Congenital melanocytic nevi: Where are we now?

Part II. Treatment options and approach to treatment

Omar A. Ibrahimi, MD, PhD,a,b Ali Alikhan, MD,c and Daniel B. Eisen, MDd Farmington, Connecticut; Boston, Massachusetts; Rochester, Minnesota; and Sacramento, California

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515.e1 515.e2 Ibrahimi, Alikhan, and Eisen JAM ACAD DERMATOL OCTOBER 2012

Treatment of congenital melanocytic nevi (CMN) is generally undertaken for 2 reasons: (1) to reduce the chances of cutaneous malignant melanoma and (2) for cosmetic reasons. Over the past century, a large number of treatments for CMN have been described in the literature. These include excision, dermabrasion, curettage, chemical peels, radiation therapy, cryotherapy, electrosurgery, and lasers. Only low-level evidence supporting these approaches is available, and large randomized controlled trials have not been published. This article explores therapeutic controversies and makes recommendations based on the best available evidence. ( J Am Acad Dermatol 2012;67:515.e1-13.)

The treatment of congen- d High rates of satisfac- ital melanocytic nevi (CMN) CAPSULE SUMMARY tion have been reported before the development of for excision when CMN malignancy is considered d Excision has been recommended as the are \20 cm in size, es- for 2 reasons: (1) to reduce first-line treatment for congenital nevi in pecially for those on the chances of cutaneous which treatment is indicated. the head and neck malignant melanoma (MM) d Data regarding the purported benefits Excision can be per- and (2) for cosmetic reasons. and risks of these procedures are formed either for cosmetic The treatment of giant CMN explored. (GCMN) is technically diffi- reasons or to attempt to re- d Excision may result in high satisfaction, duce the risk of development cult, and complete removal but its efficacy at reducing the incidence of MM. Given that CMN may of these lesions is often of malignant melanoma is unproven. penetrate deeply, excision to impossible. Approaches to d the level of the fascia is ad- removal can broadly be Fears regarding the use of lasers for vocated in order to assure classified into 2 groups: treatment are unsubstantiated, but removal of as much of the full- and partial-thickness treatment effectiveness with lasers has lesion as possible and to removal procedures (Table been variable. I). Full-thickness procedures avoid recurrence. However, the excision of CMN to re- remove the entire dermis and duce the chance of malignancy is controversial. epidermis and varying amounts of subcutaneous Proponents claim that the removal of these nevi tissue. They are likely to remove more nevus cells reduce the risk of associated MM.1 Although the than partial-thickness procedures, but the effective- absolute risk of MM in many studies appears to be ness of either method for preventing future malig- low, it is still considerably higher than the general nancy remains a topic of debate. It is important to population.1 In addition, the true lifetime risk of MM stress that lifelong surveillance is warranted regard- may be underestimated given the skewing towards a less of if partial- or full-thickness treatments are younger average age of patients in many studies. In undertaken. the case of GCMN, most MMs develop deep within FULL-THICKNESS PROCEDURES the nevi (data supporting this assertion is sparse), Complete excision where detection from routine observation is likely to Key points be delayed until the development of advanced 1 d Although excision more completely removes disease. Finally, the incidence of cutaneous MM is nevus cells within CMN than partial- noted to be lower in patients who have undergone 1 thickness treatment approaches, there is no excision than in those who choose observation. solid evidence that this reduces the risk of In contrast, several arguments against routine malignant melanoma more effectively surgical excision of CMN have been advanced,

From the Department of Dermatology,a University of Connecticut Presented in part at the University of California, Davis Department Health Center, Farmington; the Wellman Center for Photo- of Dermatology Clinical Grand Rounds Conference, October 14, medicine,b Massachusetts General Hospital, Harvard Medical 2009, and the Division of Plastic Surgery Grand Rounds School, Boston; the Department of Dermatology,c Mayo Clinic, Conference, October 25, 2011. Rochester; and the University of California Davis Medical Reprint requests: Daniel B. Eisen, MD, University of California, Center,d Sacramento, California. Davis, School of Medicine, Department of Dermatology, 3301 C Funding sources: None. St, Ste 1400, Sacramento, CA 95816. E-mail: dbeisen@ucdavis. Dr Ibrahimi has received speaking honoraria from Lumenis. Drs edu. Eisen and Alikhan have no conflicts of interest. 0190-9622/$36.00 JAM ACAD DERMATOL Ibrahimi, Alikhan, and Eisen 515.e3 VOLUME 67, NUMBER 4

