What is the best approach to manage a child with a suspicious mole?

Management of a Child with a Suspicious Mole

Children with suspicious moles should be referred to a pediatric dermatologist or general dermatologist with expertise in pigmented lesions for proper evaluation and management. 1

Initial Evaluation

Clinical Assessment

• Examine the mole for concerning features using the ABCDE criteria:
  • Asymmetry
  • Border irregularity
  • Color heterogeneity
  • Diameter >6 mm
  • Evolution or change 2
• Alternative assessment using "three change criteria":
  • Change in size
  • Change in color
  • Change in shape 2
• Additional warning signs:
  • Symptoms (itching, bleeding)
  • Inflammation
  • Elevation (flat, palpable, nodular) 1

Examination Techniques

• Visual inspection of the entire mole
• Palpation of the mole (critical as melanoma can present as deep nodules without overlying color change) 1
• Dermoscopy by a trained clinician (increases diagnostic accuracy and helps differentiate melanocytic from non-melanocytic lesions) 2, 3
• Complete skin examination to document other pigmented lesions 1
• Regional lymph node examination 1

Risk Stratification

High-Risk Features

1. Giant congenital melanocytic nevi (CMN)
2. Multiple medium-sized CMN or ≥10 "satellite" lesions
3. Family history of melanoma (especially ≥3 cases)
4. Previous melanoma history
5. Atypical mole syndrome 1

Lower-Risk Features

1. Solitary small or medium CMN without concerning features
2. Prepubertal age (malignant melanoma is extremely rare before puberty) 4

Management Approach

For Suspicious Moles

1. Do not remove suspicious lesions in primary care 1
2. Refer urgently to a dermatologist when the mole shows:
   • New appearance after puberty with changes in shape, color, or size
   • Long-standing mole changing in shape, color, or size
   • Three or more colors or loss of symmetry
   • Itching or bleeding
   • Growth under a nail 1

Biopsy Recommendations

• Complete excisional biopsy is the standard for suspicious lesions:
  • Full-thickness skin biopsy
  • Include entire lesion with 2-5 mm clinical margin laterally
  • Include cuff of subdermal fat 1, 2
• Avoid shave and punch biopsies as they compromise pathological staging 1
• Incisional biopsy is only acceptable in specific situations (e.g., facial lentigo maligna) and should never be performed in primary care 1

For Congenital Melanocytic Nevi (CMN)

1. Small and medium CMN without concerning features:

   • Referral can be delayed or deferred to primary care provider
   • Regular monitoring for changes 1

2. Large, giant, or multiple CMN:

   • Establish care with a pediatric dermatologist in the neonatal period
   • More frequent follow-up (every 3 months during infancy or times of expected nevus change) 1
   • MRI screening for neural melanosis in high-risk cases (multiple medium CMN, ≥10 "satellite" lesions, giant CMN) 1

Follow-up Recommendations

Monitoring Schedule

• High-risk patients: More frequent follow-up (every 3 months initially)
• After the first year, in absence of concerns, visit frequency can gradually decrease
• Eventually, yearly dermatologist evaluation for large, giant, and multiple CMN 1

Patient/Parent Education

• Teach self-examination techniques
• Advise on specific changes that suggest melanoma
• Provide written information and access to images of moles and melanomas
• Instruct on photoprotection (sunscreen, hats, protective clothing) 1

Between Visits

• Parents/caregivers should monitor nevi visually and with palpation
• Report concerning changes promptly:
  • Rapid growth
  • Bleeding
  • Pain
  • Development of lump or nodule
  • Ulceration 1

Important Caveats

1. Prepubertal children: Melanoma is extremely rare before puberty, so prophylactic removal of pigmented moles is generally not indicated in this age group unless there are specific concerning features 4

2. Dermoscopy in children: Some benign lesions in children can have dermoscopic features similar to melanoma in adults, requiring expertise in pediatric dermoscopy 3, 5

3. Prophylactic excision: The prophylactic excision of small congenital nevi without suspicious features is not recommended 1

4. Melanoma in childhood: Unlike adult melanomas, pediatric melanomas are often symmetric, amelanotic, nodular lesions that may not manifest the classic ABCD features but will show at least one melanoma-specific structure on dermoscopy 3

5. Documentation: Serial photographs can be helpful to monitor nevus appearance and changes over time 1