Congenital Melanocytic Nevi: Treatment Modalities and Management Options

Erbium: YAG laser treatment efficacy and association with histologic features for giant congenital melanocytic nevi management

BACKGROUND

Limited research exists on laser treatment of giant congenital melanocytic nevus (GCMN).

OBJECTIVE

We sought to elucidate the efficacy of the Erbium: YAG laser on GCMN and the histologic factors associated with a positive clinical response.

METHODS AND MATERIALS

Between 2019 and 2022, we enrolled 30 medium-to-giant CMN patients who underwent Er: YAG laser treatment. All patients received biopsies before and after laser treatments. Clinical efficacy outcomes were evaluated by the investigator's global assessment (IGA), 5-point scale of depigmentation, and Vancouver Scar Scale (VSS) scores at least 6 months after treatment.

RESULTS

Of the 30 cases, 18 (60.0%) showed improvement (IGA score ≥3). Eight (26.7%) patients showed repigmentation. Eight (26.7%) patients developed hypertrophic scars. The average IGA, depigmentation, and VSS scores were 2.93, 3.57, and 3.20. The IGA score was higher (3.24 ± 1.18 vs. 2.22 ± 0.97, p = 0.031) and a lower repigmentation rate (14.3% vs. 55.6%, p = 0.032) was observed in the cases with Grenz zone. The IGA score was higher (3.33 ± 1.24 vs. 2.13 ± 0.89, p = 0.023) and the repigmentation rate was lower (11.1% vs. 50.0%, p = 0.034) also in the cases with the melanocytes nests with aggregation of melanin. Lesions with superficial ablation resulted in less hypertrophic scar formation than those with deep ablation (5.9% vs. 53.8%, p < 0.05).

CONCLUSION

The Er: YAG laser demonstrated effective clinical results for GCMNs. The grenz zone and the melanocytes nests with aggregation of melanin are promising predictors of laser efficacy.

[Therapeutic management of a kissing nevus of the eyelid]

Congenital divided melanocytic nevi of the upper and lower eyelid are rare pigmented changes of the eyelids. These processes are also known as "kissing nevi," "panda nevi," and "split ocular nevi," and were first described by Fuchs in 1919. About 120 cases have been described in the literature so far. Congenital melanocytic nevi are either present at birth (small nevi are already found in about 1% of neonates) or manifest predominantly during the first decade of life. These rare melanocytic changes of the eyelids should be controlled regularly, as malignant transformation can occur. The actual incidence of malignant transformation is highly variable in the literature, ranging from 2 to 40% depending on the duration of follow-up, with an average of 14% for the whole lifetime. Moreover, nevi of the eyelids may be considered cosmetically disturbing and cause functional problems. Therapeutic removal (dermabrasion, cryotherapy, laser therapy, and surgical excision with ophthalmoplastic reconstruction) is rarely medically indicated due to the low risk of malignant transformation. Removal can be performed in cases of secondary amblyopia in ptosis, compression of the lacrimal point, epiphora, or cosmetic desire. Treatment becomes necessary not only in case of suspicious manifestation or impairment of eyelid function, but it also helps to avoid possible bullying at school among children and is recommended at age 4 to 6 (before school age).

The surgical management and outcomes of kissing nevi of the eyelids

PURPOSE

To describe the clinical characteristics, surgical technique, and outcomes in patients with kissing nevi who underwent surgical management in two tertiary referral centers.

METHODS

Medical chart review was conducted for all patients who underwent surgical repair in Moorfields Eye Hospital and The Children's Hospital of Philadelphia. Demographics, medical history, lesion characteristics, surgical intervention, and outcomes were collected. Main outcome measures were surgical interventions as well as functional and cosmetic outcomes.

RESULTS

Thirteen patients were included. Mean age at presentation was 23.46 years (±19.35,4-61), and the mean number of surgeries per patients was 1.9 (±1.3,1-5). Initial procedure included incisional biopsy in three cases (23%) and complete excision and reconstruction in 10 cases (77%). Surgery involved the upper and lower anterior lamella in all cases, the upper posterior lamella in 4 patients (31%), and the lower posterior lamella in 2 patients (15%). Local flaps were utilized in 3 cases and grafts in 5 cases. Complications included: trichiasis (n = 2, 15%), lower eyelid ectropion (n = 2, 15%), mild ptosis (n = 1, 8%), and upper/lower punctal ectropion (n = 1, 8%). Twelve patients (92%) were satisfied with the final functional and cosmetic outcome. No recurrence or malignant transformation were observed in any patient.

