The Framingham School Nevus Study: A Pilot Study The Framingham School Nevus Study A Pilot Study Susan A. Oliveria, ScD, MPH; Alan C. Geller, MPH; Stephen W. Dusza, MPH; Ashfaq A. Marghoob, MD; Dana Sachs, MD; Martin A. Weinstock, MD; Marcia Buckminster, RN; Allan C. Halpern, MD Objectives: To (1) describe nevus patterns using digital photography and dermoscopy; (2) evaluate the relationship between host and environmental factors and prevalence of nevi in schoolchildren; and (3) demonstrate the feasibility of conducting a longitudi- nal study. Design: Cross-sectional survey and 1-year prospective follow-up study. Participants: Students from 2 classrooms, grades 6 and 7, in the Framingham, Mass, school system (N = 52). Main Outcome Measures: A survey was completed by students and 1 of their parents that included ques- tions on demographic and phenotypic characteristics, family history of skin cancer, and sun exposure and protection practices. An examination of nevi on the back was performed that included digital photography and digital dermoscopy. Follow-up child and parent surveys and examinations were conducted at 1-year follow-up. Results: At baseline, the median number of back nevi was 15 (mean [SD], 21.9 [15.3]). Older age, male sex, fair skin, belief that a tan is healthier, tendency to burn, and spo- radic use of sunscreen were positively associated with mole count, although age was the only statistically significant fac- tor. Predominant dermoscopic patterns for the index ne- vus were as follows: 38% globular, 14% reticulated, 38% structureless, and 10% combinations of the above pat- terns with no predominant characteristic. The overall par- ticipation rate from baseline to follow-up was 81% (42/ 52) for the skin examination process. At the 1-year follow-up examination, new nevi were identified in 36% of students (n = 15), while 9.6% of baseline index nevi had changes in the dermoscopic pattern. Dominant dermoscopic pattern was related to nevus size: smaller nevi tended to be struc- tureless, while larger nevi were of mixed pattern. Conclusion: This study supports the feasibility and util- ity of digital photography and dermoscopy for the lon- gitudinal study of nevus evolution in early adolescence. Arch Dermatol. 2004;140:545-551 T HE INCIDENCE AND MORTAL- ity rates of melanoma con- tinue to rise at exception- ally high rates.1 Melanoma is more common in people with many moles (nevi) and/or atypical (dysplastic) nevi.2-6 Current knowledge of the evolution of nevi has been largely de- rived from cross-sectional studies, which suggest that adolescence is an important time of life for the formation and evolu- tion of nevi.7-10 However, there has been very limited research on the formation and evolution of individual common nevi dur- ing adolescence. Knowledge of the evolution of nevi in children derives primarily from cross- sectional studies using visual examina- tions to identify and document nevi.7,8,11-20 Many of these studies distinguish be- tween common acquired and atypical (dys- plastic) nevi. Common acquired nevi by definition are absent at birth, often pres- ent in the early years of childhood, pres- ent in greater numbers in early to middle life, and do not multiply thereafter.21 They predominate on sun-exposed skin above the waist. It is generally believed that the common acquired nevus undergoes a pre- dictable evolution over a period of years or decades. Initially, it appears as a tiny pinpoint macule (1 to 2 mm in diameter, uniformly tan or brown but occasionally black) and gradually enlarges to a maxi- mum size of 4 to 6 mm. 2 1 , 2 2 Cross- sectional studies consistently demon- strate that nevi increase in number with age during childhood and adolescence and that sun exposure is an important corre- late of the development of nevi. Older chil- dren (ages 13-14 years) have 30% to 50% more nevi than younger children (ages 9-10 years).12 Several studies have shown that constitutional factors such as hair, eye, STUDY From the Dermatology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (Drs Oliveria, Marghoob, Sachs, and Halpern and Mr Dusza); Department of Dermatology, Boston University, Boston, Mass (Mr Geller); Dermatoepidemiology Unit, Veterans Affairs Medical Center and Department of Dermatology, Rhode Island Hospital and Brown University, Providence (Dr Weinstock); and School Health Services, Framingham Public Schools, Framingham, Mass (Ms Buckminster). The authors have no relevant financial interest in this article. (REPRINTED) ARCH DERMATOL / VOL 140, MAY 2004 WWW.ARCHDERMATOL.COM 545 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 and skin color as well as environmental factors are as- sociated with the number of nevi.7,8,12-20,23,24 Common ac- quired nevi appear to be at least 3-fold less common in blacks and Asians than in whites.14,20,25,26 Like