to the editor: Atypical nevus syndrome is commonly seen in primary care. While most people have 30 to 40 nevi on their bodies, those with atypical nevus syndrome often have hundreds. To make matters more difficult, many of these nevi are quite atypical in appearance and meet the American Cancer Society criteria for concern, namely asymmetry, border irregularity, color variegation and diameter greater than 6 mm (the ABCD criteria).
Many systems of photo documentation have been described, but the logistics of whole-body photography exceed the capacity of most family physicians.
In 1990, I began using a videocassete recorder equipped with a macro lens to document the skin condition of these patients and to provide a basis for periodic follow-up. I have found this technique to be effective and efficient for managing scores of patients with this condition.
Before the video is made, the patient's skin is thoroughly examined from scalp to sole. All nevi of concern are marked with a simple inked rubber stamp 1 to 3 cm in length that is placed close to the lesion. The current date is programmed onto the videocassette recorder and a systematic video recording of the entire skin surface is completed. All marked nevi are also magnified with the macro lens, providing great detail for each worrisome lesion. The ability of the videocassette recorder to zoom in and out on these lesions allows for unambiguous localization. A monitoring screen is coupled to the videocassette recorder during the taping to assure video quality. The completed video is then given to the patient for safekeeping.
In three to six months, depending on the degree of concern, the patient is again examined, and all suspicious lesions are restamped. The original skin scan is then reviewed and the “freeze frame” mode is used to capture the best magnified image of each lesion. Simple headset magnification loupes enhance adequate comparison of lesion size, shape, color and symmetry. The initial videotape soundtrack recording of the examiner's impressions is also of great benefit. This process of skin review is then repeated every six months for patients with a history of melanoma and every six to 12 months for those with atypical nevus syndrome.
Changes in established skin lesions are very apparent and easy to follow with this technique. Surprisingly, many nevi become smaller and less pigmented as the patient avoids sun exposure. Some atypical nevi disappear altogether. New nevus growth is also easily detected with this procedure. Markedly atypical lesions and aggressively changing nevi are immediately removed. The higher the pathologic grade of atypia, the more frequently the examination is performed.
I have found this to be a satisfactory means of monitoring these patients. It has significantly minimized the need for excisional biopsies and has greatly reduced the concern that important nevus changes will be missed. The cost of the equipment is nominal. With practice, the initial study takes 30 to 45 minutes and follow-up studies somewhat less.