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Scalp Nevi in Children Rarely Warrant Excision


 

NEW YORK — Scalp nevi in young children almost always are benign and seldom warrant excision, Dr. Jean Bolognia said at the American Academy of Dermatology's Academy 2007 meeting.

Despite the absence of medical necessity, many dermatologists routinely remove these lesions. In part, they are responding to parental pressures but also to a misperception that scalp nevi are somehow harbingers of future problems. "They've never been proven to be bad, yet everyone thinks they are bad," said Dr. Bolognia of the department of dermatology at Yale University, New Haven, Conn.

Several decades ago, researchers at the National Cancer Institute were studying malignant melanoma clusters in families. They found that children who had scalp nevi were predisposed to having large numbers of moles later in life, though there was no evidence that these nevi became melanoma. Nonetheless, the NCI report suggested that scalp nevi be removed, and it has become almost customary in dermatology to do so.

Dr. Bolognia believes it is time to question that practice. She acknowledged that scalp nevi often are seen in "moley" children, and that, in some cases, the nevi have a detrimental effect on the child's appearance and self-image. The nevi may be disturbing to look at, but so are hypertrophic scars, she pointed out. Self-conscious children with many nevi probably will end up having numerous surgeries and that means many scars. This is not necessarily a great trade-off, Dr. Bolognia suggested.

She urged caution in jumping to excision if there's no medical necessity or strong cosmetic consideration. "Once you get on the 'excision train' with a family, it is very difficult to get off. The parents will be bringing the kid in very frequently," Dr. Bolognia said. A child with several nevi on the scalp and 10 or more on his or her body will probably need close dermatologic attention for life, but the lesions should not be construed as red flags for melanoma, she stressed.

Many moley children and adolescents have fairly large "fried egg" lesions on their trunks. These have a deeply pigmented central area, akin to the yolk of a fried egg, surrounded by a broader, lightly pigmented field. Dr. Bolognia said these are the "Paris Hiltons" of nevi: They are sensational and attract a lot of attention, much of it negative. In reality, though, they are harmless. "Unless there's a superimposed change, these lesions are symmetrical and are not precursors of malignant melanoma," she said. Because they are conspicuous, they are easy to follow over time, especially compared with the multiple, tiny black nevi that some patients have.

If these "fried eggs" are left alone, the darker central area will gradually become intradermal nevus tissue, and the lightly pigmented field will gradually fade.

Eclipse nevi (lesions with pale centers and darkened, often stellate rims) also get negative attention, and many dermatologists are inclined to remove them. But again, unless there are worrisome changes, these nevi are completely benign and will usually disappear over time. "You often see these on the scalps of children. They are completely benign, so just follow them closely. There's no need to excise them," Dr. Bolognia said.

Many people with large numbers of moles develop halo nevi, which are completely benign in most cases. The central pigmented spot usually fades and disappears, leaving the hypopigmented halo behind. These can be disconcerting to patients and their families, especially if there are many such halos. Reassure patients that 95% of these halos will repigment, though it may take years. At any rate, unless there are strong indicators of melanoma, halo nevi do not warrant excision.

If excision of a nevus truly is necessary, or if parents are relentless in demanding it, saucerization is Dr. Bolognia's procedure of choice. "It leaves a better scar," she noted. Some might argue that excision of nevi, even if they are benign, essentially is harmless, so long as scarring doesn't become a problem. Insurers, however, may not see it that way.

In a separate presentation at the conference, Dr. Clay J. Cockerell, a dermatopathologist at the University of Texas at Dallas, and a past president of the American Academy of Dermatology, said that he expects third-party payers to start clamping down on unnecessary surgeries in the near future.

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