common acquired nevi, atypical (dysplastic) nevi are by definition absent at birth. An early predictive fac- tor is an increased number of morphologically normal nevi, first noted around age 5 to 8 years, and the development of nevi in the scalp area.21 The characteristic clinical fea- tures of dysplastic nevi generally do not appear until ages 10 to 15 years, at which time the number and appearance of an affected patient’s nevi may change dramatically: 21% of Australian children aged 15 years have at least 1 dys- plastic nevus compared with 11% of 9-year-olds.23 Cross- sectional observations have also led to the recognition in some children and adolescents of large darkly pigmented nevi with features similar to small congenital nevi.27 Nevi appear to share a common causal pathway with melanoma that involves interplay between constitutional factors and sun exposure.12 It has been proposed that, akin to the model of tumor progression in colonic neoplasia de- scribed by Vogelstein et al,28 nevi represent intermediate steps in the evolution of a significant subset of superficial spreading melanomas, the most common histogenic sub- type of the disease.22,29 Recent studies distinguish be- tween common nevi and atypical (dysplastic) nevi as im- portant risk markers and lesional steps in melanocytic tumor progression.2,3,30 A limitation of these studies is the lack of a consistent definition of nevi, which is related to the ex- isting controversy surrounding the clinical and histologic definitions of common and atypical nevi.31 An improved understanding of the natural history of nevi at the subsur- face (dermoscopic) level may generate new biologic hy- potheses regarding the evolution of nevi. Knowledge of the causes and evolution of nevi has significant public health importance for the primary and secondary prevention of melanoma. Understanding the evolution of nevi during adolescence is important for im- proving the early detection of relatively rare melanomas that occur in this age group and perhaps even more im- portant for avoiding unnecessary excisions of large num- bers of changing benign nevi. We report the results of a pilot study in schoolchildren, grades 6 and 7, in Framing- ham, Mass. This study provides preliminary data for the first population-based longitudinal study of nevi in US children. The overall objectives of the study were to de- scribe nevi patterns using digital photography and der- moscopy, evaluate the roles of host and environmental factors and prevalence of nevi in schoolchildren, and dem- onstrate the feasibility of conducting this type of re- search in a cohort of US schoolchildren. METHODS STUDY SITE AND STUDY OVERVIEW The present study was conducted with children and their par- ents from the Framingham, Mass, school system. We identi- fied 2 classrooms from grades 6 and 7 and obtained informed consent from 100% of the children and their parents (N = 52). Children were asked to complete a self-administered survey, and a survey was also provided to 1 parent of each child for completion. During December 2001, skin examination and pho- tography of back nevi were performed in concert with manda- tory screening examinations for scoliosis (curvature of the spine) that are conducted annually in Massachusetts for grades 5 through 9. Follow-up child and parent surveys and skin ex- aminations were conducted 1 year later. SKIN EXAMINATION AND PHOTOGRAPHY PROCESS The examination was limited to the back and included digital photography and digital dermoscopy. The study examination took an average of 2.5 minutes for boys and 3 minutes for girls. All children completed an informal exit interview to elicit feed- back about the study process. The only significant complaint reported by the children was that the room was too cold. The scoliosis examination was performed by the school nurse behind a privacy curtain. Boys were asked to remove their shirts, and girls were asked to wear a loose fitting shirt (with a bathing suit underneath) that could be readily lifted off and draped in front of them. At baseline, immediately following the scoliosis examina- tion, an overview digital photograph of each student’s back and a close-up digital photograph of the largest nevus on the back were taken. Digital dermoscopy was also performed on the larg- est nevus. Appropriate clothing and draping techniques were used in consideration of the student’s comfort and modesty. The school nurse instructed the student to hold his or her hair off the shoulders and neck, using an elastic band or hair clip as necessary. For girls, the nurse lifted up the straps of the swimsuit top to ensure that no nevi were hidden and so that all nevi could be assessed. Also, if the tops of pants covered the iliac crest, the nurse instructed the student to roll the top of the pants slightly so that the back area