Methods for removing nevi in children and adults

A nevus is a benign spot or growth of congenital or acquired origin. Neoplasms can have a different shape and size and vary from flattened spots to large-scale papilloma-shaped elements. Most of these formations are not dangerous to the health of the patient, but they can cause some inconvenience, both aesthetic and functional. In addition, some of them can degenerate into melanoma - a malignant tumor. For these reasons, in some cases, the doctor prescribes the removal of the nevus. [1]

Nevus removal quota

The cost of removing a nevus differs not only depending on the region. Other factors, such as the type, size, location of the neoplasm, also matter. The final price is affected by the number of sessions, the complexity of the intervention, the use of painkillers and other medications, and the need for subsequent recovery after surgery. Of course, all medical manipulations justify the amount of money spent and allow you to get rid of a dermatological problem, but often it is the financial side of the issue that keeps patients from a timely visit to the doctor. Many people have a question: is it possible to remove a nevus for free? Sometimes it is really possible if the pathological element is removed not for aesthetic reasons, but for medical reasons. The patient should visit his attending (family) doctor, get a referral to a specialized specialist (dermatologist-oncologist or surgeon), who will give an opinion and, in turn, refer him to the manipulation. This opportunity is assessed on an individual basis.

Indications for the procedure

Removal of a nevus is indicated in such cases:

• if the problematic element is located in an area with a high probability of damage - for example, in places of friction of clothes and shoes, on fingers and toes, on the head or neck;
• if the presence of a nevus is negatively reflected in terms of the aesthetics of the appearance - in particular, the removal of a nevus is often necessary when it is localized in the face, décolleté area;
• if the neoplasm is injured, behaves suspiciously, or grows rapidly.

Urgently consult a doctor about the removal of a nevus  [2]if it:

• begins to darken or change color;
• it becomes inflamed around the perimeter, a red rim appears;
• from previously flat becomes bumpy;
• accelerates its growth;
• covered with cracks or sores;
• makes itself felt by unpleasant sensations, such as pain, tingling, itching, a feeling of pressure and fullness;
• starts to bleed.

Preparation

Before removing the nevus, the doctor examines it, if necessary, conducts a more thorough examination - for example, performs dermatoscopy. It is also important for the specialist to make sure that the patient has no contraindications to the removal procedure.

The scale of preparation for removal depends, first of all, on the method of anesthesia that is supposed to be used. If the intervention will take place under general anesthesia, then it is important that the stomach is empty at the time of the operation, because even the smallest amount of food or water in the stomach can pose a real threat to the patient's life.

Before any removal of the nevus, it is advisable to take a shower, since after the intervention, water procedures will be somewhat limited. On the eve of the operation, you should inform the doctor about which medicines the patient is taking on an ongoing basis. In advance, you should stop taking drugs that affect blood clotting - in particular, anticoagulants, antiplatelet agents (acetylsalicylic acid, Cardiomagnyl, Aspekard, etc.).

In general, the removal of a nevus does not require any specific preparatory measures. It is important to follow all the recommendations of the doctor, and the intervention will be as comfortable and without complications as possible.

Technique of the nevus removal

To date, the most common methods are cryodestruction (freezing with liquid nitrogen), electrocoagulation, as well as laser, radio wave and surgical removal of the nevus. In the latter case, local anesthesia is used: the surgeon excises and removes the pigment element with the capture of nearby healthy tissue, after which it sutures the wound. The intervention area is covered with an aseptic bandage. Unfortunately, in the future, a scar is invariably formed at the site of the operation. Large neoplasms are excised in stages, but quickly, since partial resection significantly increases the risk of malignant transformation of the growth. In such cases, it is recommended to remove the nevus under general anesthesia.

