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June 27, 2012 / molehunter

A mildy dyspastic naevus

The dermatologist’s dilemma-how anxious do I need to be about slightly worrying moles?

At one extreme, we run the risk of falsely reassuring patients with potentially life threatening skin cancers. At the other extreme, we terrify people and cover them with avoidable scars. I heard expert dermoscopist Profesor Peter H. Soyer (Google him) say ‘the first thing that happens when you start using dermoscopy is that you excise fewer benign lesions’. This fits my experience. But you will still excise an irreducible minimum of lesions that turn out to be benign, since the only unequivocal proof (?) is histopathological examination of the lesion afer it has been cut out. And even histopathology has been known to fail. We will always be managing uncertainty. A history of recent change, a personal or family history of skin cancer, and patient anxiety are all factors that might tip the balance to excise rather than measure and observe.

This patient has several naevi which were a bit dark, a bit irregular or both. The most irregular looking was excised.

histology was of a mildly dysplastic naevus. On reflection, the dermoscopy is somewhat irregular but not alarming. We see a fairly average reticular network, an even fade out at the edge, a slightly off central black blotch, and a few areas of hypopigmentation. I think that different doctors might have had diferent opinions about this lesion. It is arguably ‘questionable’, (or indeed questionably arguable!). Anyway, it was proved to be harmless.

We are all on a learning curve and no 2 lesions are alike. It is no sin to remove a certain number of suspected naevi that turn out to be benign, but it does cost money and cause discomfort and scarring. Dermoscopy with training can reduce excisions of benign lesions. Probably we should be doing audit on our respective proportions of benign to malignant excisions. I do not know that the ‘right’ figure should be, but I suspect that if we are removing 10 or more non malignant naevi for every melanoma that is too many, if only 2 or 3 we may be sailing too close to the wind. I suggest this is one for the international dermoscopy society to sort out by research.


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