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Black and Brown Skin Lesions
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Black and brown skin lesions can be considered as melanocytic neoplasms. The important task is to exclude malignant melanoma (MM) that is increasing in incidence and is potentially fatal.1
Detailed accounts can be found in articles on some of the important pigmented skin lesions:
- Becker's Naevus
- Blue Naevus
- Congenital Pigmented Naevus
- Compound Naevus
- Epidermal Naevus Syndromes
- Halo Naevus
- Intradermal Naevus
- Junctional Naevus
- Malignant Melanoma
- Sebaceous Naevus
- Seborrhoeic Wart
The most common pigmented lesions include:
Common naevi
Most adults will have approximately 30 moles which they have been acquiring from infancy. New common moles rarely develop after age 40 years and any that do are suspicious.
Typical features of common naevi are:
- Symmetrical in area
- Even brown colouring (light or dark)
- Sharp margin
- <5 mm in diameter
- Profile varying from flat to pedunculated
Any one with >50 moles is at greatly increased risk of MM, that may or may not arise from an existing mole. These patients need careful skin monitoring including baseline skin photography. Any lesion that starts to change colour, bleed, itch, be painful or increase in size needs excisional biopsy.
Atypical moles
Also known as dysplastic naevi, these are found in approx.1 in 12 Caucasians and do not usually become evident until puberty. These are easily mistaken for MM because of their:
- Lack of symmetry
- Lack of sharp margin
- Size >6 mm
- Variation in colour within the lesion

Unlike common moles they continue to appear throughout life and occur in areas not often exposed to the sun, e.g. buttocks. They are a strong, independent risk factor for MM, especially when they are present in numbers (12% risk over 10 years). Patients should be very careful with sunlight and undergo regular skin surveillance. Excision of dysplastic naevi is not performed routinely.
Congenital naevi
These are found in approx. 1% of newborns and characteristically have:
- Variegated brown colour
- Sharp edge
- Rough surface
- Hair growing out of them
They are classified according to size:
- <1.5 cm - small
- 1.5 to 20 cm - medium
- >20 cm - large
Very large ones are known as giant naevi. Patients with large congenital naevi have a risk of up to 10% of developing MM often by age 10 years. These appear either within the lesion or as CNS melanoma.2 Treatment is either excision or close monitoring. Laser treatment is also now available. 3
Malignant melanoma
Characterised by 'ABCDE' rule:
- Asymmetrical shape
- Irregular border
- Variegated colour
- Diameter changing
- Enlargement
However, not all these features may be present and, if MM cannot be excluded, then excision biopsy is required.4

Blue naevus
Despite its name, this lesion is usually a shade of blue-black. It is also called the Tièche-Jadassohn naevus.5 These occur in children and adolescents as solid papules or nodules of 10 mm in diameter with a round or oval, irregular shape. Mostly found on the back of the hand or top of foot; also on the head, lower back and buttocks. Newly occurring lesion may need excision biopsy to exclude nodular MM. 6

Spitz' naevus
This is a dark brown, smooth, firm papule or nodule that rarely occurs after age 40 years. These grow rapidly on the head and neck. Require careful excision with 5 mm border to avoid recurrence.7
Document references
- Cutaneous Melanoma, SIGN (2003)
- Au S; CNS melanoma. eMedicine, September 2006.
- Dave R, Mahaffey PJ; Combined early treatment of congenital melanocytic naevus with carbon dioxide and NdYag lasers. Br J Plast Surg. 2004 Dec;57(8):720-4. [abstract]
- Cancer Research UK; Overview of Malignant Melanoma; Updated January 2007
- Whonamedit.com, Tieche-Jadassohn naevus.; Historical and biographical information on the lesion's eponymous discoverers.
- Colour Atlas and Synopsis of Clinical Dermatology. Fitzpatrick TB et al. McGraw-Hill 2001.
- Strungs I; Common and uncommon variants of melanocytic naevi. Pathology. 2004 Oct;36(5):396-403. [abstract]
Internet and further reading
- Univ. Iowa; Dept. of Dermatology - College of Medicine, Dermatology Differential Diagnosis by Morphology, Differential by colour (blue).
- Roth R, Acker S; Blue Nevi; eMedicine, March 2009.
- The prevention, diagnosis, referral and management of melanoma of the skin, Royal College of Physicians and British Association of Dermatologists (September 2007)
- SIGN; Cutaneous melanoma. (2003); A very thorough, detailed and evidence based approach with recommendations based on levels of evidence.
- Swetter SM; Malignant Melanoma. eMedicine, January 2008.
- NICE Clinical Guideline; Skin tumours including melanoma. February 2006.
Document ID: 1867
Document Version: 23
Document Reference: bgp997
Last Updated: 16 Jun 2009
Planned Review: 15 Jun 2012
The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.
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