CONCLUSION

The surgical management of kissing nevi can be challenging, and commonly includes the use of local flaps or grafts, often requiring multiple interventions. The approach should be based on lesion size and location, proximity and involvement of key anatomical landmarks, as well as individual facial characteristics. Surgical management has a favorable functional and cosmetic outcome in the majority of patients.

Surgical management of facial congenital melanocytic nevi: Experiences and outcomes at an academic center

BACKGROUND

Congenital melanocytic nevi (CMN), benign pigmented birthmarks caused by the mutation of melanocytic cells during embryofetal development, can cause aesthetic problem when it is located on the face. Surgical managements of facial CMN are required by both pediatric patients and their parents. Surgical management, including excision or staged excision, skin grafting, dermabrasion, tissue expansion or multiple re-expansion combined with flaps transplantation, have been reported previously. However, a systematical report about facial CMN management is still scarce.

OBJECTIVE

Herein, we have reviewed our serious of patients with facial CMN, noting their size, location, and histological examination, summarizing the surgical relation behind reconstructive and cosmetic treatment, and proposing a newly classification for facial CMN among pediatric patients, hoping to share a useful surgical algorithm for these lesions on this specific part.

CONCLUSION

Proper surgical strategy should be made based on the size and location of the nevi and the adjacent relationship between the location and relaxed skin tension lines and aesthetic units. Postoperative ant-scar treatment improves aesthetic outcomes. With our experience and surgical algorithm about facial CMN surgery, a favorable outcome can be achieved.

Case report of a challenging medium-sized congenital melanocytic nevus (CMN): Highlighting a role for reflectance confocal microscopy (RCM) for evaluating changing CMN in children

A 3.5-month-old boy presented with a changing medium-sized congenital melanocytic nevus on his leg. Due to atypical features on dermoscopy and reflectance confocal microscopy (RCM), an excision of the area of concern was performed. Histopathology showed many of the pathological features usually associated with a diagnosis of melanoma in situ in older patients, but due to the young age of the patient, absence of mitoses, and the degree of atypia, a diagnosis of a dysplastic compound nevus arising in a congenital compound (predominantly dermal) nevus was favored. In our case, RCM corresponded to histopathology helped target the area of concern and map the clinical and subclinical components to facilitate an optimal biopsy.

Histological and Immunohistochemical Changes of Congenital Melanocytic Nevi With Age

ABSTRACT

Clinical but not histological changes of congenital melanocytic nevi (CMN) with age are well characterized. Our objective was to analyze histological changes of CMN with age and discuss possible clinical implications of our findings. We investigated serial excisions of 21 patients with CMN and compared histological and immunohistochemical features over time. The median number of serial excisions was 6 [interquartile range (IQR) 5-7], the median age at the first excision was 12 months (IQR 5-98), and the median time between the first and last analyzed excision was 53 months (IQR 45-64). The projected adult size of the excised CMN was "large" or "giant" in 14 of the 21 CMN (67%) and "medium" in the remaining lesions (33%). Nineteen CMN (90%) involved the subcutaneous fat, and 16 of the 21 CMN (76%) reached the lower surgical margin. The histological pattern and depth did not change over time but the cellularity and HMB-45 expression of dermal melanocytes decreased in 16 of the 21 patients (76%) and in 15 of the 21 patients (71%), respectively (both P < 0.001). Patients with decreasing HMB-45 expression were significantly younger at the first excision (median 6 months, IQR 4-28) than patients with unchanged HMB-45 expression (median 176 months, IQR 12-186; P = 0.018). The expression of Ki-67 and p16 did not change significantly with age. Our study demonstrates that (1) the cellularity and pigment production of CMN decreases with age, (2) the histological pattern and extension in depth remain stable, and (3) clear resection margins can rarely be achieved in larger CMN.

An update on congenital melanocytic nevus syndrome: A case report and literature review

Congenital melanocytic nevus syndrome (CMNS) is a rare condition characterized by pigmented skin lesions that are usually present at birth and are associated with an increased risk of neurological abnormalities and malignant melanoma. It mostly results from a post-zygotic NRAS mutation of neural-derived crest cells, leading to uncontrolled cell growth. Because of the increased knowledge of the genetics underlying CMNS, targeted therapy becomes a promising treatment option. We present a case of CMNS in a newborn. Physical examination at birth showed a giant congenital melanocytic nevus, extending from the occipital to the lower lumbar region. A magnetic resonance imaging scan revealed multiple cerebral and cerebellar parenchymal lesions. Genetic analysis of the cutaneous lesions showed the presence of an NRAS Q61R mutation. The patient was treated with dermabrasion to reduce the color intensity of the nevus. However, this was complicated by recurrent wound infections and laborious wound healing. At the age of 1 year, the patient had an age-appropriate psychomotor development, without neurological deficits.