near the iliac crest could be photographed. The area photographed was defined from the nape of the neck to the posterior iliac crests. The field of view of the photographs was 51 cm (20 in) wide and 76 cm (30 in) high. The largest pig- mented nevus on the back was chosen for close-up photography and dermoscopy by 2 examiners, a nondermatologist and a der- matologist. Agreement was reached in 49 of 50 instances. At the 1-year follow-up examination, the number of nevi undergoing close- up and digital photography was increased to 4 per student. Close-up photographic and dermoscopic images were ob- tained using a digital camera system with and without an epi- luminescence microscopy attachment. The overview and close-up pictures were automatically stored directly on a lap- top computer in a proprietary database archived by study num- ber, nevus number, image type, and date. The pictures were encrypted on entry into the database and viewable only through the secure software. Security level access to the software is avail- able only to key study personnel. CHILD AND PARENT SURVEYS The child and parent surveys were self-administered at base- line and at 1-year follow-up. They included questions on de- mographics, skin type, family history of skin cancer (parents only), eye and hair color, and sun protection practices, includ- ing the use of hats and sunscreen, limiting time in the sun, seek- ing shade, and frequency of sunburns. Parents were also asked questions regarding their child’s sun protection practices and exposure. IMAGE ASSESSMENT The digital images were reviewed for clarity by 2 dermatologists (A.A.M. and A.C.H.). All overview images were of excellent qual- ity and consistent resolution, readily permitting the recognition (REPRINTED) ARCH DERMATOL / VOL 140, MAY 2004 WWW.ARCHDERMATOL.COM 546 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 of nevi 2 mm or more in diameter and the distinction of nevi from inflammatory lesions. The inclusion of fiducial size mark- ers, as a fixed basis for comparison, demonstrated consistency of magnification in the images as viewed on the monitors. All close-up photographic and dermoscopic images were sharp and readily evaluated for the presence of clinical and dermoscopic features. Inclusion of fiducial markers in the images demon- strated excellent consistency of color rendition on calibrated moni- tors. Dermatologists (A.A.M. and A.C.H.) counted back nevi in- dependently. The interobserver nevus counts were highly correlated with a correlation coefficient, r2= 0.97. The close-up photographic and dermoscopic images were assessed for individual clinical attributes, including nevus asym- metry, color, border, dermoscopic pattern (eg, globular, reticu- lar, structureless, and complex/mixed), and the presence of der- moscopic structures (eg, globules). Following the first-year pilot examinations, all images were independently evaluated by the dermatologists. We conducted a small reproducibility study to determine whether a physician could be trained to correctly iden- tify and categorize dermoscopic features of nevi according to the study protocol. A physician (A.A.M.) who participated in the pi- lot study and classified the dermoscopic features of the images was responsible for training a dermatologist (D.S.) who had not participated in the pilot study. Once the training session was com- pleted, the 2 physicians independently reviewed the same 20 im- ages. Nevi were evaluated for the presence or absence of each of 6 dermoscopic features: reticular pigment network, globules, structureless areas, blotches, dots, and streaks. The results showed that there was consensus between the physicians regarding the presence or absence of dermoscopic pat- terns. The physicians achieved 100% agreement on reticular pig- ment network, 70% agreement on globules, 80% agreement on structureless areas, and 100% agreement on blotches. The � val- ues for interrater reliability for these patterns ranged from 0.35 to 1.0. Ninety percent agreement was reached for prominence of the reticulation (� = 0.73). None of the nevi in the reproduc- ibility study appeared to have dots, streaks, blotches, or periph- eral globules, and thus the interobserver agreement for these char- acteristics could not be evaluated. Based on these results, a further simplified schema was applied to the 1-year follow-up images. In the final schema, nevi were classified on dermoscopy into 4 groups: reticular, globular, structureless, and complex (mixed) based on the overall global pattern. Dermoscopic blotches, dots, streaks, peripheral globules, and vascular structures were con- sidered local features and occurred infrequently. Thus, they did not change the overall lesion classification. STATISTICAL ANALYSIS Descriptive statistics were calculated to characterize the study cohort and describe the