Dysplastic Nevi: Diagnostic Challenges, Management Controversies, and Clinical Decision-Making

Conclusions

• Dysplastic nevi should be viewed as markers of melanoma risk rather than inevitable pre-melanomas.
• Histologic grading of dysplastic nevi is highly subjective, with only modest agreement and accuracy except at the extremes of benignity and obvious melanoma.
• Practice patterns vary widely, especially for moderately dysplastic nevi, reflecting uncertainty in their management.
• Most dysplastic nevi do not recur after biopsy, and upstaging to melanoma on re-excision is rare.
• Moderately dysplastic nevi with positive margins showed no same-site melanomas in the presented multicenter cohort, supporting observation in selected cases.
• Close clinical follow-up with routine skin surveillance is reasonable for mild and moderate dysplastic nevi when the lesion has been adequately sampled and no residual pigment remains.
• Re-excision remains appropriate to consider for severely dysplastic nevi and some moderate-to-severe lesions because of diagnostic uncertainty.
• Patients with multiple dysplastic nevi have elevated risk for future melanomas elsewhere on the body, so they warrant ongoing surveillance.
• The decision to re-excise or monitor should incorporate pretest clinical suspicion, dermoscopic features, pathology nuances, patient anxiety, and overall risk context.
• Shared decision-making and patient education improve understanding and confidence even if they do not necessarily change the ultimate choice of excision versus monitoring.