response to therapies. They reported a negative Abbreviations used: correlation of satisfaction with increasing pro- CMN: congenital melanocytic nevi jected adult size (PAS). A significant proportion Er:YAG: erbium:yttrium-aluminum-garnet of parents felt that surgery had worsened the GCMN: giant congenital melanocytic nevi MM: malignant melanoma appearance of their child’s CMN when the PAS Nd:YAG: neodymium-doped yttrium aluminum was [20 cm. When the PAS was \20 cm, almost garnet 90% felt that the procedure was worthwhile, and NMRL: normal-mode ruby laser PAS: projected adult size even more thought so when the lesion was located QSRL: Q-switched ruby laser on the head and neck (95-96%). They also reported the phenomenon of new nevus forma- tion (at the edges of the treated area) in 28% of including that: (1) the absolute incidence of MM is their study patients who underwent excision. 8 low in patients with CMN, while surgery has associ- Others have also reported similar findings. This ated risks, including sepsis, scarring, recurrence, and was significant in those with complete excision of restrictions to joint mobility; (2) excision of cutane- their nevi, but not those with partial excision or 3 ous MM would not reduce the risk of extracutaneous other treatment methods. The authors hypothe- melanoma, which accounts for a significant propor- size potential mechanisms for repigmentation, tion of melanomas in these patients; and (3) excision including the activation of nonnevus melanocytes of CMN may mask the development of MM,2 pre- by tissue expanders or the spread of nevus cells sumably by hiding it beneath scar, grafts, or skin from the main nevus in a type of benign regener- flaps. Contrary to the claim that MM in the setting of ative process analogous to recurrent nevus/ 3 GCMN may be understated, some claim it may be pseudomelanoma. 9 overstated.3 It is noted that differentiating between Ruiz-Maldonado et al stated that the results of proliferative nodules and MM is difficult both histo- surgery from their 22 patients who underwent exci- logically and clinically, and errors may result in the sion with various reconstructive methods were more overdiagnosis of MM in patients with GCMN and often ‘‘fair and poor’’ than ‘‘good.’’ However, others proliferative nodules. In addition, the risk of MM is have reached opposite conclusions, although these highest in those with the largest CMN, which, con- findings may be biased by the inclusion of mostly foundingly, are typically too large to be completely small CMN, which would be expected to have better 5 excised.4 Therefore, the risks of MM may errone- outcomes. ously appear to be higher in those who have not undergone excision because this group of patients Serial excision has intrinsically higher risks of MM than those with Key point smaller GCMN that are more easily excised. d Data regarding serial excision is sparse, but Randomized, controlled data on this topic are not anecdotal reports indicate positive outcomes yet available.4 Concerning outcomes after surgery, Kruk et al5 Staged excision has been advocated for large found, in their group of 295 patients, that those with CMNs for more than a century, based on the rationale nevi\5 cm in diameter could be successfully excised that smaller procedures give the skin a chance to with a single procedure. For patients with larger stretch gradually, thereby increasing the likelihood nevi, multiple procedures were frequently required, of a good outcome.10,11 Fujiwara et al10 recommend such as serial excision or the use of tissue ex- excision between 6 months and 2 years of age. They panders.5 Gosain et al6 described their experience note that the skin is most elastic early in life and that with 53 patients with CMN [20 cm in diameter.6 subcutaneous fat is at its thickest during this time,10,11 Serial excision was used most commonly on the but others have not found better outcomes with early extremities, accounting for 50% of reconstructions in intervention.3 these areas, while expanded flaps were used most Various methods of serial excision have been commonly in head and neck procedures (49% in this proposed.12-14 Data are highly limited regarding area). Most areas required [1 type of reconstructive any of these techniques, and no comparison method.6 Warner et al,7 who reported their experi- studies have been performed. In general, most ence with 40 patients with GCMN, also found the reports describe results that are good or excellent, need for multiple surgical procedures. but specific outcome measures are lacking. Kinsler et al3 followed 305 families with CMN Complications include failure to remove the entire prospectively using questionnaires to evaluate lesion, dehiscence, and scar widening. 515.e4 Ibrahimi, Alikhan, and Eisen JAM ACAD DERMATOL OCTOBER 2012