Treatment of maxillofacial congenital melanocytic nevus with percutaneous radiofrequency thermal ablation: A case series study

When congenital melanocytic nevus (CMN) is in the maxillofacial region, a safer, more effective and fewer side-effects treatment is needed for patients with high requirement for appearance. The objective of this study was to investigate the effectiveness of radiofrequency thermal ablation (RFA) for CMN in the maxillofacial region. We reviewed 21 patients treated with RFA for CMN followed by a blinded retrospective analysis of serial photographs taken during the course of their therapy. Questionnaires were used to evaluate perceived therapeutic response and complications of this treatment. Most CMNs stopped growing, faded in color and became smaller. Reduction in size of 90% to 100% was obtained in two patients (10%), 75% to 90% in six patients (29%), 50% to 75% in two patients (10%), <50% in eight patients (38%), and three had no reduction (13%). Clear effect of clinical response score was obtained in two patients (10%), excellent in four patients (19%), good in 14 patients (67%), and fair in one patient (4%). No serious complication, severe hypertrophic scarring, and evidence of recurrence was observed in any case. Percutaneous RFA, as a minimally invasive and safe treatment, may provide an alternative treatment for maxillofacial CMN.

Congenital melanocytic naevi: An up-to-date overview

Congenital melanocytic naevi are hamartomas of the neuroectoderm caused by genetic mosaicism. Congenital melanocytic naevi are seen in 1-6% of all live births and commonly classified based on the projected size in adults. Congenital melanocytic naevi appear in different colours, shapes, and sizes, and occasionally present with complications. In this review, we sought to evaluate congenital melanocytic naevi, their clinical, dermatoscopic, and reflectance confocal microscopic features, behavioural pattern over time, new trends in classification, underlying genetic factors and their influence on clinical manifestations and management, associated risks, complications, magnetic resonance imaging findings and their management in the light of recent literature.

Spastic quadriplegia following intradermal use of hydrogen peroxide in the tardive curettage procedure for the treatment of a giant congenital nevus

The possible transformation of a giant congenital melanocytic nevi (GCMN) in malignant melanoma estimated from 0.05% to 40% depend on the size of the lesions. Many are the surgical procedures proposed, including: full or partial-thickness excisions, dermabrasion, curettage in the first weeks of life and laser treatment. The curettage technique has been proposed in the literature for the treatment of GCMN in the first few weeks of life and defined as a relatively atraumatic surgery procedure without general complications. The authors report the first case in the literature of embolization due to use of subcutaneous peroxide infiltration before a tardive curettage procedure in a newborn case of GCMN resulting in spastic quadriplegia with dystonic reaction. Consequently, a lawsuit, due to this medical malpractice, has been opened.

Clinical Analysis of Cultured Epidermal Autograft (JACE) Transplantation for Giant Congenital Melanocytic Nevus

Background:

Cultured epidermal transplantation (JACE) is performed for giant congenital melanocytic nevus (GCMN), but there are few reports on its postoperative course and surgical content or indications. We aimed to investigate the postoperative course of GCMN patients undergoing cultured epidermal autograft transplantation and compare the outcomes between 2 nevus tissue resection methods.

Methods:

Twelve GCMN patients aged 0 months to 8 years and 9 months were included in this single-center case series study. Cultured epidermal autograft transplantation was performed at 19 sites of the patients’ extremities and trunks, after excision of the nevus either by using an electric dermatome, which we initially used in 2017, or by curettage with a sharp spoon and use of a hydrosurgery system (Versajet), which we started performing in 2018. Univariate and multivariate analyses were performed for factors associated with postoperative hypertrophic scar formation.

Results:

In all cases, >90% of the grafts survived, and the dark brown color of the nevus was reduced. Average postoperative observation period was 16.5 months. Hypertrophic scar formation was observed postoperatively at 9 wound sites out of the 12 sites with GCMN removed with a dermatome and at only 1 site with GCMN removed by curettage with use of a hydrosurgery system. In the univariate and multivariate analyses, hypertrophic scar formation was associated with age at surgery.

Conclusion:

In cultured epidermal autograft transplantation for GCMN, nevus tissue removal at an early age by curettage with use of a hydrosurgery system can provide good results while reducing complications, including recurrence and hypertrophic scar formation.