Removal of a nevus with a laser involves the use of an infrared beam, which accurately affects only the area of the neoplasm, without injuring healthy tissues. The surgeon directs the beam to the adjusted depth, after which the vessels that feed the neoplasm are sealed. Laser removal of a nevus is a short procedure and takes about 5-10 minutes, ending with the treatment of the damaged area with an antiseptic solution. The patient can go home almost immediately. [3].  [4]. [5]

Radio wave removal of nevi involves the use of the so-called "radio knife", which emits high-frequency thermal waves. These waves are directed to pathologically altered tissues, due to which the removal occurs. [6]The intervention consists of the following steps:

• chipping the area with a local anesthetic, preoperative treatment;
• removal of a nevus by radioexcision (radioexcision) using a working electrode using the Surgitron apparatus;
• antiseptic treatment of damaged tissues.

The incision occurs under the influence of heat, which is released by the tissues at the moment of resistance to the penetration of high-frequency waves emanating from a thin wire - a surgical electrode. Under the influence of heat, the affected cells disintegrate and evaporate, due to which the tissues move away from each other.

Removal of a nevus with Surgitron lasts no more than 10-20 minutes, however, this term depends on the size and number of neoplasms to be removed.

Removal of a nevus with liquid nitrogen is otherwise called cryodestruction. The methodology includes the following steps:

• With the help of special equipment or a mini-applicator, the surgeon applies liquid nitrogen to the growth. The tissue is exposed to a temperature of -195.7°C.
• Under the influence of cold, the pathological element freezes, the cytoplasm in its cells crystallizes, and the membranes are damaged. The neoplasm is necrotic.
• For some time, the tissues near the removed growth turn red and swell. The formed crust disappears, exposing healthy tissue.

With large spots, often one procedure is not enough. Indications for re-treatment are evaluated individually. If necessary, the removal of the nevus with the help of a dermatome is supplemented by transplantation of a skin area. [7]

Removal of a nevus by electrocoagulation is carried out using high-thermal exposure. The procedure is performed using local anesthesia and the so-called "electroknife", which simultaneously cuts the tissues and coagulates the vessels. This method is preferably used to remove pedunculated nevi, or elements that protrude strongly above the skin surface. Electrocoagulation can be supplemented with laser resurfacing, a procedure necessary to smooth the wound edges and level the treated area. This ensures an optimal cosmetic effect after healing. [8]

Removal of nevi on the face

Nevus spots on the face are often removed due to their unaesthetic appearance. In addition, other reasons for deletion are known:

• when carrying out daily hygiene procedures, the neoplasm is often injured - for example, during shaving or during the application of scrubs or other exfoliating agents;
• there is a high risk of malignant transformation.

Nevus growths in the facial area can be removed in a variety of ways, including surgery, radio waves, laser, or liquid nitrogen. However, with most methods, scars can remain on delicate skin. Therefore, specialists often choose the laser method of removal, as it is more gentle and accurate. During the procedure, the laser beam penetrates only to the required depth with a given intensity. At the same time, tissue disinfection and coagulation of damaged vessels occur, which positively affects the further process of skin restoration. Removal is usually painless and safe.

Removal of a nevus on the eyelid

Nevi located near the eyes or on the eyelids cause not only visual and mechanical discomfort: they are easily damaged when removing makeup or during hygiene procedures.

Nevus growths near the eyes are removed in a special way, because the close proximity to the organs of vision and thin, sensitive skin integuments play a role.

Removal is performed as accurately, accurately and carefully as possible, carefully dosing the depth of penetration into the tissue. In addition, it must be remembered that many small vessels pass through the eyelids, and their damage can cause quite severe bleeding.

The most difficult area for intervention is the area above and below the line of ciliary growth. If the nevus is located in this way, then it is removed only according to strict indications.

Eyelid surgery should only be performed by an experienced specialist who has enough practice to perform such an accurate and literally “jewelry” manipulation. The most popular and recommended procedure is the use of a laser.

Removal of pigmented nevi

Dysplastic or pigmented nevi are popularly called moles, less often - age spots. Such formations are different, both in size and in configuration, ranging from small growths to extensive spilled spots.