Table I. Available treatment methods for congenital melanocytic nevi

Method Advantages (type of evidence) Disadvantages (type of evidence) No treatment (observation) Majority (31/48) of untreated CMNs in Risk of melanoma remains unchanged (IV); 1 prospective study noted to lighten with does not address psychosocial burden (IV) time (IIB); no risk of complications from treatment (IV) Excision Removes more nevus cells than any other Repigmentation or new satellite nevi often treatment (IV); might reduce the occur after procedures with larger nevi incidence of MM (III); improves cosmetic (IIB); cosmetic appearance may be appearance for many small to medium worsened for large CMN and GCMN (IIB); CMN (IIB) and possibly some GCMN (IV) might mask appearance of MM, especially if resurfaced with skin grafts (IV); unlikely to remove all nevus cells for large CMN or GCMN (IV); larger lesions frequently require serial excision, tissue expansion, or skin grafts (IV); results in scar, sometimes disfiguring (IV); potential for joint contractures (IV) Dermatome shaving Removes some CMN cells and therefore Does not remove as many CMN cells as might reduce risk of MM (IV); scars excision (IV); results in scar, sometimes and other surgery-related adverse disfiguring (IV); detection of MM might be outcomes might be less than with more difficult (IV) excision (IV); cosmetic outcomes are fair to excellent (III) Curettage Removes some CMN cells and therefore Does not remove as many CMN cells as might reduce the risk of MM (IV); scars excision (IV); results in scar, sometimes and other surgery-related adverse disfiguring (III); detection of MM might be outcomes might be less than with more difficult (IV) excision (III); improves cosmetic outcome (III); minimal equipment requirement (IV) Dermabrasion Removes some CMN cells and therefore Does not remove as many CMN cells as might reduce the risk of MM (IV); scars excision (IV); results in scar, sometimes and other surgery-related adverse disfiguring (III); detection of MM might be outcomes might be less than with more difficult (IV) excision (III); improves cosmetic outcome (III); minimal equipment requirement (IV) Chemical peels Removes/destroys some CMN cells and Does not remove as many CMN cells as therefore might reduce the risk of MM excision (IV); may result in scar (IV); (IV); scars and other surgery-related detection of MM might be more adverse outcomes might be less than difficult (IV) with excision (III); improves cosmetic outcome (III); minimal equipment requirement (IV) Cryotherapy Removes/destroys some CMN cells and Does not remove as many CMN cells as therefore might reduce the risk of MM excision (IV); may result in scar or (IV); scars and other surgery-related hypopigmentation (IV); detection of MM adverse outcomes might be less than might be more difficult (IV) with excision (III); improves cosmetic outcome (III); minimal equipment requirement (IV) Electrosurgery Destroys some CMN cells and therefore Does not remove as many CMN cells as might reduce the risk of MM (IV); scars excision (IV); may result in scar or and other surgery-related adverse hypopigmentation (IV); detection of MM outcomes might be less than with might be more difficult (IV); theoretical excision (IV); improves cosmetic outcome risk of malignant transformation (IV) (IV); minimal equipment requirement (IV) Radiation therapy None (IV) Poor efficacy (IV); risk of radiation induced neoplasms (IIB) and radiation dermatitis (IIA) Continued JAM ACAD DERMATOL Ibrahimi, Alikhan, and Eisen 515.e5 VOLUME 67, NUMBER 4

Table I. Cont’d

Method Advantages (type of evidence) Disadvantages (type of evidence) Ablative lasers Can precisely remove tissue to depth of Does not remove as many CMN cells as pigmented cells (IV); might reduce the risk excision (IV); results in scar, sometimes of MM (IV); scars and other surgery- disfiguring (III); detection of MM might be related adverse outcomes might be less more difficult (IV) than with excision (IV); improves cosmetic outcome (III); can be combined with pigment-specific lasers (IV) Pigment-specific lasers Precisely targets melanosomes and Does not remove as many CMN cells as melanocytes (IIA); might reduce the risk of excision (IV); results in scar, sometimes MM (IV); scars and other surgery-related disfiguring (III); detection of MM might be adverse outcomes might be less than more difficult (IV); risk of malignant with excision (III); improves cosmetic transformation is circumstantial (IV), with outcome (III) small studies showing no malignant transformation (III)

Level IA evidence includes evidence from metaanalysis of randomized controlled trials; level IB evidence includes evidence from at least 1 randomized controlled trial; level IIA evidence includes evidence from at least 1 controlled study without randomization; level IIB evidence includes evidence from at least 1 other type of experimental study; level III evidence includes evidence from nonexperimental descriptive studies, such as comparative studies, correlation studies, and case-control studies; and level IV evidence includes evidence from expert committee reports or opinions or clinical experience of respected authorities, or both. CMN, Congenital melanocytic nevus; GCMN, giant congenital melanocytic nevi; MM, malignant melanoma.