Giant congenital melanocytic nevus of the scalp: from clinical-histological to molecular diagnosis

Congenital melanocytic nevus (CMN) is a benign proliferative skin disease in the epidermis and dermis. Large to giant CMNs are estimated to be associated with an increased lifetime risk of malignancy. It is necessary to estimate and monitor the risk of malignant transformation for giant CMNs. To date, the clinical “ABCD” criteria and immunohistochemistry studies can be confusing and, to some extent, subjective. Accordingly, the elucidation of genomic analyses of nevi is required to better understand the malignant transformation of CMNs. Here, we describe two large to giant CMNs of the scalp with opposite clinical-histological and molecular evaluations of potential malignancy risk. To our knowledge, this is the first description of a genetic study of large to giant CMNs of the scalp in East Asia. We recommend reviewing the molecular diagnosis together with careful medical history and histological information to facilitate the evaluation of the potential malignancy risk.

Acquisition of Somatic NRAS Mutations in Central Nervous System Melanocytes: A Predisposing Risk Factor to Primary Melanoma of the Central Nervous System, a Frequently Forgotten Pitfall in Congenital Nevi

Congenital melanocytic nevi (CMN) are benign melanocytic proliferations that are usually present at birth. A somatic mosaicism for an NRAS point mutation is responsible for the several phenotypic abnormalities that may be associated with congenital nevi. We report the case of a 7-year-old boy with a proliferative nodule (PN) arising in a Giant CMN completely excised and with several visceral and intraspinal melanoma metastases with no evidence of primary cutaneous melanoma. The careful analysis of the clinical, morphologic, and molecular features allowed the distinction of between the benign PN (BPN) and the melanoma. The BPN showed a characteristic comparative genomic hybridization pattern with gains or losses of whole chromosomes, whereas the melanoma displayed gains or losses involving complex partial chromosomal copy number gains or losses. Leptomeningeal melanocytes are more susceptible to transformation by oncogenic NRAS than cutaneous melanocytes, and central nervous system melanomas are more common than cutaneous melanomas in the setting of CMN. Thus, it has been recommended to characterize the congenital disease in patients with 2 CMN at birth, independently of size and site, with a single magnetic resonance imaging screening younger than the age of 1 year.

Lentigo maligna melanoma with a history of cosmetic treatment: Prevalence, surgical outcomes and considerations

INTRODUCTION

Lentigo maligna (LM) is melanoma in situ on sun-damaged skin and presents diagnostic challenges due to overlapping features with benign pigmented lesions. Cosmetic treatments may be inadvertently performed on LM. The aim of this study is to estimate the prevalence of LM with prior cosmetic treatment, and evaluate surgical outcomes.

STUDY DESIGN AND METHODS

Retrospective review of biopsy-proven LM presenting over a 10-year-period (2006-2015). Prior cosmetic treatment and biopsies were recorded. Records were reviewed for demographic data, clinical characteristics, and surgical outcomes.

RESULTS

37/503 (7.4%) patients with LM reported prior cosmetic therapy. Most (95%) were on the head and neck; mean size 1.9 cm. Most patients reported cryotherapy (73%), followed by laser (29.7%), topical bleaching agents (18.9%), and electrodessication, and/or curettage (5.3%). Ten patients (27%) received two or more modalities. Eight patients (21.6%) reported prior benign biopsies. Six patients (16%) had invasive disease, two on initial biopsy and 4/34 (11.7%) upstaged upon excision. Average margin for clearance was 9.1 mm.

CONCLUSION

Prior cosmetic treatment of LM is not uncommon, and may delay diagnosis and obscure borders, resulting in wider surgical margins. Clinicians should consider a biopsy confirming the benign nature of equivocal lesions prior to cosmetic treatment. Lasers Surg. Med. 49:819-826, 2017. © 2017 Wiley Periodicals, Inc.

A prospective study of patients with large congenital melanocytic nevi and the risk of melanoma

BACKGROUND:

Large congenital melanocytic nevus (LCMN) is considered a risk factor for melanoma, although the magnitude of this risk is controversial.

OBJECTIVE:

To evaluate the risk of melanoma development in patients with LCMN seen at a dermatology referral center in Brazil during a twelve-year period. To the best of our knowledge, there are no published similar studies on large congenital melanocytic nevus in South America.

METHODS:

Our prospective cohort included only patients with congenital nevi ≥20cm. The cumulative risk of developing melanoma and the standardized morbidity ratio were calculated for patients followed up prospectively for at least 1 month.

