Information on Moles
“Mole” is not really a medical term. It is a general term that refers to any discolored spot on the skin. Moles can be any color – brown, black, pink, red, white, grey, purple, or a mixture of colors. They can be flat or raised. Medically, we are most concerned about discolored spots that might be melanomas (a potentially dangerous type of skin cancer that can spread throughout the body if not completely removed) or spots that might turn into melanomas. Moles are important because some of the types of spots we call moles can be melanomas. Most “moles” are harmless; but finding the ones that are not harmless can save your life.
How do I know if a mole is harmful?
The only way to know with any degree of certainty is to cut it out and have it analyzed microscopically. Generally, it is impractical and undesirable to remove every mole on the body. The practical question becomes how do I know which moles should be removed to be analyzed? There are two generally accepted primary guidelines (and two more that I recommend).
The earliest (and probably best) indicator of possible danger is a change in a mole. A change is any change. Often patients think that change means only darker or bigger or bleeds, but change can also mean lighter, smaller, different shape, different size, a different feeling (like itching), or hair falling out of a mole. If a mole is different in any way, it should be carefully considered for removal. Sometimes a mole just seems different or you start noticing it more but are not sure it has changed. That subtle a difference still deserves an evaluation by a dermatologist. Change is an especially important guideline because studies show that change is something more likely to be picked up by a patient than by a doctor. But if a mole changes, there is no reason to be frightened. Most moles that change are harmless. But some are not. And the ones that are not are usually curable when discovered at what usually turns out to be an early stage.
The second major indicator of possible trouble is irregularity in a mole. An early attempt to teach public awareness about this guideline was the ABCD (and now some advocate an ABCDE) system of evaluating moles.
The “A” is for asymmetry, the “B” for border irregularity, the “C” for color irregularity, the “D” is for a diameter greater than 6 millimeters (about the size of a pencil eraser), and “E” is for evolving. The American Melanoma Website has a nice discussion of the ABCD system www.melanomafoundation.org/prevention/abcd.htm. But that system will both cause overreaction to harmless moles and under reaction to others. For instance, all moles have some degree of asymmetry, some degree of border irregularity, some degree of color irregularity, and I have diagnosed several melanomas less than the size of a pencil eraser. As for “E” (evolving), there is something called a regressed melanoma which will begin by getting smaller. (By the way, if you go to the American Melanoma Foundation website cited above, there are several errors in page on ABCD’s of melanoma. Under the discussion of color they state that “The color is uneven. Shades of brown, tan, and black are present.” True enough, except melanomas may also have shades of pink, white, or blue. So-called amelanotic melanomas may be entirely pink without any darker tan, brown, or black. In the section entitled “Other Warning Signs” scaly appearance is cited as a warning sign. In general scaling in a mole is a good sign, not a bad one. Scaling is generally only of concern when it is a change.) The American Academy of Dermatology has a generally sound discussion of the ABCDE system (www.aad.org/public/exams/abcde.html). Yet another variation of the ABCD system is the ABCD’S with S referring to a change in sensation. A website that discusses this variation and includes a nice graphic on doing self skin exams is www.medicalcenter.osu.edu/PatientEd/Materials/PDFDocs/dis-cond/cancer/melano.pdf.
So, how do you evaluate for irregularity if all moles are irregular to a degree? Here’s what I suggest. First, evaluate your moles based upon what is normal for you. It is unlikely that you have ten or fifteen melanomas. Second, look for any mole that exhibits what is called the “ugly duckling” sign. An ugly duckling mole is a mole that is different than your other moles. Third, don’t forget the importance of change. If a mole is more irregular than before, that mole is concerning. Finally, see a dermatologist certified by the American Board of Dermatology and Cutaneous Surgery for a compete skin exam at least once a year. Change is best diagnosed by the patient, but irregularity is usually best diagnosed by a trained and properly credential dermatologist. (You can get the name, address, and phone number of a properly credentialed dermatologist by going to the American Academy of Dermatology website www.aad.org. Those that have the letters FAAD after their name are board certified by the American Board of Dermatology. More information about certification by that board is available on its website www.abderm.org.