PARTIAL-THICKNESS REMOVAL Abrasive removal methods PROCEDURES Key points Key point d Results after curettage range from poor to d Partial-thickness removal procedures may good reduce risk of malignant melanoma, but d Dermabrasion successfully reduces pigmen- this has never been proven tation in most cases when performed in the newborn period Partial-thickness removal procedures will un- doubtedly remove a considerable amount of nevus Both curettage and dermabrasion rely on a cell burden from the patient, but they are likely to ‘‘cleavage plane’’ that is present within the dermis leave some cells present within the reticular dermis between the nevus and underlying tissue during the or subcutaneous plane. Many patients will therefore first few weeks of life.20 The nevi are said to have find these procedures unsatisfactory as tumor reduc- increasing adherence with time, making their re- tion methods, but they might be suitable from an moval much more difficult after 6 months of age.21 aesthetic improvement perspective. The reduction in Only anecdotal reports are available to substantiate nevus cell burden using these methods should in this claim. theory reduce the risk of MM developing within the Curettage. Curettage for GCMN was first re- CMN. However, like full-thickness excision, the risk ported by Moss21 in 1987. He advocated for reduction has never been quantified or proven. treatment during the first few weeks of life. The advantages of this technique are reported to be its simplicity, minimal instrument requirements, low Dermatome excision blood loss, and fast healing time. Some worry Key point d that MM maybe more difficult to detect after Fair to excellent results have been reported 22 with dermatome excision this procedure, but others claim the opposite. Data regarding this technique are limited to Cronin15 was the first to pioneer the superficial 26 patients, some of whom had small CMN.21,22 removal of GCMN in 1953 using a dermatome.16 Results ranged from poor to good. Complications Various methods have been described, some of included hypertrophic scarring and some which suggest saving the excised epidermis and patients with infections that required systemic reattaching it after enzymatic debridement of the antibiotics.22 nevus cells.17-19 Fair to excellent results have been Dermabrasion. Variable outcomes (from poor reported, but in our opinion, the associated photo- to excellent) have been reported after dermabrasion graphs of outcomes were unimpressive. for CMN.10,24,25 The largest study on this topic was 515.e6 Ibrahimi, Alikhan, and Eisen JAM ACAD DERMATOL OCTOBER 2012 performed by Rompel et al,23 who found in their transformation to MM. In 195732 and 1963,33 Walton retrospective review of 215 patients that there were et al published results from a study in which 355 no serious long-term complications. Hypertrophic biopsy specimens of nevi were treated with electro- scarring was present in portions of the treatment area dessication and later excised. After follow-up rang- in 14.6% of patients, but results were still deemed ing from 1 to 7 years, no malignant degeneration was satisfactory, even in these patients. A reduction in observed. Nevi were not specified as either congen- pigment from 0% to 20% of the initial color was ital or acquired. Stratton34 reported a single patient achieved in nearly all patients as long as they were with a large facial CMN treated with 5 sessions of treated within the newborn period. electrocoagulation and curettage. Treatment of the lesion resulted in a soft, pliable scar. Chemical peels Key point Radiation d Only small numbers of patients have been Key point reported to have treatment with chemical d Only anecdotal information exists on the use peels of radiotherapy Chemical peels were being performed on CMN 24 Literature regarding the use of radiotherapy for at least as early as 1912. Like dermabrasion, the CMN is sparse. In 1921, MacKee35 wrote that al- reported results vary. In general, only small though others had succeeded in removing pig- numbers of patients have been treated with 25-29 mented nevi with both radiographs and beta rays this technique. Reported complications of radium, he was unable to obtain notable improve- include infection, recurrence of pigmentation, and ment in these lesions without the induction of scarring. significant skin reactions. He recommended that nevi not be removed using these methods. Like Cryotherapy nearly all other treatment methods, melanoma has Key point been reported after radiotherapy.36 d Information on cryotherapy is limited and has not been reproduced in recent years Laser 30 In 1907, Pusey described the use of CO2 snow Concerns regarding laser treatment for the treatment of a GCMN on the face. He noted Key points that a ‘‘hideous deformity’’ was replaced by a slight d Primarily in vitro data suggests a theoretical scar. The photographic images showed a dramatic increased risk of melanoma after laser treat- improvement. Similarly, in 1912, Fox24 noted some ment of CMN improvement in a single patient with a garment-type d Laser treatment does not result in complete CMN after treatment with a combination of nitric eradication of all nevus cells acid, phenol, and carbonic acid snow (cryotherapy). ‘‘Before’’ and ‘‘after’’ images were not published, and Laser therapy for congenital nevi can be catego- no specifics as to how the lesion improved were rized as nonspecific or specific. CO2 and provided. erbium:yttrium-aluminum-garnet (Er:YAG) lasers, Muti31 published a case series of 4 patients with which ablate tissue based upon water content, medium-sized CMN that were treated with nitrogen have efficacy and adverse event profiles similar to protoxideecooled cryoprobes. No outcome mea- other nonspecific destructive methods, such as der- sures were described, but associated photos re- mabrasion. The use of pigment-specific lasers, such vealed good clearance of the lesion with some as the ruby, alexandrite, and neodymium-doped resulting scarring. yttrium aluminum garnet (Nd:YAG), are highly en- ticing from a theoretical standpoint. These lasers effectively target pigmented cells and minimize Electrosurgery damage to the surrounding tissue. The use of these Key point lasers in a Q-switched mode causes the death of d Information regarding the use of electrosur- gery is limited nevus cells via selective photothermolysis of mela- nosomes.37-40 The use of lasers with millisecond Little information is available regarding electro- pulse durations also leads to the death of melano- surgery for CMN. Analogous to the theoretical prob- cytes with the potential for localized collateral lems with laser ablative surgery, electrosurgical heating, which may destroy nonemelanin-contain- treatment of nevi could theoretically lead to ing melanocytes and other cells. Despite these JAM ACAD DERMATOL Ibrahimi, Alikhan, and Eisen 515.e7 VOLUME 67, NUMBER 4 theoretical advantages, there is debate about the Q-switched ruby lasers (QSRLs) have been pop- long-term safety and efficacy of laser therapy for ular in the past for treatment of congenital nevi congenital nevi.6,41-45 because of their wavelength (694 nm), which is Unlike ultraviolet light, pigment-specific lasers selectively absorbed by melanin, and because of have wavelengths that do not appear to directly their nanosecond pulse durations that closely match damage DNA. Therefore, any mutagenic effect the thermal relaxation time of melanosomes.39,60 would have to result from heat. The association of Initial reports of QSRLs featured responses rang- squamous cell carcinomas within burn scars is often ing from poor to excellent.48,53,61-67 All histologic used to support concerns regarding the use of lasers analyses showed residual nevus cells after treatment, to treat nevi.46-48 In fact, several case reports exist leaving open the possibility of future malignant where melanomas have been diagnosed after laser degeneration.59 Multiple treatments were almost therapy.43,49-52 However, many of these lesions were always necessary.53,66 Study durations were typically likely misdiagnosed malignant lesions before ther- just a few months, and therefore the persistence of apy. In addition, another concern regarding the efficacy is largely unknown. Treatment failures with possibility for malignancy is the regrowth of some QSRL are thought to result from their short pulse nevi after laser irradiation.53 This behavior may durations and limited depth of penetration indicate a proliferative response to laser injury or (1 mm).53,68,69 resulting changes in the cellular matrix.48 In fact, the Ueda et al70 suggested that long-pulsed lasers recurrences of nevi after excision or CO2 laser might allow more heat dispersion to surrounding resurfacing closely mimics melanoma both clinically cells, allowing for more effective targeting of nevus and histologically.54,55 This phenotypic finding has nests, including nonpigmented melanocytes rather been coined ‘‘pseudomelanoma.’’ It is, however, than individual nevus cells.70 Studies using NMRLs considered a benign process. have shown efficacy at nevus clearance of small to Finally, some argue that ablation of the pigmented giant sized CMN in Japanese patients.59,70-72 Like portion of a nevus might mask the occurrence of QSRLs, the clinical results have been variable, and tumors within the treated area.44 Others argue the most follow-up periods for published reports are too opposite, and data are lacking to support either short to make generalized statements regarding the contention. persistence of improvements. Laboratory studies examining malignant changes Because NMRLs closely match the thermal relax- after laser irradiation have been performed.56-59 ation time of the epidermis, Kono et al68 theorized Results have varied, with some giving cause for that treatment first with a NMRL, which causes concern and others not. The relevance of these epidermal separation at the dermoepidermal junc- in vitro studies to actual real world human risk tion, would allow for increased depth of penetra- remains to be determined, because these studies tion with subsequent QSRL treatments. At least 4 used malignant cells instead of nevus cells. studies have been reported on the use of combined Regarding in vivo studies, Grevelink et al48 looked NMRL and QSRL.66,68,73,74 The first 4 studies re- at the effect of Q-switched laser irradiation on ported positive results. The largest one, by Kono congenital nevi in 5 patients. They studied the et al,68 studied 34 patients and demonstrated [70% histologic effects of both Q-switched Nd:YAG and lightening with all histologic types, but greater ruby lasers compared to no treatment. They found efficacy was correlated with more superficial intra- no malignant degeneration, but noted that nevus dermal CMN types.73 Overall, 31 of 34 patients cells persisted in all lesions, especially in the deeper were judged as having excellent and good re- portions of the dermis. Imayama et al59 performed a sponses, 3 with fair results, and none with poor long-term clinical and histologic study of CMN clinical results. treated with normal mode ruby laser (NMRL) in 10 Kono et al’s68 favorable outcomes were not rep- patients.59 Malignant changes were absent from all licated by Helsing et al’s74 2006 study of 14 children studied nevi, but nevus cells remained, even in the with medium-sized facial CMN. Twelve children nevi with good cosmetic results. were treated with combined QSRL and NMRL and 2 with NMRL only. After a median of 3 treatments, Ruby laser no outcomes were satisfactory as judged by Key points photography. d Outcomes after ruby laser treatment have The most recent study on the use of ruby lasers for been variable CMN was published in 2009 by Kishi, et al.75 They d Early treatment has been hypothesized to treated 9 Japanese patients from 1 month of age with have better results serial 2- to 4-week QSRL treatments with escalating 515.e8 Ibrahimi, Alikhan, and Eisen JAM ACAD DERMATOL OCTOBER 2012

