Management of dysplastic nevi: a 6 year follow-up survey assessing practice trends among US dermatologists

Dear Editor,

The diagnosis and management of dysplastic nevi (DN) has been, and remains, controversial (1). The goal of this study was to assess the continuing evolution of practice trends for DN evaluation and management over a 20 year interval by comparing responses to our previous Journal of the American Academy of Dermatology (JAAD) studies published in 2001 and 2015 (2,3). Using similar methodologies from the prior studies, 479 dermatologists responded to survey questions about their management of dysplastic nevi (2). Data were collected about respondent’s years in practice (YIP, categorized as less than 5 years, 6–14 years, 15–25 years and 26 years plus) and practice type. Descriptive statistics were analyzed with Microsoft Excel^®. Specific significant differences noted between 2015 and 2021 survey and the corresponding subset comparative analysis (based on clinical experience) is displayed in Table 1.

Table 1. Significant differences noted between 2015 and 2021 survey and corresponding subset comparative analysis based on clinical experience.

Statement	Group	%	Group	%	Difference (%)		p-Value
Typically re-excise if severe DN margins are negative	2015	49	2021	58	+9		<0.01
Do not re-excise if DN margins are negative	2015	51	2021	42	−9		<0.01
Sometimes use technology for DN evaluation	2015	11	2021	25	+14		<0.01
Never use technology for DN evaluation	2015	89	2021	74	−15		<0.01
Always recommend ophthalmologic exams for DN patients	2015	7	2021	12	+5		<0.01
Usually recommend ophthalmologic exams for DN patients	2015	8	2021	13	+5		<0.01
Never recommend ophthalmologic exams for DN patients	2015	54	2021	47	−7		<0.05
Question	YIP	%	YIP	%	YIP	%	YIP	%
Re-excise severe DN if (-) margins
2015	<5	68	6–14	58	15–25	53	26+	39
2021	<5	66	6–14	66	15–25	58	26+	41
% Difference (vs. 2015)		−2		+8		+5		+2
p-Value		NS		<0.01		NS		NS
Do not typically re-excise DN if (−) margins
2015	<5	32	6–14	43	15–25	50	26+	62
2021	<5	24	6–14	21	15–25	34	26+	53
% Difference (vs. 2015)		−8		−22		−16		−9
p-Value		<0.01		<0.01		<0.01		<0.01
Typically order step sections
2015	<5	21	6–14	29	15–25	31	26+	41
2021	<5	32	6–14	23	15–25	27	26+	42
% Difference (vs. 2015)		+11		−6		−4		+1
p-Value		<0.01		<0.05		NS		NS
Use of Dermoscopy
2015	<5	95	6–14	86	15–25	73	26+	76
2021	<5	99	6–14	97	15–25	82	26+	83
% Difference (vs. 2015)		+4		+11		+9		+7
p-Value		<0.01		<0.01		<0.01		<0.01
Follow up every 3–12 months based on individual DN patient risk	YIP		YIP
2015	<5	35	6+	24
2021	<5	26	6+	24
% Difference (vs. 2015)		−9		0
p-Value		<0.01		NS
Re-excise moderate DN if (+) margins	YIP		YIP
2015	0–25	74	26+	56
2021	0–25	55	26+	45
% Difference (vs. 2015)		−19		−11
p-Value		<0.01		<0.01
Avg surgical margins for excisional removal of DN
2015	<5	2.7 mm	6–14	2.5 mm	15+	2.2 mm
2021	<5	2.7 mm	6–14	2.9 mm	15+	2.4 mm
% Difference (vs. 2015)		0		+0.4		+0.2

Dermatologists still increasingly believe there is additional risk for melanoma in DN patients (78% in 2015, 59% in 2001, 80% currently). However, fewer dermatologists still currently attempt total removals when biopsying DN to achieve clear margins (86% in 2001, 69% in 2005, 68% currently). Both of these changes from 2015 to the present were non-significant. Average surgical margins grew larger over time (1.92 mm in 2001, 2.32 mm in 2015 vs. 2.56 mm currently).

For DNs with positive margins, there was minimal non-significant change in desiring to re-excise for severe (98% in 2015 vs. 97% currently), moderate (67% in 2015 vs. 63% currently) and mild DN (12% in 2015 vs. 11% currently). 3% of respondents did not re-excise at all, which is an increase in 2% from 2015. For DNs with negative margins from 2015 to present, there was a significant increase in the decision to re-excise severe DN (49% in 2015 vs. 58% in 2021, p < 0.01) and a significant decrease in the decision to not re-excise at all (51% in 2015 vs. 42% in 2021, p < 0.01).

In the current study, dermatologists with 5 YIP or less averaged the largest surgical margins (2.7 mm) vs. 6–14 YIP (2.5 mm) and 15+ YIP (2.2 mm). Experienced dermatologists, with greater than 15 YIP, averaged narrower surgical margins in 2015 when compared to the present (2.2 mm in 2015 vs. 2.4 mm currently). There was no change in average surgical margins for removal of DN in dermatologists less than 5 YIP in this same time frame but margins grew by 0.4 mm for dermatologists in 6–14 YIP (2.5 mm in 2015 and 2.9 mm currently). When comparing the current study to 2015, experienced dermatologists (>26 YIP) in 2015 were also significantly more likely to re-excise moderate DN with positive margins (56% in 2015 and 45% in 2021, p < 0.01) and were slightly less likely to re-excise severe DN with negative margins (39% in 2015 and 41% in 2021, NS).

The use of dermoscopy grew by only 4% since 2015 compared to a 56% increase in the prior interval (from 2001 to 2015) and remained inversely related to YIP. Dermoscopy was used by 99% of dermatologists in the current study who were less than 5 YIP. Dermatologists in 6–14 YIP had the largest growth in the use of dermoscopy (86% in 2015 and 97% in 2021, p < 0.01). Ancillary technology usage increased significantly. Dermatologists who ‘sometimes’ use technology in DN evaluation (i.e. confocal microscopy, electrical impedance spectroscopy, genetic testing) grew from 11% to 25% (p < 0.01) from 2015 to the present.

Follow-up intervals for patients with no personal history of melanoma remained similar (25% in 2015 vs. 24% currently). Ordering of step sections and the usage of total cutaneous imaging for patients with multiple DN did not change significantly. However, there was an increase in ordering of step sections by 11% for dermatologists in practice less than 5 years (32% in 2021 vs. 21% in 2015, p < 0.01). Recommendations for ‘usually’ performing skin exams for blood relatives of DN patients had a non-significant increase (22% in 2015 vs. 26% in 2021) and ‘usually’ recommending ophthalmologic exams in this population had a significant 5% increase (8% in 2015 vs. 13% in 2021, p < 0.01).

Overall, the use of dermoscopy and technology has grown since previous studies as well as an increase in average surgical margins. There were also significant changes in screening practices (ophthalmic exams) and with decisions to re-excise DN with negative margins. The majority of respondents indicated that the medical literature, followed by information presented at medical conferences, had the largest influence on their management of DN over the past 5 years (38% and 24% respectively).

The debate over optimal management of DN patients and adoption of best practices continues. This study provides valuable information into current DN management and its evolution among US dermatologists. Since 2015, some changes in management were subtle and others were larger. The data presented here shows the optimal way better educate dermatologists on this subject is to introduce and review the literature at medical conferences. Further studies are needed, but information from this study may help to assess and close practice gaps for this controversial but important area of dermatology.

Disclosure statement

No potential conflict of interest was reported by the author(s).