RESULTS:

Sixty-three patients were enrolled in this study. One patient who developed melanoma prior to enrollment was excluded, and five were eliminated because of insufficient follow-up time. Mean follow-up for the remaining 57 patients was 5.5 years (median 5.2 years). Median age of entry into the study was 2.6 years. Most patients (75.4%) underwent only clinical observation. Melanomas occurred in 2 (3.5%) patients. Five-year cumulative risk for melanoma was 4.8% (95% CI: 1.9-11.5%). Standardized morbidity ratio was 1584 (95% CI: 266-5232, p<0.001).

STUDY LIMITATIONS:

The small sample size reduces the accuracy of risk estimates.

CONCLUSIONS:

This study analyzed prospectively for the first time data from South America demonstrating that patients with LCMN have a higher risk of developing melanoma than the general population (p<0.001).

Brazilian guidelines for diagnosis, treatment and follow-up of primary cutaneous melanoma - Part II

The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In this second part, the following clinical questions were answered: 1) which patients with primary cutaneous melanoma benefit from sentinel lymph node biopsy? 2) Follow-up with body mapping is indicated for which patients? 3) Is preventive excision of acral nevi beneficious to patients? 4) Is preventive excision of giant congenital nevi beneficious to patients? 5) How should stages 0 and I primary cutaneous melanoma patients be followed?

Laser treatment of periocular skin conditions

Advances in laser technology in recent decades have increased the options for the treatment of dermatologic conditions of the eye and eyelid. Benign tumors can be laser-ablated with relative ease, and vascular and melanocytic lesions can be precisely targeted with modern lasers. In this contribution, we review treatment of periocular pigmented lesions, including melanocytic nevi and nevus of Ota; vascular lesions including telangiectasias, port wine stains, and infantile hemangiomas; hair removal; eyeliner tattoo removal; laser ablation of common benign periocular tumors, such as syringomas, xanthelasma, milia, and seborrheic keratoses; and laser resurfacing. The recent advent of fractionated laser technology has resulted in dramatically decreased healing times for periocular skin resurfacing and fewer adverse effects. Fractionated laser resurfacing has now nearly supplanted traditional full-field laser resurfacing, and safe treatment of rhytides on the thin skin of the eyelids is possible. Proper eye protection is, of course, essential when using lasers near the eye. Patient preparation, safety precautions, and risks--intraocular and extraocular--are discussed herein. As laser technology continues to advance, we are sure to see improvements in current treatments, as well as development of new applications of cutaneous lasers.

Giant congenital melanocytic nevi: selected aspects of diagnostics and treatment

Background

Treatment of giant melanocytic nevi (GMN) remains a multidisciplinary challenge. We present analysis of diagnostics, treatment, and follow-up in children with GMN to establish obligatory procedures in these patients.

Material/Methods

In 24 children with GMN, we analyzed: localization, main nevus diameter, satellite nevi, brain MRI, catecholamines concentrations in 24-h urine collection, surgery stages number, and histological examinations. The t test was used to compare catecholamines concentrations in patient subgroups.

Results

Nine children had “bathing trunk” nevus, 7 had main nevus on the back, 6 on head/neck, and 2 on neck/shoulder and neck/thorax. Brain MRI revealed neurocutaneous melanosis (NCM) in 7/24 children (29.2%), symptomatic in 1. Among urine catecholamines levels from 20 patients (33 samples), dopamine concentration was elevated in 28/33, noradrenaline in 15, adrenaline in 11, and vanillylmandelic acid in 4. In 6 NCM children, all catecholamines concentrations were higher than in patients without NCM (statistically insignificant). In all patients, histological examination of excised nevi revealed compound nevus, with neurofibromatic component in 15 and melanoma in 2. They remain without recurrence/metastases at 8- and 3-year-follow-up. There were 4/7 NCM patients with more than 1 follow-up MRI; in 1 a new melanin deposit was found and in 3 there was no progression.

Conclusions

Early excision with histological examination speeds the diagnosis of melanoma. Brain MRI is necessary to confirm/rule-out NCM. High urine dopamine concentration in GMN children, especially with NCM, is an unpublished finding that can indicate patients with more serious neurological disease. Treatment of GMN children should be tailored individually for each case with respect to all medical/psychological aspects.