Fig 1. Treatment algorithm. Given the paucity of evidence, treatment recommendations are largely conjectural in nature. Concerning the use of surgery to reduce the risks of cutaneous malignant melanoma, we recommend avoiding its use where significant disfigurement or compromised function is likely to result, because evidence regarding its efficacy is limited and chances of malignancy are low. fluences. The mean follow-up was 29 months. After a Kim76 treated 53 patients with CMN with a mean of 9.6 treatments, color was reduced to 0% to Q-switched alexandrite laser (QSAL). Sixteen of 20% of baseline in all patients. Eight patients expe- these patients also received CO2 laser therapy in rienced mild repigmentation. All were retreated with between QSAL treatment sessions. An average of 1 to 2 more sessions, which resulted in relightening 72% improvement was noted with QSAL alone, that persisted for at least 1 year. The last patient and even higher rates were noted with combined experienced repigmentation of his lesion to a level treatment. Complications included skin textural close to baseline within 2 weeks of his last treatment. changes (67.3%), hypopigmentation (30%), The authors speculated the success of their therapy hyperpigmentation (28%), depressed scarring might be caused by the more transparent nature of (3.8%), and hypertrophic changes (7.5%). infant skin. Repigmentation was seen in most patients (83%) after an average of 5.45 months. The degree of Alexandrite laser repigmentation was not specified. The authors Key point concluded that treatment with QSAL provided d Response to alexandrite laser treatment ap- cosmetic benefit with low complications. How pears good, but complications and repig- long standing the results of QSAL therapy are is mentation are frequent currently unknown. JAM ACAD DERMATOL Ibrahimi, Alikhan, and Eisen 515.e9 VOLUME 67, NUMBER 4

