What is the most appropriate course of action for a man with benign nevi and a family history of malignant melanoma?

Refer to Dermatologist

This patient with benign nevi and a first-degree family history of malignant melanoma should be referred to a dermatologist for evaluation and ongoing surveillance. 1

Rationale for Dermatology Referral

Family History Risk Assessment

• A family history of melanoma significantly increases this patient's melanoma risk, particularly when combined with the presence of multiple benign nevi. 1, 2
• Individuals with a first-degree relative diagnosed with melanoma warrant specialist evaluation to assess their overall risk profile and determine appropriate surveillance intervals. 1
• While genetic counseling referral is typically reserved for families with three or more melanoma cases (or two cases with specific features like multiple primaries or atypical mole syndrome), a single affected first-degree relative still places this patient in a higher-risk category requiring specialist assessment. 1

Clinical Evaluation Needs

• Patients with multiple nevi and family history require expert clinical and dermoscopic examination to distinguish benign nevi from atypical (dysplastic) nevi, which carry additional melanoma risk. 3, 4
• Dermatologists can perform baseline photography to document all lesions, enabling detection of new or changing nevi over time—a critical surveillance tool for high-risk patients. 1, 3, 4
• The presence of nevi on the mandible and neck requires careful evaluation, as these locations may pose diagnostic challenges that benefit from specialist expertise. 4

Why Other Options Are Inappropriate

Reassurance alone (Option A) is inadequate because this patient has objective risk factors (family history plus multiple nevi) that warrant ongoing monitoring rather than dismissal. 1

Prophylactic excision of benign nevi (Option B) is not recommended unless there are specific concerning features (asymmetry, border irregularity, color variation, diameter >6mm, or evolution). 1, 3 Removing benign nevi without clinical suspicion provides no mortality benefit and creates unnecessary morbidity.

"Conservative management" (Option C) is too vague and fails to establish the structured surveillance this patient requires. Without defining what "conservative" means, this approach risks inadequate monitoring of a patient at elevated risk. 1

Recommended Management Approach

Initial Dermatology Visit Should Include:

• Complete skin examination with documentation of all nevi, including size, location, and clinical characteristics. 1, 4
• Dermoscopic evaluation of any atypical-appearing lesions to assess for features concerning for melanoma. 3
• Baseline photography (both close-up and distant views) to facilitate future comparison. 1, 3
• Patient education on monthly self-examination and the ABCDE criteria (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution/change). 1, 5

Surveillance Intervals:

• Patients at moderately increased risk (which includes those with family history and multiple nevi) should receive periodic dermatologic surveillance, though the exact interval should be individualized based on the number and characteristics of nevi found. 1
• Typical surveillance ranges from every 6-12 months for moderate-risk patients. 1

Critical Warning Signs Requiring Urgent Re-evaluation:

• Rapid growth or darkening of any nevus. 3
• Bleeding, ulceration, or pain in a nevus. 1, 3
• Development of nodules or color variegation. 3
• Any new pigmented lesion appearing after age 40. 5

Common Pitfalls to Avoid

Do not perform diagnostic shave biopsies on suspicious lesions, as this compromises accurate diagnosis and staging if melanoma is present. 4, 5 If biopsy is needed, complete excisional biopsy with 2mm margins and subcutaneous fat is preferred. 1, 4

Do not partially remove nevi for diagnosis, as this can create a pseudomelanoma picture that causes diagnostic confusion and patient anxiety. 1, 4

Answer: D. Refer to dermatologist