Abbas Alshammari MD, Army Clinic, Qatar
on March 21, 2006
There is no doubt to feel some sort of distress in facing such
child with this presentation. In addition to the bad outcome
because of the risk of melanoma, I think the psychological impact
of disfigurement especially at that site of involvement should
be considered against "wait and see". I see the best
solution is a staged excision and grafting and I don't expect
any role for dermabrasion or curretage as an option.
H. Randolph Byers, MD, PhD. Professor of Dermatology,
Department of Dermatology, Boston University School of Medicine,
Boston, MA, USA on March 21, 2006
As the Dermatopathologist evaluating the depth of nevomelanocytic
destruction by the two ruby lasers in Duke et al., I was amazed
how well the melanocytes survived in the mid and deep dermis.
As giant congenital nevi extend into the mid and deep dermis,
laser treatment would leave many if not most of the nevomelanocytes
and the risk would only be partially reduced as melanoma appears
to arise in the dermis in such lesions. Similarly, dermabrasion
would likely be insufficient.
I recall one teenager with a giant bathing trunk congenital
nevus that was followed clinically and had developed a number
of epidermal inclusion cysts. Unfortunately a deep nodule of
melanoma was followed as a probable epidermal inclusion cyst
until it was excised at a thickness of greater than 10 mm.
In my opinion, early surgical intervention with multiple staged
excisions with tissue expansion and or grafting is the best
approach as well as close clinical follow-up for the remaining
areas that are too difficult to be removed or in areas that
would produce too much scaring. I refer to our surgical colleagues
for the best surgical approach and dermatologists for follow-up.
Jeffrey Dover MD, Adjunct Professor of Medicine (Dermatology)
at Dartmouth Medical School, and Director, SkinCare Physicians
of Chestnut Hill, Boston, MA, USA on May 21, 2006
Very difficult case indeed. I am still not sure how best to
manage these kids. Some believe that a destructive treatment
such as dermabrasion or laser treatment decreases the number
of melanocytes and this decreases the risk of melanoma. I am
not sure this is true and the cosmetic results are dreadful.
It may be better to wait and watch.
David Elpern MD. Williamstown, MA, USA on
March 21, 2006
Removing this nevus is well-nigh impossible. I'd be curious
to hear how this was going to be done. I had a patient around
20 years ago with an almost identical process. She too, had
many smaller nevi scattered over the integument.
You have to remember the mot: "to cure sometimes, to relieve
often, to comfort always." You have to adopt this patient.
She needs one dermatologist to make a relationship with her
and her parents.
Gather as much information as you can. As others have mentioned,
this type of lesion can be psychologically devastating. My patient
grew up in Hawaii and never went to the beach. She hid her body.
She did not get the education her siblings did and had a baby
out of wedlock at a young age. She was a sad person, always
worried about what others thought of her.
Take your time. Digest all the advice and festine lente: hurry
slowly. Good luck.
Amy S. Paller, M.D. Walter J. Hamlin Professor of Dermatology
and Pediatrics, Feinberg School of Medicine Northwestern University,
Chicago, IL, USA on March 22, 2006
Large bathing trunk nevi here in Chicago are referred to our
head of plastic surgery who does expanders and serially removes.
Not sure this is the best thing, and she has already gotten
to 3 years of age without melanoma, but that is our standard
of care.
Khalifa Shaquie MD, PhD, Professor of Dermatology,
College of Medicine, University of Baghdad, Baghdad, Iraq
on March 22, 2006
Multiple drugs regime therapy should be strongly encouraged
in dermatology, like what we do in acne vulgaris, rosacea, TB,
Behcet's Disease, pemphigus vulgaris, melasma, SLE, DLE etc.
The aim of this multiple drugs regime in one disease is to maximise
response, accelerate healing, minimising dose, decreasing resistance
in case of organism and reducing the side effects. This idea
could be applied in this problem case (bathing nevus) like doing
dermabrasion followed by ruby laser after a certain time to
reach and damage the deep nevus cells. Staging excision although
appears logical but is a difficult and prolonged task.
Michael Albom MD, Clinical Professor of Dermatology,
Ronald O. Perelman Department of Dermatology, New York University
Medical Center, New York, NY, USA on March 23, 2006
My heart goes out to this little girl because we know that
she will endure much physical and emotional turmoil in her life
irrespective of how her case is ultimately managed.
I have a few further thoughts about this child. Hopefully,
a network of support can be developed for her. She will need
not only excellent medical and surgical care, but also kind
and understanding parents, appropriate psychological support
for those times when things get difficult with peers in school
and as a teenager when a whole array of conundrums will become
manifest. Unfortunately, because we live in such a tumultuous
world, this child will be exposed to those who will be glad
to add to her own personal torment as she develops. One can
only hope and pray that she will receive much love by those
who come to play the most pivotal roles in her life. It would
be divine if she could be guided especially by those who will
teach her, from this moment on, that her true value in this
world cannot be defined by the covering in which she is wrapped.
It may be wishful thinking on my part, but I have hopes that
she may be able to flourish if she can eventually find it within
herself to believe that she was put on this planet for some
purposeful aspect of its betterment as well as her own.
You and David continue to do a great service for the betterment
of mankind. I admire both of you because it is clear that you
are not only excellent physicians, but you also perceive the
bigger picture: the physician's role in the value of humanity.
Medicine that is practiced as a sterile academic discipline
has severe limitations in providing wellness for our patients.
It seems as if statistical p-values for outcomes in published
papers are more vital to present than knowing how the actual
patients progressed during their illnesses. We seem to avoid
addressing the suffering endured by the patients and, how as
physicians, we can optimally help to allay that suffering. There
is little discussion as to how delving into that suffering affects
us as physicians, the toll it takes on us, and what we may do
to maintain our own wellness as we attempt to help those in
need. Perhaps healing is best facilitated by conscious awareness
and practice of empathy and compassion. Patients tend to report
that their progress was better than not when they felt cared
for by their doctors irrespective of the actual outcomes. Our
perception of wellness is our conscious reality of wellness.
I believe that you both know this and try to educate us to be
better healers and not just "doctors." Keep up the
good work.
Nedhal Khalifa MD, Assistant Professor, Department
of Dermatology, Medical School, Arabian Gulf University, Bahrain
on March 24, 2006
A very challenging case indeed. However, the size of such lesion
limits the management options. Surgical excision is likely to
result in significant scarring which may not be appreciated
by the patient. I would prefer to be more conservative. Regular
follow ups, educate the family to look for signs of malignancy
and biopsy before deciding to excise any part of it. Good Luck.
Ilene Rothman MD, New York, NY, USA on April
22, 2006
I would consider an MRI for 2 reasons; 1) rule out neurocutaneous
melanosis; if present, it may decrease the need to try to remove
the bulk of the skin lesions as the neural portion would still
remain unaccessable; and 2) to rule out the small but real chance
of underlying spinal dysraphism. We are seeing a patient currently
with a giant congenital nevus on the lower back (not bathing
trunk distribution) who proved to have a tethered cord diagnosed
on MRI.
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