Fig 2. Multiple treatments with different laser systems may be necessary to achieve cosmetic improvement of congenital nevi. A, Nevus on the left upper lip of a 7-year-old girl. B, Appearance after 4 monthly Q-switched ruby laser treatments. C, Six months later, the lesion began to recur. D, The final appearance 10 years later, after an additional 3 separate Q-switched alexandrite laser treatments and additional treatment with a 5-millisecond long- pulsed alexandrite laser. (Photograph courtesy of Mitchel P. Goldman, MD. Reproduced with permission from: Treatment of Benign Pigmented Lesions, in, Cutaneous and Cosmetic Laser Surgery, Mitchel P. Goldman (Ed.). 2006 Elsevier, London. Ó 2012 Mitchel P. Goldman, MD.)

79 CO2 laser Reynolds described 7 patients with giant CMN Key points treated with CO2 laser. Follow-up ranged from 1.5 d CO2 laser has been used both as monotreat- to 6 years. Four patients required repeat treatments. ment and in combination with other Formal outcome measures were not reported. The Q-switched devices authors stated that the results were encouraging, d Multiple treatments are necessary but the included photographs showed significant d Data on outcomes are limited recurrence or persistence of the lesions after treatment. Similar to Kono et al’s68 concept of combined QSRL and NMRL therapy, Choi et al77 recommended Erbium:yttrium-aluminum-garnet laser the use of CO laser followed immediately by QSRL. 2 Key point They theorized that ablative resurfacing would allow d Similar to CO lasers, limited data suggest for the deeper penetration of QSRL energy, allowing 2 that multiple treatments may significantly for more pigment removal. Their study included 15 lighten the nevi, but complications and re- patients who received between 4 and 7 treatment pigmentation are common sessions. Thirty-three percent had responses rated as excellent, 47% were rated as good, and 20% Lapiere et al80 appear to be one of the first groups as poor. to describe the use of Er:YAG lasers for CMN. Their Chong et al78 also investigated dual laser therapy 2002 report included a single patient who underwent for CMN. They used an ablative CO2 laser followed 1 treatment at 9 days of age. The outcome was by QSAL. All patients noted significant improve- reported as excellent and no pigmentation was seen ment of their nevi after 2 to 9 treatments. Three of after 16 months of follow-up. The authors stated that the 11 patients developed hypertrophic scars, and one of the advantages of Er:YAG lasers is that they 1 developed postinflammatory hyperpigmentation. ablate tissue in a linear nature with each subsequent 515.e10 Ibrahimi, Alikhan, and Eisen JAM ACAD DERMATOL OCTOBER 2012