Lasers for nevi: a review

A nevus is described as a benign, often pigmented, skin growth that can be congenital or acquired. Different types of nevi are located at different depths within the skin. Traditional treatments for nevi include topical treatments, dermabrasion, and excision, which are generally ineffective, invasive, and often result in scars and dyspigmentation. Lately, laser therapy has been used as an alternative. Based on the theory of selective photothermolysis, melanin can be specifically targeted, minimizing adverse effects and increasing effectiveness of laser treatments. Several types of lasers and lights have been studied for this purpose without a concise agreement as to which is the best. In general, quality-switched lasers are preferred for the treatment of pigmented lesions. However, there is controversy about this therapy because certain nevi may have malignant potential. This article serves as a comprehensive review of available laser treatments for nevi and discusses the appropriate measures that should be taken before and after laser therapy. Based on the reviewed literature, laser treatment has generally been proven to be a safe and effective therapy for nevi with minimal side effects.

Giant congenital melanocytic nevus

Giant congenital melanocytic nevus is usually defined as a melanocytic lesion present at birth that will reach a diameter ≥ 20 cm in adulthood. Its incidence is estimated in <1:20,000 newborns. Despite its rarity, this lesion is important because it may associate with severe complications such as malignant melanoma, affect the central nervous system (neurocutaneous melanosis), and have major psychosocial impact on the patient and his family due to its unsightly appearance. Giant congenital melanocytic nevus generally presents as a brown lesion, with flat or mammilated surface, well-demarcated borders and hypertrichosis. Congenital melanocytic nevus is primarily a clinical diagnosis. However, congenital nevi are histologically distinguished from acquired nevi mainly by their larger size, the spread of the nevus cells to the deep layers of the skin and by their more varied architecture and morphology. Although giant congenital melanocytic nevus is recognized as a risk factor for the development of melanoma, the precise magnitude of this risk is still controversial. The estimated lifetime risk of developing melanoma varies from 5 to 10%. On account of these uncertainties and the size of the lesions, the management of giant congenital melanocytic nevus needs individualization. Treatment may include surgical and non-surgical procedures, psychological intervention and/or clinical follow-up, with special attention to changes in color, texture or on the surface of the lesion. The only absolute indication for surgery in giant congenital melanocytic nevus is the development of a malignant neoplasm on the lesion.

Changes of PI3K/AKT/BCL2 signaling proteins in congenital Giant Nevi: melanocytes contribute to their increased survival and integrity

Congenital Giant Nevi (CGN) are rare melanocytic lesions with the potential to regress into malignant melanoma. Simultaneous up-regulation and cooperative interactions of signaling pathways are crucial events in the pathogenesis of melanocytes. Our study aimed to identify changes in the expression and activation of proteins controlling survival and/or apoptosis of the key signaling pathways PI3K/AKT/BCL2 and Wnt/β-catenin of CGN melanocytes. We applied a model of cultured melanocytes from paired CGN and normal appearing skin, and Western blot (WB) analyzed the expression and activation profile of survival and anti-apoptotic proteins of these signaling pathways, growth pattern, cell cycle and apoptosis. WB analysis demonstrated a significant higher expression level of activated AKT and of BCL2 proteins in the CGN melanocytes compared with paired melanocytes from normal appearing skin. A relative increase in the level of GSK3 and FOXO1 proteins, down stream targets of AKT, as well as of pβ-catenin was also detected in the CGN melanocytes compared with the controls. These changes were not affected by growth of the CGN melanocytes in reduced serum (starvation). Both cell populations shared a similar growth pattern, with no significant differences in the proportion of apoptotic cells and in cell cycle fractions. These data demonstrate for the first time, changes in signaling proteins of cultured CGN melanocytes. Further, suggesting that the changes in AKT/BCL2 signaling molecules might mediate growth and anti-apoptosis processes at least in part, thus increasing the survival potential of CGN melanocytes and maintaining their integrity.

Management of small and intermediate congenital nevi: a nationwide survey in Italy

OBJECTIVE

Small- and intermediate-sized congenital nevi (SCN and ICN) undergo periodic clinical monitoring or surgical excision. We analyzed the management of SCN and ICN in the Italian hospital network.

METHODS

A nationwide survey of a representative sample of centers was conducted. Data were analyzed grouping centers by melanoma incidence into high-volume (>25 diagnoses per year) and low-volume (≤ 25 diagnoses per year).

RESULTS

In the pediatric population, 11% of SCN and 22% of ICN are excised, the remainder undergoing clinical monitoring at intervals of 6 months to 2 years (SCN) and of 6 months to 1 year (ICN). In adults, 24% of SCN and 41% of ICN are excised. Clinical monitoring of SCN varies from 6-monthly (most common among low-volume hospitals) to every 2 years; preferred strategies for ICN are follow-up at 1 year (51%) or follow-up at 6 months (42%). For prophylactic surgery, complete excision is preferred.

