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    What is a birthmark?

    A birthmark is a localized proliferation of pigment cells of the skin (melanocytes) that appears as a dark spot. It is a benign skin change, colloquially known as beauty spots or liver spots. The technical term for a birthmark is nevus (plural nevi). The number of moles increases with age. New moles can appear at a young age up to the age of forty. Pigment spots that appear at an advanced age are called age spots.

    So the spots increase with age. The appearance of benign changes in the skin is accompanied by reduced elasticity due to collagen loss. The humidity is decreasing. In addition, external factors (external influences), such as UV rays and an unhealthy or healthy diet, play an important role in your skin condition and can also promote dry skin. Depending on the interaction of the factors, you thus struggle with premature skin aging and newly appearing or enlarging skin changes.

    A common birthmark is usually smaller than about 5 millimeters in diameter. The spot is round or oval, light brown to dark brown. It has a smooth surface and can be sharply distinguished from the surrounding skin. Birthmarks are particularly common on areas of the body that have been exposed to the sun (actinic keratosis). Depending on hereditary predisposition, an adult Central European develops an average of 10 to 40 moles with a diameter of more than two millimetres on the entire body in the course of time. From a number of 50 moles, there is a slightly increased risk of skin cancer [1]. The risk of a birthmark developing into a skin cancer is small. When measured over a one-year period, the risk ranges from 1:200,000 to 1:33,000 depending on age [2]. In over 70 percent of cases, black skin cancer develops in areas where no mole is present [3].

    How does a birthmark appear?

    The origin of the pigment cells can be traced back to the first weeks of the unborn child. Under the influence of messenger substances, the cells from the region of the future spinal cord (also called neural crest) develop into connective tissue cells, cartilage cells, nerve cells and pigment cells. Certain messenger substances initiate the development from precursor cells to pigment cells. UV light can change the genetic material in pigment cells. Certain changes in the genetic material lead to the proliferation of pigment cells, which become visible as moles (Grichnik JM, et al., 2014, Exp Dermatol).

    How are moles divided?

    Skin marks are classified according to the age at which they appear. Congenital moles occur in the womb or in the first weeks of life. Moles that develop in childhood and later are called acquired moles. Pigment marks that develop after the age of 40 are age spots.

    Moles are also distinguished according to their location in the layers of the skin. A birthmark that appears at the boundary layer between the epidermis and the dermis is called a junctional nevus. If pigment cells are found in both the epidermis and the dermis, it is called a compound nevus. The technical term for a birthmark whose pigment cells are only found in the dermis is dermal nevus.

    The arrangement of the pigment cells in the skin is examined with a special magnifying glass (dermatoscope). The arrangement of the pigment cells can be divided into patterns such as lines, plaques, circles or dots. Moles on the palms of the hands or soles of the feet show parallel lines in the furrows of the skin (Kittler H., 2015, Dermatoscopy: Pattern analysis of pigmented and unpigmented skin lesions). Other features that help to differentiate between pigment spots are color, size and the site of the birthmark.

    What types of pigmented spots are there?

    The most common types of pigmentation spots are:

    • Freckles (ephelids).
    • Liver spot (Lentigo simplex, age spot: Lentigo solaris).
    • Acquired birthmark (nevus of the junctional type, the compound type or the dermal nevus).
    • Congenital birthmark (congenital nevus cell nevus).
    • Cafe au Lait spot (pigment nevus).

    Among the rare special forms are:

    • Blue nevus (Naevus caeruleus).
    • Halo or sutton nevus.
    • Spitz nevus (spindle cell and epithelioid cell nevus).
    • Reed nevus (spindle cell nevus).
    • Spilus nevus.
    • Becker nevus.
    • Large congenital mole on the face (Ota nevus).
    • Large congenital mole on the shoulder (nevus Ito).

    For skin lesions, regular monitoring is recommended.

    What is a conspicuous skin mole (atypical or dysplastic nevus)?

    The unusual appearance of atypical nevi can be distinguished from birthmarks using the ABCDE rule. Even when looking at the individual cells under the microscope, changes can be seen in comparison to normal moles. Atypical moles only appear during or after puberty. They are often larger than 6 millimeters in diameter, raised or irregularly patterned. People with fair skin, red or blond hair, blue or green eyes and freckles are particularly at risk. Sunburn, especially during childhood, increases the risk of developing atypical moles.

    Atypical moles occur in Europe in about 10 percent of the population (range: 7-24 percent) (Tucker M.A., 2009, Hematol Oncol Clin North Am). It is assumed that the risk of developing skin cancer increases with the number of atypical moles (Gandini S., et al., 2005, Eur J Cancer). The risk of developing black skin cancer in conspicuous moles is estimated to be approximately 1:30,000 to 1:40,000 (Tsao H., et al., 2003, Arch Dermatol).