prevalence of back nevi. The preva- lence of nevi was described by age group and median mole count. Univariate statistics including odds ratios and 95% confidence intervals were used to describe the relationship between host and environmental factors and median mole count. Dermo- scopic features of the index moles at follow-up were presented using descriptive statistics stratified by size of the index nevi and upper vs lower back. RESULTS BASELINE RESULTS We obtained informed consent from 100% (N = 52) of the children and their parents. Completed surveys were re- turned for 51 of 52 children and parents. Examinations, digital photography and dermoscopy were performed on 50 children (participation rate, 96%; 50/52); 2 children were absent from school on the day of the scheduled ex- amination. The characteristics of the study cohort at base- line are summarized in Table 1; 90% were white; 57% were girls; and the median age was 12.5 years (range, 11-13.8). Eighty percent of children (n = 39) stated that their skin was fair/very fair (corroborated by 97% of par- ents’ responses [n = 38]). Eighty-six percent of children reported having at least 1 sunburn the previous sum- mer (n = 42). Parent respondents were generally female (n = 44; 86%) with a median age of 42 years. Nearly two thirds of them (n = 33) stated that they were at average to high risk of developing skin cancer. More than 25% (n = 14) reported a first-degree relative with skin cancer, and 70% (n = 36) reported themselves to be fair skinned. At baseline, the median number of back nevi was 15, and the mean (SD) number of nevi was 21.9 (15.3) (range, 2-70) based on the review of digital images (Figure 1). The prevalence of nevi described by age is presented in Figure 2. An important and significant trend with increasing age and median mole count was ob- served. No differences were apparent when analyses were stratified by male vs female student. Table 2 summa- Table 1. Demographic Characteristics of Student Population Characteristic Finding* Mean (SD) age, y 12.4 (0.68) Sex Male 22 (43) Female 29 (57) Race White 46 (90) Nonwhite† 4 (8) Color of untanned skin Very fair/fair 41 (80) Olive/very dark 10 (20) No. of sunburns during previous summer 0 7 (14) 1 23 (45) 2 12 (24) �3 9 (18) Do people look healthier with a tan? Yes 24 (47) No 15 (29) Don’t know 11 (22) What happens to your skin after you go outside in the sun for 45 minutes in the summer? Always burn 1 (2) Usually burn 8 (16) Sometimes burn 20 (39) Rarely burn 21 (41) How often do you apply sunscreen when you go to the beach or pool? Never/less than half of the time 15 (29) Most days/every day 33 (65) During the past summer, when outside, how often do you have sunscreen on? Never/less than half of the time 32 (63) Most days/every day 18 (35) *While n = 51, responses do not total 51 because of missing or incomplete questionnaire data. Unless otherwise indicated, data are number (percentage) of respondents. †Asian, Hispanic, and other. (REPRINTED) ARCH DERMATOL / VOL 140, MAY 2004 WWW.ARCHDERMATOL.COM 547 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 rizes the univariate statistics for host and environmen- tal factors and median mole count. Older age, male sex, fair skin, belief that a tan is healthier, tendency to burn, and sporadic use of sunscreen were positively associ- ated with higher median mole count, although only age was statistically significant. On close-up clinical examination, the median di- ameter of the largest nevus was 4 mm, and the mean (SD) diameter was 4.3 (1.7) mm. Asymmetry was specified across 0, 1, or 2 axes. All nevi were asymmetric: 94% were asymmetric in 1 axis, and 6% were asymmetric in 2 axes. Clinical borders were assessed as fuzzy or distinct and as regular or irregular. Eighty-percent (40) of the nevi had fuzzy borders and 58% (29) had regular borders. Ne- vus color was assessed by the presence of 7 colors: light brown, medium brown, dark brown, red, black, white, and blue/gray. The predominant colors present in the nevi were the shades of brown: 62% (31) of the nevi con- tained light brown; 52% (26), medium brown; and 30% (15), dark brown. Red was observed in 20% (10) of the nevi, and black, white, and blue/gray were not observed in any of the index nevi. All of these clinical features were compared be- tween younger and older students (dichotomized at the median age), between boys and girls, and based on skin color (very fair to fair vs olive to very dark). There were no significant differences detected for any of these com- parisons. No children demonstrated nevi requiring re- ferral to a dermatologist. Nevi were classified into groups based on the predominant dermoscopic characteristic. Pre- dominant dermoscopic patterns for the index nevus were as follows: 38% (19) globular, 14% (7) reticulated, 38% (19) structureless, and 