts of the skin.
•    Reapply at least every two hours, and more often after sweating or exposure to wind and snow.
•    Carry a travel-sized sunscreen and lip balm with you on the slopes. Reapply on the chairlift, especially after a long, snow-blown run.

Cover up.
•    Wear items like ski masks, which will cover most of the skin, leaving very little exposed to the wind and sun.
•    UV-blocking sunglasses or goggles that offer 100% UV protection and have wraparound or large frames protect your eyelids and the sensitive skin around your eyes, common sites for skin cancer and sun-induced aging. The sun’s rays and glare can impair your vision, so it’s important to wear sunglasses or goggles to clearly see the terrain. Plus, it will increase your enjoyment and performance while skiing.
Be mindful of time spent in the sun, regardless of the season.
•    Keep track of the time you spend in full sunlight. If possible, ski early in the morning and later on in the day, before 10AM and after 4PM. This helps avoid long lines and decreases the amount of time spent outdoors in the most intense hours of sunlight.
•    If you are on the slopes for most of the day, take a few breaks indoors to reapply sunscreen.
•    Drink plenty of water to avoid dehydration from the sun.
Enjoy the winter season, but be sure to take care of your skin to avoid the damage the cold season can cause. The first organization in the U.S committed to educating the public and medical professionals about sun safety, The Skin Cancer Foundation is still the only global organization solely devoted to the prevention, detection and treatment of skin cancer. The mission of the Foundation is to decrease the incidence of skin cancer through public and professional education and research.