Pigmented elements can appear on almost any part of the body, including the face. They are recommended for removal as a matter of priority, since they have a risk of malignant transformation and are often injured.

The method of removing a pigment spot is determined during medical consultation and diagnosis. The specialist will select and recommend exactly the technique that will allow you to remove the build-up with minimal discomfort and an optimal recovery period.

If it is planned to remove a large dysplastic nevus, then the doctor must draw up a special scheme for further care and medication.

Removal of an intradermal nevus

Intradermal, or intradermal nevus, is often and ubiquitously found in humans. It is commonly referred to as a birthmark. It is a densely elastic papule, consisting of non-cellular structures localized in the middle (sometimes in the lower) dermal layer.

The average size of such a formation is 10 mm, the most common configuration is hemispherical, color shades range from light brown to almost black.

Light intradermal elements may contain dark blotches, and sometimes small capillaries become noticeable on the surface. Growths are congenital, or appear during puberty or later.

The technique for eliminating the neoplasm is determined by a dermatologist or surgeon. It is possible to perform classical surgical excision (for example, if the nevus is large or localized in a hard-to-reach area), electrocoagulation (high-temperature exposure), radio destruction (hardware procedure "Surgitron", with individual selection of the radio wave length). [9]

Removal of papillomatous nevus

Papillomatous nevus can be recognized by a tuberous outgrowth strongly protruding above the skin surface, which in appearance resembles a papilloma. It happens both congenital and acquired. This element is extremely prone to damage, and also gives the owner considerable psychological discomfort. Therefore, despite the slight tendency of the growth to malignancy, it is still recommended to remove it.

The formation can be eliminated by laser surgery, cryodestruction, radio wave method, electrocoagulation, or by surgical excision. Any of these procedures is performed using local anesthesia.

The most optimal cosmetic effect is achieved with laser removal of the nevus. But this method is not prescribed if we are talking about small spots with dubious diagnosis, requiring subsequent histological examination of tissues. [10]

Blue nevus removal

A blue nevus is an acquired formation protruding above the skin surface, often hemispherical, smooth, bluish-blue (less often brownish) in color, without hair growth. Often localized in the face, arms and legs, buttocks. In its development, the growth goes through the stages of fibrosis and proliferation of melanocytes. If fibrosis prevails, then they speak of regression of the neoplasm.

You should think about removing such a build-up if it begins to rapidly increase or peel off. The danger of malignant transformation is evidenced by the heterogeneity of the color shade, the appearance of additional inclusions and nodules inside the element.

One of the most common ways to remove a blue spot is considered to be laser surgery: due to the precise choice of the depth and frequency of the impulse action, only the nevus tissue is removed during the procedure. Healthy tissues are not damaged.

Removal of a large nevus

Removal of a giant nevus is carried out according to the following indications:

• to improve the appearance of a person;
• to reduce the likelihood of malignant degeneration of the neoplasm.

If possible, a large stain is removed, the sooner the better. With congenital pathology, the earliest possible operation is performed, especially if the problem area is located on the face, or in places subject to regular damage or friction. Difficulties with removal may arise when the nevus is localized near vital organs or structures.

Often the size of the affected area is so extensive that it requires a gradual, phased removal. In many cases, the use of a tissue expander and graft is required to correct the consequences of the intervention.

It is important to understand that patients with giant melanocytic masses have an increased risk of developing aggressive melanoma, a malignant process that develops from melanocytes. This risk is estimated at about 5-10%. If rebirth occurs, then the prognosis in this situation is unfavorable, and the survival rate is extremely low. In addition, there is a risk of the formation of other oncological formations - for example, sarcomas, lipomas, as well as tumors of the nervous system. To avoid such complications, the removal of the melanocytic nevus should be performed in advance.

Removal of a nevus of the conjunctiva

Conjunctival nevi can be represented by pigmented or non-pigmented elements localized in any area of the bulbar conjunctiva, or, much less often, on the conjunctiva of the eyelids.