10% (5) combinations of the above patterns with no predominant characteristic. FOLLOW-UP RESULTS At 1-year follow-up, 42 of 51 surveys (parent and child) were returned, for a response rate of 82%, and 42 of 50 children completed the follow-up examination, for a par- ticipation rate of 84%. There was an overall participa- tion rate from baseline to follow-up of 81% (42/52) for the skin examination process. Of the 8 students who did not participate in the follow-up (42/50), 2 refused to par- ticipate, 2 were absent on the day of the examination, 2 had moved to nearby schools in Framingham, and 2 had moved to other school systems. An increased number of nevi were observed at the 1-year follow-up examination: new nevi were identified in 36% of students (n = 15). We assessed changes in der- moscopic pattern in the single baseline index nevus over the year follow-up interval and observed changes in 10% of these lesions (n = 5). The results of the dermoscopic classification of nevi at the follow-up examination are sum- marized in Table 3. Dominant dermoscopic pattern ap- pears to be related to nevus size: smaller nevi tend to be structureless, while larger nevi are of mixed pattern. Table 3 also summarizes the results of a stratified analysis for globular and reticular nevi by anatomic site, suggesting that reticulation is more common on the upper back. COMMENT We report results of a pilot study in Framingham, Mass, schoolchildren that describes the prevalence of nevi us- ing digital photography and digital dermoscopy. This is the first study to document clinical and dermoscopic fea- tures of common nevi in schoolchildren using recent ad- vances in technology and to explore the interrelation- ship between nevi and host and environmental factors. Knowledge of the causes and evolution of nevi has significant public health importance for the primary and secondary prevention of melanoma. Public health cam- paigns and clinical efforts to reduce melanoma deaths cur- rently target individuals with many nevi or apparently atypical nevi. Identification of factors that predict the de- velopment of multiple and atypical nevi will improve tar- geting of primary prevention efforts in early life. Be- cause these factors may be apparent earlier in life, there is an opportunity to intervene when sun protection ef- forts are more likely to succeed. Nevus phenotype is cur- rently used to identify high-risk individuals for directed efforts in sun protection and early detection. In regard to the secondary prevention of melanoma, recent efforts in early detection have intensified across all age groups with an emphasis on the importance of change in a ne- vus as a sensitive marker of early curable disease. Our results showed that the median number of back nevi was 15, with a significant association of increasing 30 25 20 15 10 5 0 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 Mole Count St ud en ts , % Figure 1. Distribution of back mole counts in 50 students. 80 60 40 20 0 10 11 12 13 14 Age, y To ta l B ac k M ol e Co un t Figure 2. Scatterplot of number of back nevi by age of student (n = 50). The regression line is based on simple linear regression with total mole count as the dependent variable and age as the predictor with the intercept being suppressed. (REPRINTED) ARCH DERMATOL / VOL 140, MAY 2004 WWW.ARCHDERMATOL.COM 548 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 age with higher median mole count. Older age, male sex, fair skin, belief that a tan is healthier, tendency to burn, and sporadic use of sunscreen were positively associ- ated with mole count, although age was the only statis- tically significant factor. Predominant dermoscopic pat- terns for the index nevus were as follows: 38% globular (n = 19), 14% reticulated (n = 7), 38% structureless (n = 19), and 10% combinations of patterns (n = 5). It has been ob- served that globules are often seen in enlarging and con- genital nevi.32,33 The fact that 38% of nevi were globular might suggest that many of these nevi were growing or congenital. We may have selected for this by evaluating young children and selecting the largest nevi for close-up photography. A total of 19 (38%) of the nevi were struc- tureless, and this may also be consistent with a congen- ital pattern.34 However, it should be noted that studies have found congenital nevi to be prevalent in only 1% to 6% of the population and the interpretation that these small nevi are congenital is only suggestive.23,35,36 Only 3 longitudinal studies have examined the evo- lution of nevi in individual children over time and as- sessed the relationship between nevus evolution and risk Table 3. Dermoscopic Pattern by Size and Site of Index Mole at Follow-up Examination of 50 Students* Characteristic No. (%) of Moles Structureless Globular/Reticular Mixed Total (N = 155) Size, mm �2.0 