So, the two major guidelines to use when evaluating your moles are change and irregularity. But I have two more to add to the usual list based upon my experience.
The first additional warning sign is a mole about which you have a funny feeling. I have had patients with moles that did not fit any of the usual guidelines but something about the mole kept bothering them. It was as if the mole created a sense of dread or anxiety that went beyond just not liking it. When removed, the moles proved to be melanomas. The body seems to have a sixth sense about itself that is worth honoring.
The second additional warning sign is a mole that your dog (or some else’s dog) sniffs or licks. I have diagnosed one melanoma in a perfectly normal looking mole that never changed. It was removed because a family member’s dog kept sniffing it. Others have reported similar episodes of dogs identifying melanomas using their sense of smell. Presumably, at least some melanomas produce a substance that at least some dogs can smell.
In summary, moles that change (in any way), moles that are irregular (think “ugly duckling” sign), moles about which you have a funny feeling, or a mole that a dog repeatedly sniffs or licks need professional attention. Remember: most suspicious moles that fall into one of the above categories are harmless. So, there is no cause of alarm. But those are the warning signs that should prompt you to seek medical attention.
How are moles removed?
It depends upon the type of mole, the location, the reason for removing it, and the preferences of the patient and the doctor. In general, the options are a shave or excisional biopsy (sometimes called a shave excision), a punch biopsy, excision with stitches, electrodesiccation (“burning it off”), freezing, and laser. The last three options do not allow for a pathologic evaluation and should not be done on moles where there is any question of the diagnosis.
A shave or excisional biopsy involves numbing a mole with a local anesthetic and then superficially removing it with a scalpel so that it can be sent for histologic diagnosis (which means sending it to the lab for evaluation by a dermatopathologist). That procedure is quick, simple, essentially painless–taking just a few minutes. There are no stitches, and so regular activities can resume right after the procedure. Many of my patients go on to work or whatever else they were planning that day immediately afterwards. The medically important issue with that procedure is that the physician be skilled enough to know how to take just the “right amount” of tissue. Taking too little can result in an erroneous diagnosis. Taking too much results in a larger scar or mark than necessary. Having a well-trained, experienced physician do the biopsy is key to getting enough without too much.
A punch biopsy is similar in that it involves numbing the mole with a local anesthetic first. It differs in that the biopsy is done with a “coring” type of instrument that puts a round hole in the skin. This procedure is preferable when there is a deep component to the mole that is not accessible with a shave biopsy or when the mole is so small it can be effectively completely removed with the punch biopsy. Sometimes a punch biopsy is used on a part of a mole that is very large and is suspected of being a melanoma. Unfortunately, using a punch biopsy procedure in that situation can often make accurate diagnosis difficult. Some stitch the punch biopsy closed after removing the tissue. I generally do not put in stitches because stitching leads to a higher incidence of infection, seldom improves the cosmetic appearance, interferes with activities later, and then needs to be removed at a later office visit–adding to inconvenience and expense.
An excision with stitches is the most invasive and potentially most thorough way to remove a mole. It also is the most involved procedure, often with the largest scar, and usually the most expensive. Often it is better to do one of the above biopsy procedures and follow it up with an excision if the histologic diagnosis shows a need for additional removal. But sometimes it makes sense to do an excision as the first procedure. Each mole presents its own unique reasons for removal, and each patient has his or her own special considerations.
Electrodesiccation, freezing with liquid nitrogen, and laser are all locally destructive techniques that can be used for removing spots on the skin. None of those should ever be used on any growth except in situations in which a competent dermatologist sees no special risk in destroying a growth without getting a histologic diagnosis (the pathology report that tells you what you have). In October, 2009 I attended a conference at Harvard Medical School about the use of lasers in dermatology and medicine. Dr. Rox Anderson, head of the team of laser experts at Harvard, stated very clearly that removing moles with laser should be considered a strictly experimental procedure.
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