Different dermatopathologists report dysplastic nevi with different descriptors. Some simply write “dysplasia,” whereas others add “mild,” “moderate” or “severe” to the description.
Follow-up recommendations for the different levels of dysplasias vary depending on which expert you ask. What are the standards?— Kathleen Haycraft, DNP, FNP/PNP-BC, DCNP, Hannibal, Mo.
The first thing to know is that your biopsy report is only as good as the pathologist who is reading it. Skin biopsies are particularly difficult to read and require expert analysis, so I am happy to hear that you are sending pigmented biopsies to a dermatopathologist instead of a general pathologist.
Dysplastic (or atypical) moles have clinical and histologic appearances that are different from typical common nevi. Simply writing “dysplastic” or “atypical” without including a recommendation to excise completely or a level of atypia (i.e., mild, moderate, or severe) is unacceptable.
The NIH consensus statement on the diagnosis and early treatment of melanomas clearly states that pathology reports for atypical nevi should include information about the degree of melanocyte atypia.
A severely dysplastic nevus should be excised with a 2-mm margin of healthy skin because of frequent overlap with melanoma in situ. A lesion that is mildly atypical with no clinically apparent residual nevus does not need re-excision. Monitor the area for a year and instruct the patient to return if there is any repigmentation or change in appearance. If the lesion was moderately dysplastic and not completely excised, a conservative re-excision should be discussed with the patient. The decision to re-excise should be made based on the original index of concern, size, location, and the patient’s history of sun exposure, personal and family history of skin cancer, and ability and interest in conservative re-excision vs. clinical follow-up.
All patients with one atypical mole should have a full skin examination and be counseled on skin self-examinations. These patients should also avoid tanning beds, excessive sunlight exposure, and use sunscreen or sun-protective clothing. The use of serial photography to monitor the skin will also be helpful in the long term-care of patients with dysplastic nevi.— Abby A. Jacobson, MS, PA-C, Delaware Valley Dermatology Group, Wilmington, Del. (181-5)
These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a question, submit it here.