26 (40.6) 22 (34.4) 16 (25.0) 64 2.1-4.0 16 (24.6) 23 (35.4) 26 (40.0) 65 �4.1 2 (7.7) 8 (30.7) 16 (61.5) 26 Site Upper back NA 17 (39.5)/8 (80.0) NA NA Lower back NA 26 (60.5)/2 (20.0) NA NA Abbreviation: NA, not applicable. *Each student contributed up to 4 index nevi. Table 2. Univariate Statistics by Median Mole Count in 50 Students Variable No. of Students* Median Mole Count OR (95% CI)† Age Younger (11.0-12.3 y) 24 12.5 1.0 Older (12.4-13.5 y) 25 23 3.6 (1.1-11.4)‡ Sex Female 28 14.5 1.0 Male 21 25 2.5 (0.68-9.41) Race White 44 18.5 1.0 Nonwhite§ 4 7.5 . . . Color of skin Olive/very dark 10 11.5 1.0 Very fair/fair 39 16 1.57 (0.41-6.07) No. of sunburns in previous summer 0-1 30 16 1.0 �1 19 15 0.90 (0.30-2.80) Do people look healthier with a tan? No 15 14 1.0 Yes 24 21 1.6 (0.49-5.87) Don’t know 10 10 0.50 (0.09-2.66) What happens to skin after 45 minutes in sun? Sometimes/rarely burn 40 15 1.0 Always/usually burn 9 25 1.38 (0.34-5.50) How often do you apply sunscreen when you go to the beach or pool?� Routinely 13 13 1.0 Sporadically 33 18 2.70 (0.71-9.98) During the past summer, when outside, how often did you have sunscreen on?� Routinely 8 12 1.0 Sporadically 40 17 3.31 (0.66-13.1) Abbreviations: CI, confidence interval; OR, odds ratio. *Responses do not total 50 because of missing or incomplete data. †Odds ratio for association between variable of interest and higher median mole count. Ellipses indicate unable to provide OR estimate owing to small contingency cell counts ‡P�.05. §Asian, Hispanic, or other. �Sporadically includes “never” and “most days”; routinely includes “every day.” (REPRINTED) ARCH DERMATOL / VOL 140, MAY 2004 WWW.ARCHDERMATOL.COM 549 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 factor exposures.17-19 Two large studies conducted in Eu- rope and Canada assessed nevi in children at 2 time points.18,19 The European study included 377 children ex- amined at ages 7 and 12 years, and the Canadian study conducted entrance and exit examinations of 309 first and fourth graders who were part of a 3-year random- ized trial of broad-spectrum sunscreen use. Both studies used nevus counts obtained from clinical examination. The results showed a significant increase in nevus counts over time and a strong association between nevus count and skin type, pigmentation characteristics, and freck- ling. In a small cohort study of 102 Australian school- children,20 melanocytic nevi were counted, and in a sub- set of 20 students aged 12 to 14 years, all nevi of the face and neck were photographically mapped and clinically assessed annually during 4 years. This study of 20 ado- lescents represents the only longitudinal study of indi- vidual nevi in this age group to date. Over the follow-up period, nevus numbers increased 47% in the first year, with smaller increases in older students.26 The selection of the back as the anatomic focus for this study was based on logistic and epidemiologic con- siderations.7,8 The existing infrastructure at the schools for administering scoliosis examinations along with the efficiency of restricting the study to the skin of the back resulted in very high participation rates and excellent data quality. The back as a site is ideal for photography stud- ies because it is a relatively flat surface, and the surface area can be determined with precision, which is re- quired for assessment of proportionate vs disproportion- ate nevus growth.37 Although it would have been opti- mal to conduct a skin examination and photography of the full body, the utility and efficiency of restricting our study to the back is supported by several epidemiologic studies: English and Armstrong8,38 have demonstrated the least interobserver variation for nevus counts of the back relative to other anatomic sites and excellent correla- tion between back nevus counts from photographs and those from direct examination. Autier et al7 have dem- onstrated a strong correlation between back and total ne- vus counts and recognize the phenotype of back nevi as an excellent marker of melanoma risk. We demonstrated the feasibility of implementing and conducting this type of research and maintaining high com- pliance with minimal loss to follow-up. The strength of this study is the high response rate achieved for survey completion and the skin examination and photography pro- cess. A limitation is the small size of the sample, which was a function of the pilot nature of the study. The co- hort sampled represents a predominantly white group. The survey data used for this analysis was obtained from the responses from the child survey. In collecting data from parent and child, we recognize that discrepancies in re- sponses will arise between them. Analysis of these dis- crepancies will permit an indirect assessment of the va- lidity of responses and will be part of a separate study