    It is therefore recommended to remove conspicuous moles without leaving any residue (Winkelmann R.R., et al., 2015, J Am Acad Dermatol. 2015).

    Which birthmark is dangerous?

    Skin cancer or precancerous lesions are conspicuous by certain characteristics. The ABCDE-rule helps to recognize suspicious or dangerous moles and to detect them if necessary. remove early before the emergence of a malignant skin tumor. Each letter stands for a characteristic. If at least one of these features is present, an examination by a dermatologist (dermatologist) should be carried out.

    • A = Asymmetry: uneven shape of the birthmark.
    • B = Boundary: irregular or blurred edges, without a clear demarcation to the healthy surrounding skin.
    • C = Coloration: different coloration with light, dark or pink parts.
    • D = Diameter: at the widest point there is a diameter of more than 6 millimeters.
    • E = Development / elevation: changes in size, shape or color / growth above the skin level.

    Moles on the sole of the foot or on the mucous membranes are often overlooked during self-examination. If the mole is itchy or bleeds, patients should also consult a dermatologist. In any case, if you are unsure whether the mark is benign, contact a dermatologist to rule out the possibility that it is a malignant change.

    Birthmark, skin cancer or a completely different diagnosis?

    In a conversation with the doctor, in case of ignorance, he enlightens them about whether it is a birthmark, wart, fibroma, style wart or any other skin change. On our skin cancer page, you will learn all about the distinction between benign skin tumors, seborrheic keratoses and benign growths as opposed to malignant skin tumors, malignant growths and any other malignant tumors of the skin. As part of a skin cancer screening, you will be examined for white and black skin cancer. It will be checked what symptoms you have and whether there are any nodules. The doctor may recommend an appropriate treatment that makes sense from a medical point of view. If there are medical reasons, the examination as well as the treatment or removal will be covered by the statutory health insurance. If you have any further questions that are not answered on our pages, please feel free to arrange a personal consultation.

    What is a congenital birthmark?

    Congenital birthmarks are patches of skin that are present at birth or skin lesions that form and become visible within the first few weeks of life. Congenital skin moles are dark and occasionally hairy. In some cases, it may be slightly raised skin lesions. They can also be a variety of colors, from tan to black. Congenital birthmarks grow over time in proportion to the growth in size of the person as they age. They consist of densely packed pigment cells. In the technical language one speaks of a congenital melanocytic nevus. Congenital birthmarks occur in 1 in 100 newborns. They occur slightly more often in women than in men (ratio of 3:2). In congenital birthmarks, the pigment cells are located in the dermis.

    The birthmarks are divided according to their size:

    • Small: less than 1.5 centimeters
    • Medium: 1.5 to 20 centimeters.
    • Large: 20 to 40 centimeters.
    • Huge: larger than 40 centimeters.

    The larger the congenital birthmark, the greater the risk of degeneration to skin cancer [4]. The risk for small congenital moles to develop a skin cancer over a lifetime is approximately one percent [5]. The risk of developing black skin cancer in the general population in Europe over a lifetime is 0.3 to 1.6 percent [6]. In addition to black skin cancer, there is also light or white skin cancer. This most often occurs on regions of the body without hair that are particularly exposed to the sun (face, neck, ears, upper arms, etc.). UV rays are considered the most common cause of both forms of cancer. For this reason, it is recommended to always use appropriate sunscreens with sufficient UV protection against UV radiation to avoid the development of malignant skin lesions. Protect yourself as a precaution and make sure you take good care of your skin, for example with anti-aging products or an anti-age treatment, so that it always receives enough moisture. This also has the positive side effect of preventing wrinkles as well as deeper wrinkles for future mature skin. In addition, have skin changes examined or checked regularly.

    Removing birthmarks without surgery

    Moles can be removed in different ways. In certain cases a birthmark can be lasered away. With the laser, high-energy light is transmitted to the skin. For fractions of a second, the tissue is strongly heated. Individual tissue layers or cells are vaporized or charred.

    Some lasers transfer the energy to chemical compounds with a specific color (hemoglobin, melanin, water). This allows pigment cells to be destroyed in a targeted manner while sparing the surrounding tissue. However, these lasers have a limited penetration depth. Pigment cells in deeper skin layers can remain and multiply again. This is particularly dangerous if black skin cancer has not been ruled out with absolute certainty in advance. Lasers also carry the risk of light-colored skin spots appearing if all pigment cells are destroyed. Other lasers, such as the CO2 laser, destroy the most superficial tissue layer without differentiating between color pigments. In 25 to 50 percent of cases, this results in scars, and in up to 18 percent of cases, wounds can become inflamed (Eggen C.A.M., et al., 2018, Br J Dermatol).