CONCLUSIONS

The Italian hospital network values management and treatment of SCN and ICN. In most cases natural evolution prompts prophylactic excision. Clinical examination is an important monitoring tool, though follow-up frequency depends on the clinician's experience and practice.

Divided nevus of the eyelid: review of embryology, pathology and treatment

Divided nevus, which is also known as "kissing nevus," "split ocular nevus" and "panda nevus" is a rare congenital dermatological abnormality that occurs on opposing margins of upper and lower eyelids. There is a paucity of literature on this rare anomaly, with most knowledge from this disease process derived from isolated case reports and series. The purpose of this study is to report a new case of divided nevus of the eyelid and to discuss the unique embryology, pathology, and potential treatment options for this rare entity. A systematic review of literature was performed of the English literature on PubMed and Medline with just under 150 cases reported in the literature. The vast majority of the divided nevi seen in this review were medium sized and of the melanocytic intradermal type. There were no described cases of malignant transformation in any of the documented cases. Numerous methods for reconstruction were described including the entire reconstructive ladder with both one and two staged approaches. In this review, we present basic guidelines to the reconstruction of these complicated defects, although ultimate treatment should be individualized and dependent on surgeon comfort.

Divided nevus of the eyelid: successful treatment with CO2 laser

BACKGROUND

Divided nevus of eyelid is a rare form of congenital nevus. It can cause cosmetic and psychological problems. The aim of the treatment is to reliably remove the lesion with minimal functional impairment, to improve the cosmetics, and to prevent canceration.

METHODS

The paired nevi were treated with CO2 laser by local anesthesia. Ablation was stopped after all the visible pigment tissues were removed and normal tissues became visible, shaping the basilar part to get good cosmetic results, avoiding thermally damaging the lower dermis as far as possible to minimize the side effect.

RESULTS

It showed good cosmetic results 5 months after the last operation without any functional impairment except for a little repigment on the upper lid, superficial scar on the lower lid, and hypopigmentation on both of the wounds.

CONCLUSIONS

With the advantages of simplicity, precision, and effectiveness, CO2 laser can be recommended to treat small divided nevus with special type and clinical characteristics. It can help to simplify the treatment, get good cosmetic results, and avoid skin graft.

Congenital melanocytic nevi

The relative risk for melanoma arising within a congenital nevus is related to the size of the lesion. The timing of and clinical presentation of development of melanoma is also related to the size of the lesion. Medical decisions are individualized taking into account the perceived risk of malignancy, psychosocial impact, and anticipated treatment outcome. In this article, the common features of congenital nevi are discussed as well as the potential individual variations and their impact on treatment recommendations.

Congenital melanocytic nevi-when to worry and how to treat: Facts and controversies

Congenital melanocytic nevi (CMN) are evident in 1% to 6% of neonates. In some studies, nevi with clinical, dermatoscopic, and histologic features identical to CMN have had a prevalence of more than 15% in older children and adults, possibly reflecting the "tardive" appearance of nevi programmed from birth. There is ongoing debate about the magnitude of the risk of melanoma and other complications associated with CMN of various sizes and the best approach to management of these lesions. We review the natural history of CMN, including proliferative nodules and erosions during infancy, neurotization, and spontaneous regression, and features of variants such as speckled lentiginous and congenital blue nevi. The risk of melanoma arising within small-sized (<1.5 cm) and medium-sized CMN is low (likely <1% over a lifetime) and virtually nonexistent before puberty. Recent data suggest that melanoma (cutaneous or extracutaneous) develops in approximately 5% of patients with a large (>20 cm) CMN, with about half of this risk in the first few years of life. Melanoma and neurocutaneous melanocytosis (NCM) are most likely in patients with CMN that have a final size of >40 cm in diameter, numerous satellite nevi, and a truncal location. One-third of individuals with NCM have multiple medium-sized (but no large) CMN. In patients at risk for NCM, a screening gadolinium-enhanced magnetic resonance imaging, preferably before age 6 months, and longitudinal neurologic assessment are recommended. Management of CMN depends on such factors as the ease of monitoring (more difficult for large, dark, thick nevi) and cosmetic and psychologic benefits of excision or other procedures. CMN require lifelong follow-up. Periodic total body skin examinations are necessary for all patients with large CMN, even when complete resection (often impossible) has been attempted.