to excellent results. Two patients developed repig- mentation requiring laser therapy with a Q-switched Nd:YAG laser. The associated images demonstrated good clearance of the pigmentation but the presence of prominent scars. Ostertag et al83 described outcomes in 10 treated patients with 1 to 6 treatments beginning in the first few weeks of life. Eight patients were said to have no or minimal pigmentation recurrence during follow- up ranging from 3 to 36 months. Results were rated as good to excellent in all responders. Two patients experienced significant repigmentation within 3 months after treatment. Viral and bacterial infections affected 3 patients. Most recently, Rajpar et al84 treated 3 children with 4 to 8 Er:YAG laser sessions. They noted significant lightening in all treated lesions without scarring. Objective outcome measures were not reported, and the included images of a single patient did not show dramatic efficacy.

APPROACH TO TREATMENT Fig 3. Complete clearance of lesions can be a challenge. Key points A, Congenital hairy nevus on the left cheek of a 12-year- d The benefits of early excision have not yet old girl. B, Clinical appearance after 11 separate laser been proven; surveillance is therefore a rea- treatments consisting of 2 Q-switched ruby laser treat- sonable option, even for GCMN ments, 1 510-nm, 300-millisecond pigment lesion laser, d Surgery that is likely to result in significant 1 Q-switched 532-nm neodymium-doped yttrium alumi- deformity or compromised function should num garnet treatment, 3 Q-switched alexandrite laser be avoided treatments, 3 treatments with a long-pulsed alexandrite d Partial-thickness removal strategies, such as laser, and 1 treatment with an intense pulsed light device. Hair density and diameter were reduced, but color re- dermabrasion or lasers, may be considered mains relatively unchanged, and some scarring is present when more aggressive surgical procedures centrally. (Photograph courtesy of Mitchel P. Goldman, are not practical MD. Reproduced with permission from: Treatment of Given the paucity of evidence regarding CMN Benign Pigmented Lesions, in, Cutaneous and Cosmetic Laser Surgery, Mitchel P. Goldman (Ed.). 2006 Elsevier, therapies, recommendations regarding treatments London. Ó 2012 Mitchel P. Goldman, MD.) will be mostly conjectural (Fig 1). In theory, excision, which removes the most tissue (and therefore the greatest number of nevus cells), should have the best pass. This contrasts with CO2 lasers, which reach a chances of reducing chances of malignant degener- plateau and also cause more thermal damage to the ation within CMN. However, no studies have docu- surrounding tissue. The authors suggest that this mented the benefit of excision over routine allows for the precise ablation of pigmented tissue surveillance or compared it to less aggressive with lower risks of scarring and pigmentation partial-thickness removal procedures. In addition, changes. excision will do nothing to reduce the chances of In 2005, Whang et al81 reported results from a extracutaneous MM or neuromelanosis. Many might retrospective study comparing treatment with a find that the small risk of malignant degeneration, dual-mode, 2940-nm Er:YAG laser versus curettage. even in GCMN, does not warrant the risks of Efficacy in terms of skin lightening appeared to be aggressive surgical procedures. Each physician and similar. Lim et al82 reported results from a retrospec- patient will need to weigh the information together. tive study of 13 patients treated with excision of as Given that risks of MM seem to correlate with CMN much of the lesion as possible followed immediately size, the consideration of treatment for malignancy by treatment with a dual-mode, 2940-nm Er:YAG reduction need only concern nevi of large size. laser to the remaining nevus. After 6 months of In addition to malignant considerations, CMN follow-up, 83% of patients were rated as having good may carry significant psychosocial consequences. JAM ACAD DERMATOL Ibrahimi, Alikhan, and Eisen 515.e11 VOLUME 67, NUMBER 4

