Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

clinically benign

1st line – observation

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ACUTE
|
clinically benign
1st line – 

observation

If the physician is confident from history and physical exam that the melanocytic nevus is benign, then treatment (i.e., removal) is not usually indicated. The patient may require only reassurance of the benign nature of the nevus. Patients can be encouraged to perform skin self-exams and to seek medical advice if they are concerned.

2nd line – surgical removal or laser therapy

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ACUTE
|
clinically benign
2nd line – 

surgical removal or laser therapy

Despite reassurance, some patients may still want the nevus to be removed. Reasons include repetitive trauma; itching, bleeding, or irritation; cosmetic reasons; or excessive anxiety that the lesion is malignant.

Punch biopsy allows complete removal of the nevus with relatively small margins of safety. This technique would not be used if there were concern for the potential for malignancy.

Excision biopsy is the definitive method for removal.[5][46] A small margin of tissue (2 mm) is provided to ensure free margins, and the depth is removed down to the level of the fat, ensuring complete removal. Disadvantages include the invasive nature of the procedure, increased risk of infection, bleeding, and hematoma. Sutures are required, necessitating the patient's return within 1 to 2 weeks for removal.

The practice of using laser devices is controversial, especially because of the lack of histopathologic diagnosis and the potential for misdiagnosis of a melanoma as a benign nevus or lentigo.[81][82] The potential for malignant change of melanocytes treated by laser is unknown, and there have been case reports of melanomas arising in sites treated by laser.[83][84] Additionally, incomplete removal of the nevus may result in a pseudomelanoma pattern.[85]

Allergy to local anesthetic is rare, especially with the amide local anesthetics such as lidocaine (vs. ester local anesthetics). The most commonly used local anesthetic is 1% lidocaine with a 1:100,000 dilution of epinephrine, which is added for its vasoconstrictive properties, helping to decrease bleeding and prolong the duration of anesthesia. Any pain is usually minimal and easily managed with acetaminophen.

Plus – topical ointment

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ACUTE
|
clinically benign
Plus – 

topical ointment

Treatment recommended for ALL patients in selected patient group

The wound should be washed with soap and warm water and the topical ointment applied as instructed.

Hydrogen peroxide may also be used to clean the wound to prevent the buildup of crust, which may interfere with healing.

The patient should keep the affected area(s) covered with an adhesive bandage to maintain a moist environment for wound healing.

Primary options

petrolatum topical: apply to the affected area(s) twice daily for 2 weeks, or until the wound is healed

Secondary options

bacitracin/neomycin/polymyxin B topical: apply to the affected area(s) two to five times daily

clinically suspicious for melanoma

1st line – surgical removal

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ACUTE
|
clinically suspicious for melanoma
1st line – 

surgical removal

Excision biopsy of the lesion is the definitive method for removal of melanocytic lesions.[5][46] A small margin of tissue (2 mm) is provided to ensure free margins, and the depth is removed down to the level of the fat, ensuring complete removal. Disadvantages include the invasive nature of the procedure, increased risk of infection, bleeding, and hematoma. Sutures are required, necessitating the patient's return within 1 to 2 weeks for removal.

Allergy to local anesthetic is rare, especially with the amide local anesthetics such as lidocaine (vs. ester local anesthetics). The most commonly used local anesthetic is 1% lidocaine with a 1:100,000 dilution of epinephrine, which is added for its vasoconstrictive properties, helping to decrease bleeding and prolong the duration of anesthesia. Any pain is usually minimal and easily managed with acetaminophen.

Plus – topical ointment

Back
ACUTE
|
clinically suspicious for melanoma
Plus – 

topical ointment

Treatment recommended for ALL patients in selected patient group

The wound should be washed with soap and warm water and the topical ointment applied as instructed.

Hydrogen peroxide may also be used to clean the wound to prevent the buildup of crust, which may interfere with healing.

The patient should keep the affected area(s) covered with an adhesive bandage to maintain a moist environment for wound healing.

Primary options

petrolatum topical: apply to the affected area(s) twice daily for two weeks, or until the wound is healed

Secondary options

bacitracin/neomycin/polymyxin B topical: apply to the affected area(s) two to five times daily

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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