Management of Raised Congenital Melanocytic Nevi
Management of raised congenital melanocytic nevi (CMN) requires careful monitoring and potential surgical intervention, with bleeding and scabbing being relatively common occurrences due to their increased skin fragility. 1
Understanding Congenital Melanocytic Nevi
Congenital melanocytic nevi are pigmented lesions present at birth or appearing shortly thereafter. They vary in size, color, and texture, with some becoming raised, hypertrichotic (hairy), verrucous, or papillated over time.
Classification by Size
- Small: <1.5 cm diameter
- Medium: 1.5-20 cm diameter
- Large: >20 cm diameter
- Giant: >40 cm diameter or covering significant body surface area
Skin Fragility and Bleeding
CMN often display increased skin fragility that can result in:
- Ulcerations
- Erosions
- Bleeding with minimal trauma 1
This fragility explains why scabbing and bleeding can occur in raised CMN. These events are relatively common and typically not indicative of malignant transformation, though any persistent or changing lesions should be evaluated promptly.
Management Approach
1. Monitoring and Skin Care
Regular dermatologic evaluation:
- For small/medium solitary CMN without concerning features: can be monitored by primary care
- For large, giant, or multiple CMN: referral to dermatologist with CMN expertise 1
Skin care recommendations:
- Cleanse with water or non-soap cleanser 2-3 times weekly
- Apply bland emollients (minimal fragrances/preservatives)
- For ulcerations/bleeding: clean with soap/water, apply petroleum jelly or bland ointment with bandage
- Consider hydrocolloid or foam dressings for wounds 1
For pruritus and eczematous changes:
- Apply bland emollients for chronic management
- Use low to mid-potency topical corticosteroids twice daily for flares 1
2. Surgical Management Considerations
The decision for surgical intervention depends on:
- Size and location of the nevus
- Patient age and overall health
- Family preference
- Risk of neurocutaneous melanosis (NCM) or melanoma 1
Surgical options include:
- Complete excision with appropriate margins
- Serial excision for larger lesions
- Tissue expansion techniques for very large lesions
For melanomas arising in congenital nevi, excision should include both the melanoma with standard margins and the entirety of the residual nevus when feasible 1.
3. Non-surgical Approaches
For cosmetic concerns without surgical removal:
- Hair removal options: shaving, waxing, threading, chemical depilation, electrolysis, or trimming are low risk 1
- Pigment-specific ablative lasers, curettage, and dermabrasion can be considered but may obscure clinical evaluation for melanoma and often result in pigment recurrence 1
Risk Assessment and Monitoring
Melanoma Risk
- Small/medium CMN: lifetime risk <1%, virtually nonexistent before puberty 2
- Large/giant CMN: approximately 5% lifetime risk, with half occurring in early childhood 2
- Highest risk factors: CMN >40cm diameter, numerous satellite nevi, truncal location 1, 2
Monitoring Protocol
- Visual inspection and palpation at each visit
- Dermoscopy by experienced physician enhances diagnostic accuracy 1
- Serial photographs to track changes over time
- Regional lymph node examination
- Prompt evaluation of concerning changes:
- Rapid growth
- Bleeding (persistent or recurrent)
- Pain
- Development of nodules
- Ulceration 1
When to Worry and Seek Immediate Evaluation
Patients/caregivers should be educated to report:
- Persistent bleeding not explained by minor trauma
- Rapid growth or change in appearance
- Development of new nodules within the nevus
- Pain or tenderness
- Ulceration that doesn't heal with basic wound care 1
Conclusion
Raised congenital melanocytic nevi require individualized management based on size, location, and risk factors. Bleeding and scabbing are common due to increased skin fragility and typically not concerning unless persistent or associated with other changes. Regular monitoring by dermatologists is essential, particularly for larger or multiple nevi, with surgical intervention considered based on melanoma risk, cosmetic concerns, and functional impact.