    The result of a laser treatment depends on the type of birthmark, the skin characteristics of the patient, the characteristics of the laser and the experience of the user. Experts agree that birthmarks must be carefully selected for laser treatment. If a suspicion of cancer cannot be ruled out, a tissue sample must be examined fine-tissue (technical term: histologically) (recommendation of the Radiation Protection Commission, February 2016).

    The independent removal of a birthmark at home is strictly discouraged. In the worst case, this can delay the diagnosis of skin cancer.

    The surgical removal of birthmarks

    The method of first choice for the safe assessment of suspected cancerous skin lesions is three-dimensional, micrographically controlled removal. The procedures of shaving, scraping or punching out have limited significance in the fine tissue examination. With a gentle treatment of the tissue and a tension-free fine skin suture, a fine line shaped scar usually remains. When planning an operation from an aesthetic point of view, the scar is aligned so that it is hardly visible. Larger congenital moles are removed in several operations so that the skin suture can heal without tension. The plastic surgeon then speaks of a serial excision.

    Removing birthmarks on the face

    In order to achieve an aesthetically optimal result of the treatment, experienced plastic surgeons work with fine instruments and magnifying glasses to optimally remove the skin change. The minor surgical procedure for birthmark removal is painless to painless as it is done under local anesthesia.

    At the beginning of the method, the doctor injects the anesthetic for local anesthesia with a very fine needle. The addition of epinephrine to the drug reduces the risk of seeing a bruise after surgery. The doctor performs surgical removal of the skin lesion using a scalpel. The procedure rarely lasts more than fifteen minutes. Experience with microsurgical techniques as well as methods of plastic surgery ensure barely visible scars. The doctor and specialist in aesthetic surgery closes the smallest wounds along the skin tension lines. Under these circumstances the wound can heal without tension and the stitches can be removed by the doctor after a few days.

    What should be considered after the removal of a birthmark?

    The wound should be cooled a little on the first day after the procedure. Showering is usually possible on the first day after treatment. However, prolonged bathing or swimming should be avoided during the first 2 weeks. A sick note is usually not necessary. The skin threads are removed after 5 to 7 days. Wound healing is usually completed after 7 to 10 days. Cigarette smoking delays wound healing and increases the risk of inflammation. After two to three weeks, scar healing can be supported by frequent application of cream. Pay attention to this care. For a particularly inconspicuous scar, it is recommended to use a protection against UV radiation during the first months.

    What does the removal of a birthmark cost?

    Health insurance will pay for the removal of moles if there is a medical necessity. Medical grounds exist when there is a reasonable suspicion of cancer. Disturbing birthmarks can also be removed if you do not like them for aesthetic reasons. Often patients are dissatisfied with moles and wish to have them removed for beautiful skin without marks, which they may try to cover with make-up. The price for the removal of benign moles depends on the size and position as well as the number of moles to be removed. You can find an order of magnitude of the prices on our cost page.

    Before and after pictures of a birthmark removal

    Information on before and after pictures regarding the removal of moles can be found on our page Before and After Pictures of Treatments.

    Testimonials for birthmark removal

    Nowadays, it is worth a lot to patients to read testimonials and reviews that they find on the internet. Visit our testimonials page now.

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    The author

    Dr. med. Stéphane Stahl

    “We provide you with extensive expert knowledge so that we can work with you to select the best possible treatment path.”

    Dr. med. Stéphane steel is the former director of the Clinic for Plastic, Reconstructive and Aesthetic Surgery / Hand Surgery at the Lüdenscheid Clinic. Dr. Stahl studied medicine at the Universities of Freiburg and Berlin. In 2011 he passed the European and 2012 the German specialist examination for plastic and aesthetic surgery. Further specialist qualifications and additional qualifications followed (including quality management, medical didactics, physical therapy, emergency medicine, laser protection officers, hand surgery) as well as prizes and awards. In 2015 he completed his habilitation in plastic and aesthetic surgery in Tübingen. He is an experienced microsurgeon, a sought-after expert and a regular speaker at specialist congresses. After a multi-stage selection process, Stéphane Stahl became a member of the American Society for Aesthetic Plastic Surgery (ASAPS), one of the world’s largest and most influential specialist societies for aesthetic surgery. His authorship includes numerous articles in respected peer review journals and standard surgical textbooks.

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