The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.
Basic Rules
- The most important indication for excision of a naevus is suspicion of malignancy. Other indications include aesthetic considerations or the location of the naevus in an area exposed to friction. If naevi are excised for cosmetic reasons, always estimate the eventual consequences of a scar and the tendency of the patient to develop keloids.
- A general practitioner can excise any naevus using local anaesthesia. Very large lesions and strong suspicion of melanoma should be referred to a specialist.
Naevi, Melanoma
- The incidence of melanoma is increasing. Suspect a melanoma if a naevus starts to grow, change its colour, develop satellites, bleed, or discharge. A melanoma cannot be ruled out on clinical grounds (see picture 1*), and it may develop on previously intact skin.
- "Ordinary-looking" naevus
- The need for excision depends on the history given by the patient concerning changes, and aesthetic considerations or annoying location. Requests for the removal of solitary naevi should generally be granted even if the doctor considers the lesion benign.
- The naevus is removed totally, but the margin of intact skin can be small.
- Benign lesions that may concern the patient include long-haired intradermal naevus, dermatofibroma (see pictures 2 and 3*), fibroma molle (see picture 4*), and cherry angioma (see picture 5*).
- The general practitioner often sees patients who require the removal of a large number of naevi, either one at a time or at the same consultation. Usually a reassuring conversation and the removal of a few large naevi calm the patient, unless the patient suffers from conversion, in which case the same problems occur again later.
- "Slightly suspect" naevus
- For example, a naevus that looks benign but that has grown or changed colour (darker) or has bled or discharged according to the patient (Whited & Grichnik, 1998; DARE-988293, 1999) [C]
- Such a naevus should always be removed, and the excisional margin is determined by the appearance and location of the naevus.
- Granuloma pyogenicum is a benign growth that usually develops at the site of disrupted skin (see picture 6*).
- The following lesions may be difficult to differentiate from melanoma:
- "Blue naevus" (see picture 7*)
- Lentigo (see picture 8*)
- Naevus spilus (see picture 9*)
- Spitz naevus (see picture 10*)
- Strong suspicion of a melanoma
- See pictures 11, 12, 13*
- Refer the patient to a plastic surgeon, a surgeon, or a specialist in otorhinolaryngology or ophthalmology if a naevus has
- Markedly grown and changed its colour (see picture 14*)
- Become exceptionally large (see picture 13*)
- Developed satellites
- Appeared on the site of a melanoma that has been excised before
- Make sure that the patient has reserved an appointment and that the naevus was removed.
Treatment and Follow-up of a Melanoma
- In cases of melanoma, the patient should be referred for further surgical treatment, and the referring physician should make sure that the patient is treated without delay.
- A larger excision of the skin and subcutaneous tissue is performed around the tumour. The extent of the excision is determined by the location, thickness (Breslow classification), and depth of infiltration (Clark classification) of the tumour.
- Very superficial melanomas (Clark I-II, Breslow <1 mm) should be excised with a 1-cm margin of intact tissue (see picture 15*). Deeper melanomas should be removed with a 2- to 5-cm margin. The site of excision is reconstructed with a pedicle flap or free graft. Prophylactic evacuation of lymph nodes is performed in some cases of melanoma.
Follow-up of a Melanoma
- Patients with a melanoma are followed-up every 3 months until 2 years have passed from the diagnosis. Thereafter, follow-up is continued every 6 months for 5 years. The unit responsible for follow-up (hospital or primary care) can be decided on locally. It is important that the same doctor always sees the patient.
- If the patient has numerous naevi or the syndrome of hereditary dysplastic naevi, follow-up of a melanoma should take place in a dermatological unit. High-quality photographs facilitate follow-up. These patients should be followed-up throughout their life.
- At follow-up visits the general condition and symptoms are investigated, and the site of excision and local lymph nodes are palpated. Satellites of melanoma are usually felt as subcutaneous nodules, and they are visible under the skin as dark spots.
- A melanoma first metastasizes into regional lymph nodes, which should be followed-up carefully by palpation. If the clinical examination suggests the spread of a melanoma, a chest x-ray, blood count, liver function tests, and liver ultrasonography should be performed.
- If a melanoma has infiltrated the regional lymph nodes, they are removed surgically. A metastasized melanoma is treated by an oncologist. Cytostatics and interferon have been moderately effective in the treatment of metastasized melanoma.