Congenital melanocytic nevi of the eyelids and periorbital region

BACKGROUND

Congenital melanocytic nevi of the eyelids and periorbital region are unusual. Although their malignant potential can be debated, they present a significant aesthetic concern and also disturb lid function. In this article, the authors present an expanded approach to evaluation and treatment of these patients.

METHODS

Forty-four consecutive patients, aged 6 months to 18 years, were treated from 1980 to 2008. All patients had congenital nevi involving one or both eyelids, with or without extension into the surrounding periorbital area and face. Follow-up ranged from 6 months to 20 years.

RESULTS

All patients were treated successfully with excision and reconstruction of their congenital eyelid and/or periorbital nevi. The involved ciliary border was preserved in all but one case, where the exophytic lesion presented function concerns. Complications included asymptomatic lateral ectropion in three patients. Asymmetry of the palpebral apertures, before treatment, was present in at least half of the patients with extensive facial nevi, and the abnormalities causing these differences may impact efforts to obtain final lid symmetry. A single patient died as a result of extensive metastatic melanoma from an extracutaneous site.

CONCLUSIONS

Early evaluation and treatment of these nevi may help in preventing the aesthetic, functional, and health-related issues for the patients. Although the current group of infants and young children will not reach full facial growth for more than another decade and a half, and therefore await critical assessment of their long-term outcomes, the authors hope that the experience gained to date will assist surgeons in managing these complex reconstructions.

[Giant congenital naevus : Indications and techniques for surgical treatment]

According to current knowledge the term giant congenital naevus is generally applied to skin alterations which consist of naevus cells, that are already conspicuous at birth and reach a diameter of at least 20 cm or more in adulthood. Surgical removal of such alterations is fundamentally indicated because there is high potential for degeneration. The surgical challenge is the functional and aesthetic reconstruction after removal. This article presents the incidence, natural course and pathology of such giant congenital naevus alterations. The advantages and disadvantages of various reconstruction procedures are presented together with an algorithm for management of these potentially malignant alterations.

Congenital pigmented nevi of the auricle: clinical experience and approach to treatment

BACKGROUND

Congenital pigmented nevi of the auricle are uncommon. The authors' approach is to excise these nevi and perform reconstruction because of the risk of malignant transformation and the aesthetic and psychological effects these nevi can have on the child. This study presents the authors' experience in treating congenital nevi of the ear and suggests treatment principles and guidelines for the reconstructive surgeon.

METHODS

Fourteen patients with congenital nevus of the ear were treated from October of 1992 to September of 2008 by the senior surgeon (B.S.B.). Nevi involving the more stable areas such as the concha can be resected and grafted early; the antihelix, scapha, and triangular fossa area can be resected and grafted next; and the helical rim, having the most easily distorted cartilage, should be treated last. Lobule reconstruction requires combined flaps and a dermal fat graft or a postauricular fascial fat flap.

RESULTS

Successful reconstruction was achieved in 10 patients. Three patients require final revision procedures (lobule reconstruction). One patient, early in our series, developed a deformed helical rim resulting from skin grafting at age 16 months, before the cartilage was firm enough to withstand the contraction forces of the skin graft. All subsequent patients with helical rim involvement had treatment delayed until the ear was at or near completion of its growth.

CONCLUSIONS

Congenital nevi of the ear present a challenging reconstruction surgeon. The authors developed a treatment plan that breaks the ear down to aesthetic units and considers the location of the nevus, patient age, and the firmness of the cartilage.

[What's new in pediatric dermatology?]

The main selected articles in pediatric dermatology covered the following topics: development and maturation of the epidermal barrier in the neonate, iatrogenic events in the neonatal ICU, diagnostic value of minor birthmarks, complications, risk factors and treatment of hemangiomas, coagulopathy in venous malformations, epidemiology and dermoscopy of congenital and acquired melanocytic nevi in childhood, growth of the body surface area, new pathogenic concepts and treatment in atopic dermatitis, the impact of filaggrin deficiency, hereditary factors in Kawasaki disease, severe and drug resistant cases, management of juvenile dermatomyositis, treatment of childhood psoriasis with biologics, the new classification of epidermolysis bullosa and therapeutic approach with cell therapy, neurological impairment in xeroderma pigmentosum, behavioural anomalies in X-linked ichthyosis, guidelines for neurofibromatosis type I, the genetics of an hereditary hypotrichosis, infantile acne, rosacea in childhood, mast cell disease management and, last but not least, treatment of hair lice with silicone.