Treatment should certainly be considered for cos- 2. Kinsler VA, Chong WK, Aylett SE, Atherton DJ. Complications metic reasons in appropriate patients. We feel that of congenital melanocytic naevi in children: analysis of 16 any elective treatment involving general anesthesia years’ experience and clinical practice. Br J Dermatol 2008;159: 907-14. should be deferred until after 3 years of age, as 3. Kinsler VA, Birley J, Atherton DJ. Great Ormond Street Hospital recommended by other authorities, until the risks are for Children registry for congenital melanocytic naevi: pro- better understood.85-87 As mentioned in part I of this spective study 1988-2007. Part 2—evaluation of treatments. Br review, there is concern regarding potential adverse J Dermatol 2009;160:387-92. impacts on neurologic, cognitive, and social devel- 4. Kinsler V, Bulstrode N. The role of surgery in the management of congenital melanocytic naevi in children: a perspective opment in young children who are subjected to from Great Ormond Street Hospital. J Plast Reconstr Aesthet general anesthesia. This might make partial- Surg 2009;62:595-601. thickness procedures more appealing, many of 5. Kruk-Jeromin J, Lewandowicz E, Rykala J. Surgical treatment of which can be accomplished with topical or local pigmented melanocytic nevi depending upon their size and anesthesia. If the outcomes are poor, the treated location. Acta Chir Plast 1999;41:20-4. 6. Gosain AK, Santoro TD, Larson DL, Gingrass RP. Giant con- area could always be treated with excision in the genital nevi: a 20-year experience and an algorithm for their future. management. Plast Reconstr Surg 2001;108:622-36. As to which partial-thickness treatments might be 7. Warner PM, Yakuboff KP, Kagan RJ, Boyce S, Warden GD. An superior, information is limited. Although the risks of 18-year experience in the management of congenital nevo- laser surgery appear to be low, outcomes are largely melanocytic nevi. Ann Plast Surg 2008;60:283-7. 8. Tromberg J, Bauer B, Benvenuto-Andrade C, Marghoob AA. inconsistent (Figs 2 and 3). Which option to choose Congenital melanocytic nevi needing treatment. Dermatol should be based upon local availability of equipment Ther 2005;18:136-50. and previous experience. Regarding surgery for 9. Ruiz-Maldonado R, Tamayo L, Laterza AM, Duran C. Giant incomplete or poor responders, satisfaction appears pigmented nevi: clinical, histopathologic, and therapeutic to be high when the nevi are 20 cm, especially for considerations. J Pediatr 1992;120:906-11. \ 10. Fujiwara M, Nakamura Y, Fukamizu H. Treatment of giant those located on the head and neck. Given the wide congenital nevus of the back by convergent serial excision. variability in size and locations of CMN, recommen- J Dermatol 2008;35:608-10. dations will need to be individualized. We agree with 11. Paul AA, Cole TJ, Ahmed EA, Whitehead RG. The need for previous authors that surgery that is likely to result in revised standards for skinfold thickness in infancy. Arch Dis significant deformity or compromised function Child 1998;78:354-8. 12. Feins NR, Rubin R, Borger JA. Ambulatory serial excision of should be avoided. giant nevi. J Pediatr Surg 1982;17:851-3. 13. Altchek ED. A technical consideration in the serial excision of a nevus. Plast Reconstr Surg 1980;66:849-50. CONCLUSION 14. Chretien-Marquet B, Bennaceur S, Fernandez R. Surgical Despite the large number of publications con- treatment of large cutaneous lesions of the back in children cerning the treatment of CMN, our understanding of by concentric cutaneous mobilization. Plast Reconstr Surg treatment effectiveness remains elusive. Excision 1997;100:926-36. 15. Cronin TD. Extensive pigmented nevi in hairbearing areas; removes the most tissue and therefore the greatest removal of pigmented layer while preserving the hair follicles. nevus cell burden, and should have the best chances Plast Reconstr Surg 1953;11:94-106. of reducing malignancy. However, given that risk of 16. Hynes W. The treatment of pigmented moles by shaving and MM transformation is low, morbidity may not be skin graft. Br J Plast Surg 1956;9:47-51. reduced after any treatment procedure. In terms of 17. Hosokawa K, Hata Y, Yano K, Matsuka K, Ito O. Treatment of tattoos with pure epidermal sheet grafting. Ann Plast Surg cosmetic outcomes, most studies for any treatment 1990;24:53-60. have been uncontrolled, have contained few pa- 18. Kishi K, Ninomiya R, Okabe K, Konno E, Katsube KI, Imanishi N, tients, and were of short duration, making decisions et al. 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