Basiloma (Basalioma, Carcinoma Basocellulare, Basal Cell Carcinoma [BCC])
- See pictures 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26*
- Basiloma or basal cell carcinoma is the most common malignant skin tumour.
- Basilomas are most commonly located in the face of persons who are elderly, light-skinned, or who have been heavily exposed to sunlight (see pictures 27 and 28*).
- A typical basiloma is a glittering tumour with elevated margins. Often ulceration develops in the centre. A so-called morphoid basiloma is difficult to recognize and its borders are difficult to determine.
- A superficial basiloma usually occurs on the trunk (see picture 29*). Differentiation from psoriasis or eczema may sometimes be difficult. Slow growth lasting many years is typical for the clinical picture.
- Solar ultraviolet B (UVB)-radiation is the most important predisposing factor.
Treatment and Follow-up
- The general practitioner can excise (Thissen, Neumann, & Schouten, 1999; DARE-992074, 2001; "Interventions for basal cell carcinoma of the skin", 2003) [C] a small, typical basiloma if he/she is familiar with the operative techniques in the area. Patients with a suspected basiloma on the eyelids or in the vicinity of the nostrils or ear canal should be referred to a specialist.
- The treatment of choice is surgery. The tumour is excised under local anaesthesia with a 5-mm margin of intact tissue, and reconstruction is performed if necessary by pedicle flap or free graft.
- A superficial basiloma, and some common basilomas, particularly in the elderly, can be treated with liquid nitrogen cryotherapy in a unit familiar with the technique (see picture 30*). New methods for the treatment of basilomas include photodynamic treatment and local treatment with imiquimod.
- A basiloma metastasizes rarely. Because local spread is common, special care should be taken in the treatment and follow-up of basilomas near the eyelids, nostrils, or ear canal.
- Small basilomas in non-risk areas can be excised by the general practitioner who is also responsible for follow-up yearly.
- Consider referring a young patient with basiloma to a dermatologist. Basiloma may be a manifestation of some rare inherited diseases (see picture 31*).
Epidermoid Carcinoma (c. epidermoides, c. spinocellulare, c. squamocellulare, spinalioma)
- Epidermoid carcinoma most commonly occurs on the face and hands. The usual form is an ulcerating prominence or scaling plaque.
- Epidermoid carcinoma may develop directly on previously healthy-looking skin, but more commonly it develops on some precancerous change (solar keratosis, leukoplakia, Bowen's disease).
- Clinically it is often difficult to distinguish from solar keratosis (see picture 32*), (see also, the Finnish Medical Society Duodecim guideline "Solar Keratosis"). Diagnosis must be confirmed by biopsy.
- An epidermoid carcinoma should be treated by surgical excision. In the face, the margin must be at least 5 mm; in other parts of the body, preferably more.
- Keratoacanthoma is a rapidly growing benign tumor (see picture 33*).
- Bowen's disease is a superficial, "incipient" (in situ) carcinoma (see picture 34*). It can be removed either surgically or by liquid nitrogen cryotherapy. The operation is usually performed by a surgeon, plastic surgeon, otologist, ophthalmologist, or dermatologist specialized in cryotherapy. The treating unit estimates the risk of relapse and determines the need for follow-up.
Lip Carcinoma
- Lip carcinoma (epidermoid carcinoma of the lip) is usually situated in the lower lip (see picture 35*). It presents first as an erosion or ulceration that can be preceded by leukoplakia.
- A lip carcinoma is treated surgically by excising the lip at the site of the tumour with a margin and by performing reconstruction.
- A lip carcinoma easily metastasizes in the lymph nodes under the skin, which should be palpated at follow-up examinations.
Prevention of Skin Cancer
There is little evidence of interventions to prevent skin cancer. Sunscreens may be effective in the prevention of solar keratoses ("Prevention of skin cancer," 1995; DARE-950349, 1999) [C]
Related Evidence
Dermatoscopy may have a potential to improve the diagnostics of malignant melanoma, but this has to be verified with higher quality studies in primary care (Mayer, 1997; DARE- 978307, 1999) [D].
*Note: All pictures identified in this summary can be found in the original guideline document.
Definitions:
Levels of Evidence
- Strong research-based evidence. Multiple relevant, high-quality scientific studies with homogeneous results.
- Moderate research-based evidence. At least one relevant, high-quality study or multiple adequate studies.
- Limited research-based evidence. At least one adequate scientific study.
- No research-based evidence. Expert panel evaluation of other information.
