What is the recommended treatment for a patient with a mildly dysplastic (abnormal cell growth) mole, considering removal with liquid nitrogen?

Liquid Nitrogen is NOT Recommended for Mildly Dysplastic Nevi

Mildly dysplastic (atypical) nevi should NOT be treated with liquid nitrogen cryotherapy—surgical excision or observation are the only appropriate management options. 1

Why Cryotherapy is Inappropriate

Cryotherapy with liquid nitrogen is fundamentally unsuitable for dysplastic nevi because:

• No histopathologic confirmation: Cryotherapy destroys tissue without allowing pathologic examination to confirm the diagnosis or assess margins, making it impossible to determine if the lesion was completely removed or if melanoma was present 2

• Risk of missed melanoma: Moderately-to-severely and severely dysplastic nevi are associated with melanoma in 18-20% of cases, and excision of biopsy-diagnosed moderately dysplastic nevi can reveal melanoma in situ in 1.6% of cases 3

• Guideline violations: UK guidelines explicitly state that cryosurgery is "not appropriate for locally recurrent disease" and should only be used "for selected cases in specialized centres" for squamous cell carcinoma—not for melanocytic lesions 2

Correct Management Algorithm for Mildly Dysplastic Nevi

If Already Biopsied with Positive Margins:

Observation is acceptable for mildly dysplastic nevi with positive histologic margins, particularly when: 1

• The patient has multiple other atypical nevi (re-excising one lesion while leaving others intact is difficult to justify) 2
• Clinical margins appear clear despite positive histologic margins 4
• The lesion shows only mild atypia 1, 5

Evidence supporting observation:

• No melanoma development occurred in incompletely excised atypical nevi followed for 5+ years 1
• Local recurrence rate is only 3.6% over 2 years for mild-to-moderate atypia 2, 1
• Re-excision of mildly dysplastic nevi results in clinically significant diagnosis change in only 0.2% of cases 4

If Observation is Chosen:

• Regular self-examination taught to patient 1
• Clinical and dermoscopic follow-up 1
• Immediate evaluation for: rapid growth/darkening, bleeding/ulceration, or nodule development 1
• Photography to document baseline and track changes 1

If Surgical Excision is Preferred:

Conservative re-excision with 2-5 mm margins is recommended when: 1

• The lesion is the patient's only atypical nevus 2, 1
• The patient or clinician prefers definitive removal for peace of mind
• The lesion is a solitary concerning finding

Proper excision technique: 2

• Full-thickness excision with 2-5 mm clinical margins 2
• Include subcutaneous fat 2
• Use surgical scalpel (never shave, punch, or cryotherapy) 2
• Submit entire specimen for histopathologic examination 2

Critical Pitfalls to Avoid

• Never use destructive methods (cryotherapy, laser, electrocautery) on pigmented lesions without prior histologic diagnosis 2
• Avoid shave biopsies for suspicious lesions as they prevent accurate Breslow thickness measurement if melanoma is present 2
• Do not perform prophylactic excision of all atypical nevi—this is futile and not recommended 2

When to Escalate Management

Complete surgical excision is mandatory for: 1

• Severely dysplastic nevi (insufficient long-term data on observation)
• Any lesion where melanoma cannot be excluded clinically
• Lesions showing clinical change despite prior "benign" pathology