report. Nevi appear to share a common causal pathway with melanoma that involves interplay between constitu- tional factors and sun exposure.12 Recent studies distin- guish between common and atypical (dysplastic) nevi as important risk markers and lesional steps in melano- cytic tumor progression.2,3,30 A limitation of these stud- ies is the lack of a consistent definition of nevi, which is related to the existing controversy surrounding the clini- cal and histologic definitions of common and atypical nevi. An improved understanding of the natural history of nevi at the subsurface (dermoscopic) level may prove espe- cially informative in this regard and will likely generate new biologic hypotheses regarding the evolution of nevi. Understanding the evolution of nevi during adoles- cence is important for improving the early detection of relatively rare melanomas that occur in this age group and perhaps even more important for avoiding unnec- essary excisions of large numbers of changing benign nevi. An analysis of data from patients aged 0 to 14 years (N = 96 255) seen in the Henry Ford Health System in the year 2001 shows that full-thickness excisions of suspect skin lesions (excluding shave excisions of epidermal or dermal lesions) were performed at rates of 1.2 per 1000 children aged 0 to 9 years and 4.2 per 1000 children aged 10 to 14 years (Christine Cole Johnson, PhD, personal written communication, January 2003). An extrapola- tion of these data to the 2000 US Census estimates sug- gests that there are over 125 000 full-thickness exci- sions of skin lesions performed on children younger than 14 years annually in the United States despite the very low incidence of skin cancer in this age group. Dermatologists (A.A.M. and A.C.H.) counted back nevi images independently. The interobserver nevus counts were highly correlated with a correlation coeffi- cient, r2= 0.97. On review, it was discovered that the pri- mary source of nevus count discrepancies was the skip- ping and double-counting of nevi on freehand counts. A tagging tool provided in the image archiving software that permits tagging of each nevus as it is counted can be used to reduce these discrepancies. We demonstrated the feasibility of conducting a study in US schoolchildren to determine the prevalence and der- moscopic features of back nevi and to attain high re- sponse rates and collect important data on host factors of children and parents. Health systems in schools can be natural settings for researchers to obtain high re- sponse rates. This study lays the foundation for future studies that will elucidate the relationship between ne- vus evolution and phenotype, genotype, and risk factor exposures in a population-based cohort. Accepted for publication September 29, 2003. This research was supported by grants provided by the American Skin Association and the National Melanoma Foundation. We would like to thank the teachers and staff in the Framingham School System and the parents and students who participated in this study. Corresponding author and reprints: Susan A. Oliveria, ScD, MPH, Dermatology Service, Memorial Sloan- Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (e-mail: oliveri1@mskcc.org). REFERENCES 1. Jemal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun MJ. Cancer statistics, 2003. CA Cancer J Clin. 2003;53:5-26. (REPRINTED) ARCH DERMATOL / VOL 140, MAY 2004 WWW.ARCHDERMATOL.COM 550 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 2. Tucker MA, Halpern A, Holly EA, et al. Clinically recognized dysplastic nevi: a cen- tral risk factor for cutaneous melanoma. JAMA. 1997;277:1439-1444. 3. Elder DE, Goldman LI, Goldman SC, Greene MH, Clark WHJ. Dysplastic nevus syndrome: a phenotypic association of sporadic cutaneous melanoma. Cancer. 1980;46:1787-1794. 4. Swerdlow AJ, English J, MacKie RM, et al. Benign melanocytic naevi as a risk factor for malignant melanoma. Br Med J (Clin Res Ed). 1986;292:1555- 1559. 5. Holly EA, Kelly JW, Shpall SN, Chiu SH. Number of melanocytic nevi as a major risk factor for malignant melanoma. J Am Acad Dermatol. 1987;17:459- 468. 6. Nordlund JJ, Kirkwood J, Forget BM, et al. Demographic study of clinically atypi- cal (dysplastic) nevi in patients with melanoma and comparison subjects. Can- cer Res. 1985;45:1855-1861. 7. Autier P, Boniol M, Severi G, et al. The body site distribution of melanocytic naevi in 6-7 year old European children. Melanoma Res. 2001;11:123-131. 8. English DR, Armstrong BK. Melanocytic nevi in children, I: anatomic sites and demographic and host factors. Am J Epidemiol. 1994;139:390-401. 9. Fritschi L, Green A, Solomon PJ. Sun exposure in Australian adolescents. J Am Acad Dermatol. 1992;27:25-28. 10. Harrison SL, MacLennan R, Speare R, Wronski I. Sun exposure and melano- cytic naevi in young Australian children. Lancet. 1994;344:1529-1532. 