Bulky moles (raised) or papillomatous nevi, also called dermal nevi, are proliferative formations on the surface of the skin that are either skin-coloured or pigmented - brown, brown, black.
Some of them are congenital, occurring up to the age of 5, and they have a low cancer risk.
More rarely, however, in recent years it has been found that melanoma can occur at any age and on a congenital papillomatous mole.
How can bulky (raised) moles be removed?
Moles can be removed by laser ablation, provided they are evaluated dermatoscopically beforehand and only if the diagnosis is benign.
Even so, there are situations where we choose to do histopathological examination and remove the entire lesion from the skin with a blade, the so-called "shave biopsy".
The base of the lesion is destroyed by the laser, so that an area of burn is left behind to be healed under local treatment, sometimes with the protection of a topical antibiotic.
The procedure is carried out under local anaesthesia with xylin, lasts only a few minutes, the pain only appears in the first few seconds and then disappears completely.
The scab will stabilise and disappear in about two weeks, leaving behind a reddened area which, if the laser treatment has been carried out correctly, will not leave any residual trace in the medium to long term, using a silicone scar gel.
Compared to older methods such as electroablation or liquid nitrogen therapy, the carbon dioxide - Co2 ablative laser has clearly superior results: Inflammation is reduced, healing/epithelialisation is much faster and without residual signs. These advantages cannot be achieved by the old ways of working.
When is it ideal to intervene on unwanted moles?
In principle, we can remove these nevi in any season, including summer, when the epithelialisation process is a little more difficult due to sweating and when we risk over-infection.
Moreover, if we expose a reddish lesion to the sun without proper protection (applying maximum sun protection factor), during the healing process we risk hyperpigmentation - the appearance of a spot in place of this lesion.
These risks disappear as the weather cools, with autumn being the season when we can have this kind of procedure without worry.
The diagnostic certainty and advanced technology helps us remove any bulky moles that bother us in one procedure, one CO2 laser session.
The lesion is dermal, so the cells are in the second layer of the skin, and in order for us to ensure that we have ablated/destroyed all the component cells, we would have to remove the entire dermis. Or the dermis is the supportive and firm layer, responsible for the healing process.
Therefore, if the aim is to remove the lesion completely, we will have a consistent residual mark, which may extend beyond the edges of the original lesion. Or if this lesion is located in an area that is easily accessible to the eye - face, neck, etc., this is not desirable.
Because we can't do that in all circumstances, we sometimes have relapses. These are cells that regenerate and, even if they are not necessarily dangerous, require dermoscopic analysis and even histopathological examination to ensure that the lesion is benign in nature.
When should we be concerned and ask for an evaluation at the dermatologist's office?
An old saying goes that "people with lots of moles are lucky". Quite possibly, however, from a medical point of view, people with many moles fall into the category of "patients at risk".
About these protruding moles we should know that some are harmless and do not bother from an aesthetic point of view. It happens that other such moles appear during life. How do we know which are dangerous and which are not?
Simple. Through dermatoscopic consultation. Any lesion, any dermal nevus should be assessed clinically and/or dermatoscopically.
Basically, there are two broad categories of lesions - pigmented proliferative lesions, which are raised lesions, and papillomatous muriform lesions or andomas, which are those dermal nevi. Unfortunately, sometimes these proliferative lesions can be tumoral.
Basically, both lesions that are clinically, visibly transformed - with changes in shape, size, colour and surface, and those that cannot be perceived with the naked eye, must necessarily be evaluated dermatoscopically, i.e. at micro level!
Surgical excision and histopathological examination must clarify the diagnosis which, even if malignant, i.e. melanoma, is insidious, curable by correct surgical excision. It is therefore dermoscopy that brings clarity and decides the diagnosis between benign (warts that can be treated by laser therapies) and malignant.
Between benign and malignant there is a grey area, where only the vigilant eye and experience of the doctor can intervene appropriately. Solitary nodular pigmented lesions must be excised, as they may hide a malignant diagnosis.
Dermoscopy helps us to understand the specificity of each lesion evaluated under the magnifying glass.
Why is it good to detect malignancy at an early stage?
The skin has several types of cancers, but the most common are carcinomas and melanoma. Carcinomas are skin cancers with a much milder prognosis, often without major, life-saving implications.
Melanoma, instead, it is the most "fierce" type of cancer. Why?
Because it can occur both on lesions, on moles that we already have, and anywhere on the skin surface of a "mole-rich" patient (80% of melanomas occur on de novo skin).
Therefore, when we have a lot of moles or personal family history, we should perform regular check-ups, do regular dermoscopy check-ups.
By regularly monitoring the entire surface, all lesions are identified and tracked as they evolve so that doctors can intervene in a timely and effective manner.
Lesions that bleed or ulcerate during the course of the disease mean that we are presenting to the doctor with an advanced tumour. Unfortunately, the vital prognosis is affected.
This is why it is necessary to visit the dermatologist's office preventively so as not to risk our lives.
Dermoscopy should therefore be part of every human's annual routine, with at-risk patients being recommended for reassessment every six months, sometimes even every three months (predominantly in new patients, those who have not been monitored at all).
There are four categories of patients at risk:
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- the patient with over 100 moles;
- patient with more than 50 dysplastic nevi;
- patient with a personal history of melanoma
- and the one with family history.
They must rigorously report to dermatoscopic control.
How do we distinguish between moles and dysplastic nevi?
This difference cannot be made by the human eye. Only dermoscopy detects each type of lesion on the entire skin surface. The asymmetry of a lesion tells us its typology, asymmetries that can only be identified with the dermoscope. Lifelong dysplastic lesions are not life-threatening.
That's why not every dysplastic nevus needs to be excised, as used in the past to prevent melanoma - only one in five melanomas develop on pre-existing moles, the rest occur de novo. Therefore, only your dermatologist will be able to tell you what type of dysplastic nevi you have, whether they need to be excised or not.
New melanoma treatments
In recent years, new targeted immunological treatments have emerged to improve the prognosis of patients with advanced disease. Here we are talking about lymph node metastatic disease or even with visceral metastases.
Immunotherapy has proven to be highly effective, extending the disease-free life span and even the survival of the metastatic melanoma patient, which can be considered a revolution. Because melanoma is a disease with an important immunological substrate, discoveries are ongoing and we hope that one day we will be able to control this tumour and, why not, cure it!