The treatment of such a neoplasm is different: both expectant tactics and radical removal are used. Among the most popular surgical techniques are excision,  [11]electroexcision, cryodestruction. Modern treatment involves radical removal of the stain with the achievement of a functional outcome with an optimal cosmetic effect.

One of the most common surgical methods today is radio wave removal, which allows you to separate and remove pathological tissues with simultaneous coagulation of damaged structures. The use of nitric oxide at the postoperative stage helps to speed up the epithelialization process and improve the cosmetic effect.

Removal of a border nevus

The borderline nevus resembles a dysplastic neoplasm, but, unlike it, has the correct shape - round or oval, as well as a uniform color. The neoplasm is located in the border, basal epidermal layer. In most cases, the growth looks slightly raised above the skin surface, it is smooth and shiny, without hair growth. Color shades - from light brown to dark (almost black). It can occur on the arms and legs, the trunk, often located in the form of several spots. 

Possible treatment options for a borderline nevus include:

• Cryodestruction. [12]
• Electrocoagulation. [13]
• Laser thermocoagulation. [14]
• UHF coagulation. [15]
• Surgical excision.

Progressive borderline growths require excision, both for prevention and for early diagnosis of cutaneous melanoma. If a malignant process is detected, a repeated intervention is performed with excision of the postoperative scar, however, the need for such an operation is decided individually.

Removal of a warty nevus

A warty nevus looks like a wart. It has an uneven surface, riddled with many "wrinkles", or small cracks. In relation to such nevi, two therapeutic approaches are used: observation and removal. It is said to be removed if the following signs are present:

• excessively bright color shade, or its change;
• structural unevenness, or uneven growth;
• the appearance of pain, itching, bleeding;
• inconvenient location that causes discomfort and / or contributes to regular trauma.

The recommended type of nevus removal is surgical, which is the excision of the growth along with subcutaneous fatty tissue. The resulting biological material is sent for histological diagnosis to make sure that there is no malignancy. If surgery is contraindicated, other methods of eliminating the problem element are used. [16]

Verrucous epidermal nevus is successfully treated with photodynamic therapy.[17], [18]

Removal of a congenital nevus

Features of the management of a patient with a congenital nevus formation are established by the doctor individually. Spot size plays a special role in the choice of tactics.

• If the size of the build-up does not exceed 1.5 mm, then it is recommended that the patient be monitored routinely until he reaches the age of 18, since the risk of early degeneration of such a neoplasm is less than 1%.
• If the size of the build-up is in the range of 1.5-10 mm, then it is either observed or removed, at the discretion of the specialist. When choosing tactics, they are guided by the presence or absence of somatic pathologies, features of the skin, and the aesthetic side of the issue.
• With large or giant nevus sizes (from 10-20 mm or more), the risks of malignancy are especially high. In this regard, it is recommended to remove such a formation, and observation is established only if it is impossible to carry out an intervention. [19]

Removal of a nevus for a child

Nevi are equally common in both adults and children. And in many cases, single formations are present in children from birth, although they may appear a little later - after a few months. To remove or not to touch the speck - the pediatric dermatologist decides after a comprehensive diagnosis. It is important to note that before the child reaches the age of 18, nevi are removed only according to strict indications. [20]

Ordinary surgical excision is a reliable way to remove a nevus, but it is used mainly in relation to large neoplasms. In addition to surgery, in childhood, electrocoagulation, radio wave or laser exposure can be used. [21]

Removal of a nevus in childhood must necessarily be carried out in a special clinic or surgical (dermatological, oncological) department, where there is appropriate diagnostic and therapeutic equipment, instruments, anesthetics. Beauty parlors are not suitable for this purpose. It is strictly forbidden to remove nevi for children on their own. 