11. Hanrahan PF, Hersey P, Menzies SW, Watson AB, D’Este CA. Examination of the ability of people to identify early changes of melanoma in computer-altered pig- mented skin lesions. Arch Dermatol. 1997;133:301-311. 12. Dwyer T, Blizzzard L, Ashbolt R. Sunburn associated with increased number of nevi in darker as well as lighter skinned adolescents of northern European de- scent. Cancer Epidemiol Biomarkers Prev. 1995;4:825-830. 13. Green A, Siskind V, Hansen ME, Hanson L, Leech P. Melanocytic nevi in school- children in Queensland. J Am Acad Dermatol. 1989;20:1054-1060. 14. Gallagher RP, Rivers JK, Yang CP, McLean DI, Coldman AJ, Silver HKB. Mela- nocytic nevus density in Asian, Indo-Pakistani, and white children: The Vancou- ver Mole Study. J Am Acad Dermatol. 1991;25:507-512. 15. Coombs BD, Sharples KJ, Cooke KR, Skegg DC, Elwood JM. Variation and co- variates of the number of benign nevi in adolescents. Am J Epidemiol. 1992; 136:344-355. 16. Fritschi L, McHenry P, Green A, Mackie R, Green I, Siskind V. Naevi in school- children in Scotland and Australia. Br J Dermatol. 1994;130:599-603. 17. Green A, Siskind V, Green L. The incidence of melanocytic naevi in adolescent children in Queensland, Australia. Melanoma Res. 1995;5:155-160. 18. Luther H, Altmeyer P, Garbe C, et al. Increase of melanocytic nevus counts in children during 5 years of follow-up and analysis of associated factors. Arch Der- matol. 1996;132:1473-1478. 19. Gallagher RP, Rivers JK, Lee TK, Bajdik CD, McLean DI, Coldman AJ. Broad- spectrum sunscreen use and the development of new nevi in white children. JAMA. 2000;283:2955-2960. 20. Siskind V, Darlington S, Green L, Green A. Evolution of melanocytic nevi on the faces and necks of adolescents: a four year longitudinal study. J Invest Derma- tol. 2002;118:500-504. 21. Greene MH, Clark WH Jr, Tucker MA, et al. Medical intelligence: current con- cepts: acquired precursors of cutaneous malignant melanoma. N Engl J Med. 1985;312:91-97. 22. Clark WH Jr, Elder DE, Guerry IV D, Epstein MN, Greene MH, Van Horn M. A study of tumor progression: the precursor lesions of superficial spreading and nodular melanoma. Hum Pathol. 1984;15:1147-1165. 23. Rivers JK, MacLennan R, Kelly JW, et al. The Eastern Australian Childhood Nevus Study: prevalence of atypical nevi, congenital nevus-like nevi, and other pigmented lesions. J Am Acad Dermatol. 1995;32:957-963. 24. Banuls J, Climent JM, Sanchez-Paya J, Botella R. The association between id- iopathic scoliosis and the number of acquired melanocytic nevi. J Am Acad Der- matol. 2001;45:35-43. 25. Coleman WP III, Gately LE III, Krementz AB, Reed RJ, Krementz ET. Nevi, len- tigines, and melanomas in blacks. Arch Dermatol. 1980;116:548-551. 26. Darlington S, Siskind V, Green L, Green A. Longitudinal study of melanocytic nevi in adolescents. J Am Acad Dermatol. 2002;46:715-722. 27. Kopf AW, Levine LJ, Rigel DS, Friedman RJ, Levenstein M. Prevalence of congenital- nevus-like nevi, nevi spili, and cafe au lait spots. Arch Dermatol. 1985;121:766- 769. 28. Vogelstein B, Fearon ER, Hamilton SR, et al. Genetic alterations during colorectal- tumor development. N Engl J Med. 1988;319:525-532. 29. Elder DE, Clark WH Jr, Elenitsas R, Guerry D IV, Halpern AC. The early and interme- diate precursor lesions of tumor progression in the melanocytic system: common acquired nevi and atypical (dysplastic) nevi. Semin Diagn Pathol. 1993;10:18-35. 30. Kanzler MH, Mraz-Gernhard S. Primary cutaneous malignant melanoma and its precursor lesions: diagnostic and therapeutic overview. J Am Acad Dermatol. 2001;45:260-276. 31. Marghoob AA, Kopf AW. Melanoma risk in individuals with clinically ayptical nevi. Dermatopathol Pract Concept. 1996;1:254-261. 32. Braun RP, Calza AM, Krischer J. The use of digital dermoscopy for the follow-up of congenital nevi: a pilot study. Pediatr Dermatol. 2001;18:277-281. 33. Kittler H, Seltenheim M, Dawid M, Pehamberger H, Wolff K, Binder M. Fre- quency and characteristics of enlarging common melanocytic nevi. Arch Der- matol. 2000;136:316-320. 34. Seidenari S, Pellacani G. Surface microscopy features of congenital nevi. Clin Dermatol. 2002;20:263-267. 35. Lorenz S, Maier C, Segerer H, Landthaler M, Hohenleutner U. Skin changes in newborn infants in the first 5 days of life. Hautarzt. 2000;51:396-400. 36. Walton RG, Jacob AH, Cox AJ. Pigmented lesions in newborn infants. Br J Der- matol. 1976;95:389-396. 37. Rhodes AR, Albert LS, Weinstock MA. Congenital nevomelanocytic nevi: pro- portionate area expansion during infancy and early childhood. J Am Acad Der- matol. 1996;34:51-62. 38. English DR, Armstrong BK. Melanoctyic nevi in children, II: observer variation in counting nevi. Am J Epidemiol. 1994;139:402-407. (REPRINTED) ARCH DERMATOL / VOL 140, MAY 2004 WWW.ARCHDERMATOL.COM 551 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021