Nevus, Keratosis, Skin Spots, Warts, Benign Growths and Moles

BENIGN GROWTHS & MOLES

Everyone has skin growths. The dermatologist is the expert on determining which are harmless and which should receive attention.
This article is not a substitute for a medical exam. If you have any serious skin issues or concerns, you need to consult your physician.

Moles

Everyone has moles, from a few to several dozen. Most people think of a mole as being a dark brown spot, but moles have a much wider range of appearance. They can be raised from the skin and very noticeable, or they may contain dark hairs. Having hairs in a mole doesn’t make it more dangerous.

Moles can appear anywhere on the skin, alone or grouped. They usually are brown in color and can be various sizes and shapes.  Special cells that contain the pigment melanin cause the brown color.  Facial moles are probably are determined before a person is born. Many of those that form in childhood and early adult life are now thought to be due to sun damage. Some may not appear until later in life, but moles that appear after age 50 should be regarded with suspicion. Moles may darken, which can happen after exposure to the sun, pregnancy and sometimes during therapy with certain steroid drugs. Moles can be safely removed for cosmetic or medical reasons.

Blood Moles

These are benign growths that consists of small blood vessels. These tumors can be located anywhere on the body. Some of the different types include spider angiomas, cherry angiomas, and angiokeratomas. We do not know the cause of most types of angiomas.

Age Spots

Multiple small brown spots that may appear on wrists, backs of the hands, forearms, and face could be solar lentigos. These are also called “liver spots” or “age spots” and occur later in life. The are flat and evenly colored.

Keratosis

After a person reaches middle age, he or she may acquire other dark areas that are not moles. The brown, wart-like growths that appear on the face or trunk and look as if they have been stuck to the skin may be seborrheic keratoses. Seborrheic keratoses are non-cancerous thickenings of the outer layer of skin. They may be just one growth or clusters. They are usually brown but can vary in color from light tan all the way to black. They’re different sizes as well –anywhere from a fraction of an inch in diameter to larger than a half dollar. A main feature of seborrheic keratoses is their waxy, pasted-on, or stuck-on look. They sometimes look like a dab of warm brown candle wax that has dropped onto the skin. Others have a rough surface.

Actinic Keratoses, also called solar keratoses, are caused by sun damage. They occur on body areas that have been heavily exposed to sunlight or exposed a little bit often for a lot of years. The face, hands, forearms and the V of the neck are the most common areas for actinic keratoses. They may get sore a times. These growths are more common among pale-skinned, fair-haired, light-eyed individuals. They are flatter, redder and rougher than seborrheic keratosis. Actinic keratoses are pre-cancerous, which means they may become skin cancers. The risk has been estimated at 1% per spot, per year,

WARTS
Warts are caused by a viral infection of the cells found in the top layer of the skin. The name of this virus is the human papillomavirus HPV). Warts are skin-colored and feel rough to the touch. Hand warts are usually found around the nails, on the fingers and on the back of the hand. They are more common where skin has been broken and in the areas where fingernails are bitten or hangnails picked. Foot warts are usually on the soles of the feet. These warts are called plantar warts (this has nothing to do with farming-the bottom of the foot is called the plantar side by doctors). Flat warts are much smaller and are less rough than hand or foot warts. They tend to grow in great numbers — 20 to 100 at any one time. They can occur anywhere, but in children they are most common on the face. In adults they are most often found in the beard area in men and on the legs in women. Skin irritation from shaving probably accounts for this.

Watch out for…

Melanoma is a serious form of skin cancer. Melanomas are often, but not always, very dark brown to bluish-black growths. Melanomas may be confused with seborrheic keratoses or moles because both can become very dark. It is wise to have any growth that turns dark or becomes irritated checked by a dermatologist. Early detection of skin cancer is the best way to assure successful treatment.

Information by : Dermatologist, Robert M Rosen, D. O.

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).

Skin Tags and Seborrheic Keratoses

Nuisances You don’t have to put up with. As time goes on, we all acquire tiny bits of extra skin called skin tags. These can range in size from 1-10 mm, and are flesh colored or brown.

Skin tags can be found on any part of the body, but are most common on the eyelids and neck, and in the armpits and groin, and under the breasts.  While skin tags are benign they can be annoying if they become irritating or rub on sporting equipment, and skin tags can interfere with shaving and can detract from one’s appearance and self-image.

Fortunately, we don’t have to put up with skin tags. These little annoyances can be easily removed in an office visit with little or no discomfort. Skin tags can almost always be removed without needing stitches, and the treated areas usually have healed completely in a week or two.

The cost of removing skin tags is quite reasonable - ranging from about $80 for a few tiny ones to about $200 for a larger number scattered over several areas.

Seborrheic keratoses are firm flat or raised, sometimes scaly or crusty flesh-colored, brown or black “barnacles” which accumulate (usually on the face and trunk) as time goes on. Some people start to develop seborrheic keratoses in their thirties, and most people have at least a few by the time they are sixty. To look at pictures of different types of moles, click on www.SkinCancerGuide.ca .

Seborrheic keratoses are usually just a nuisance, but - like skin tags — they can rub on clothing and equipment, and their appearance can sometimes be so distressing that they interfere with choice of clothing, sports like swimming, and intimacy.  Because seborrheic keratoses grow above the skin (but not down into the skin) they can be easily scraped off, and the treated areas heal up nicely within a few weeks. Sometimes the healed area remains pink for a few months after the seborrheic keratosis is removed.

The cost of removing seborrheic keratoses is similar to that for removal of skin tags: about $80 for one or two, with the cost gradually increasing depending on the number and size of seborrheic keratoses to be removed.

The cost of removing skin tags and seborrheic keratoses is a tax-deductible medical expense, just like things like dental bills.  So, if you are annoyed by skin tags or seborrheic keratoses you can be confident that it is simple and inexpensive to rid yourself of these nuisances.

By Kevin C. Smith MD FACP FRCPC

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