Recommendations for parents of children with pathological nevus formations are as follows:

• In the presence of congenital nevi, it is important to regularly consult a dermatologist or oncologist. Such observation should continue until the patient reaches the age of 20 (unless there are indications for the removal of the pathological stain).
• Medium-sized growths in the absence of contraindications can be removed at the age of 7-12 years.
• If it is necessary to remove a large or giant nevus formation, it is recommended to additionally consult with a plastic surgeon.
• Measures should be taken to avoid injury to the nevi and to avoid exposure to ultraviolet radiation.

Histology after nevus removal

Histological examination is most often carried out after the complete removal of the nevus, less often only a small sample of biomaterial is taken for diagnosis.

The tissues to be examined are placed in a special suspension and examined under a powerful microscope. The specialist identifies or excludes dangerous cellular structures, draws up a conclusion, on the basis of which a diagnosis is made in the future.

The advantage of this method is that histology is able to detect malignant cells at a very early stage of their development. Such information allows the doctor to prescribe the correct treatment, excluding the further development of adverse effects.

Not all nevi require histology. Be sure to do this research:

• if there are sores, cracks on the surface of the nevi;
• if all the hairs from the neoplasm suddenly disappeared;
• if discomfort, itching, burning, pain appeared in the area of the nevus;
• if the skin near the nevus spot is reddened, swollen;
• if the size, shape, color shade, structure of the build-up have changed.

At the slightest suspicion of malignancy of the neoplasm, it should be removed, and the resulting biomaterial should be sent for further histological examination. In some cases, diagnosis is carried out before the removal of the nevus in order to mark the boundaries of the operation and draw up a further treatment and recovery regimen.

Contraindications to the procedure

In general, there are no absolute contraindications to the removal of a nevus. However, there are a number of relative contraindications, in the presence of which only the doctor decides whether to perform the operation or not. We are talking about such diseases and conditions:

• malignant processes, regardless of their localization;
• viral hepatitis, HIV, diabetes mellitus;
• the period of pregnancy and breastfeeding;
• relapses of chronic pathologies;
• infectious and inflammatory pathologies;
• mental disorders;
• decompensated states, severe pathologies of the cardiovascular and respiratory systems;
• violations of the blood coagulation system;
• increased skin photosensitivity;
• autoimmune pathologies;
• dermatological diseases in the area of the proposed intervention;
• active herpes.

If a patient has a suspicious nevus, with an increased likelihood of malignancy, then there are practically no contraindications to its removal.

Complications after the procedure

Some of the possible complications include:

• Redness of the skin in the area of the removed nevus may be present throughout the entire healing period, which is considered the norm. However, if swelling and pain join the redness, then you should definitely seek medical help: signs of inflammation indicate the development of an infectious-inflammatory process in the wound.
• Pain is most often present for several days after the procedure, and gradually disappears as the tissues heal. If complications develop in the form of an inflammatory reaction, then the pain intensifies, becomes pulsating, supplemented by swelling and hyperemia.
• A pit or depression on the skin appears if the nevus to be removed was located deep in the tissues: the defect becomes noticeable after the crust falls off. The smoothing of the deepening is still gradually taking place, but this process can continue for quite a long time - from six months to 2 years, or even more.
• The temperature after removal of the nevus may rise slightly within 24 hours, after which it normalizes. This effect is associated with the body's response to a violation of tissue integrity and general stress. If after 48 hours the temperature does not stabilize, and signs of an inflammatory process appear in the wound area, then it is urgent to consult a doctor.
• The discharge of pus from the wound indicates that a pyogenic infection has entered it, which could occur both during the intervention and with improper care of the wound surface. A doctor should deal with the treatment of a purulent process.
• The change in the pigmentation of the skin in the area of damage is often temporary and is corrected independently for several months.

Consequences after the procedure

Adverse consequences can occur with improper or insufficient postoperative care of the wound surface. Most often, problems are caused by infection in the wound, peeling off the formed crust. We must not forget that the seam after removal of the nevus must be treated with disinfecting solutions, and after the scab falls off, healing and resolving ointments should be used to prevent the formation of a rough scar.

If the intervention was carried out using laser technology, and the size of the neoplasm was small, then after healing, there will be practically no visible traces on the skin. A scar after removal of a nevus almost always remains if surgical excision was used, as well as in cases of improper wound care. For example, forcible peeling off the crust necessarily leads to the further formation of an ugly and even rough scar.

To improve the appearance of the damaged area and exclude the formation of a scar at the healing stage, special absorbable external preparations should be used - for example, Contractubex ointment, Kontrarubets, Solcoseryl, etc.

Nevus recurrence after removal

In general, the recurrence rate of excised nevi is low, with one prospective study finding only 3.4% recurrences  [22],  [23] and necessitates reoperation, sometimes multiple, unless radical surgical excision is involved. Recurrent nevus is defined as a separate nosological unit, which indicates the existing differential diagnostic difficulties in this matter.

Re-growth of the neoplasm most often occurs within six months after the removal of the primary element. If the removal of the nevus occurred in layers to the subcutaneous tissue, then recurrence was noted only in isolated cases. [24]

The probability of re-growth is determined by the following clinical and epidemiological risk factors:

• gender (relapses occur more often in women);
• age (more often at a young age);
• anatomical location (relapses occur more often after removal of nevi in the back and upper limbs);
• removal period (mainly within six months after the operation).

The recommended method for removing a recurrent nevus is surgical excision followed by histological examination.

Can removing a nevus cause melanoma?

Complete and simultaneous removal of a nevus cannot give impetus to the development of a malignant process. However, melanoma can be provoked by a partial biopsy, so it is not recommended to perform it in such a volume: if necessary, only superficial smears are taken for histological examination, provided that damage, cracks or erosion are present on the neoplasm.

Malignant degeneration also occurs after partial excision of nevus elements, so such an intervention is usually not practiced. The stain or outgrowth is removed completely, and only after that the biomaterial is sent for histological examination. In this case, the risk of malignancy is practically absent.

Care after the procedure

The main condition for fast and high-quality tissue regeneration after removal of the nevus is compliance with all medical recommendations. For 10-14 days after the procedure, the following rules should be followed:

• do not touch or remove the formed crust on the wound;
• treat the removal area with drugs prescribed by the doctor;
• after independent discharge of the crust, use special healing and absorbable ointments;
• do not wet the wound until the crust is removed;
• do not apply cosmetics to the operated area;
• do not expose the area with the removed nevus to ultraviolet rays, do not sunbathe and do not visit the solarium;
• do not drink alcohol (so as not to provoke bleeding due to vasodilation).

If everything is done correctly, then the risk of unpleasant consequences is reduced to zero.

How to treat a wound after removing a nevus?

After the procedure for removing the nevus, the wound is treated twice a day, in the morning and in the evening. For processing, a pink solution of potassium permanganate or the pharmaceutical preparation Fukortsin is used. You can sprinkle the wound surface with Baneocin. A few days later, at the discretion of the doctor, external preparations with a restorative effect are prescribed, such as Bepanten, Solcoseryl, Emalan, as well as methyluracil ointment.

For 5-10 days, you should not wet the wound, and even more so peel off the resulting crust. If water still gets on the wound, then it should be dried with an alcohol solution: tincture of calendula or propolis, and even an ordinary solution of brilliant green, will do.

After the scab discharges on its own and the pink “young” skin is exposed, the surface can be lubricated with restorative preparations - for example, Contractubex, Bruise-off, Rescuer, etc. Ointments are applied 2-4 times a day. The duration of treatment can range from 3-4 weeks to several months.

In the future, in order to avoid changes in pigmentation, the damaged area is regularly lubricated with sunscreens with SPF 15-30, and during periods of increased solar activity - with SPF 50.

The duration of healing and full recovery after removal of the nevus is individual. This term usually varies from 2-3 weeks to 1.5-2 months. Healing takes a little longer in elderly patients, diabetics and people with a weakened immune system.