The Gray Zone of Dysplastic Nevi: A National Survey of Italian Dermatologists

The diagnosis of dysplastic nevi (DN) remains one of the most debated areas in dermatology, both clinically and histopathologically. Although the 2018 World Health Organization (WHO) classification considers DN potential precursors of melanoma, no shared consensus exists regarding their definition, diagnosis, and treatment. This lack of standardization results in divergent and often inconsistent clinical approaches [1, 2]. To better understand current practices and opinions, we conducted an anonymous national survey involving 410 Italian dermatologists. The questionnaire consisted of 12 multiple-choice questions exploring two main domains related to DN: beliefs and perceptions (including the recognition of a morphological and biological ‘gray zone’ and the relationship between DN and melanoma) and therapeutic approaches in the presence of histologic dysplasia. The survey was administered during a national dermatology congress held in November 2024, targeting practicing Italian dermatologists. No inclusion or exclusion criteria were applied. Most participants acknowledged the existence of a “gray zone” morphologically (76.2%) and biologically (61.4%) between melanocytic nevi and melanoma. However, only 21.8% considered DN melanoma precursors. In line with this, 98.3% disagreed with the WHO statement that all melanomas originate from benign precursors [1]. Most participants acknowledged that some melanomas arise from preexisting nevi. However, in patients with multiple nevi or dysplastic nevus syndrome, many believed melanomas arise de novo. Concerning therapeutic approaches, 93.2% of respondents indicated they never re-excise lesions with a histopathologic diagnosis of mild to moderate dysplastic nevus. In cases of severe dysplasia, 13.3% always re-excise, 34.8% do so in a minority of cases, and 34.0% never re-excise. Legal considerations were the leading reason for re-excision (66.2%), exceeding clinical indications (33.8%). Among factors influencing the decision to re-excise, lesion evolution was considered most relevant (55.5%), followed by morphology (45.6%), patient age (41.5%), and lesion site (25%) (Table 1). Our findings confirm the existence of wide variability in DN management among Italian dermatologists, consistent with international data [2, 3]. The striking disconnection between the WHO classification of melanocytic proliferations and the real-world scenario represented by dermatologists highlights the need for a critical reassessment of current paradigms. It is well established that diagnostic concordance among pathologists is particularly low for lesions showing moderate to severe atypia, with interobserver reproducibility below 60% and diagnostic accuracy ranging from 25% to 40% [4]. While some studies have suggested that DN may represent intermediate lesions along the nevus-to-melanoma pathway [5], their actual role as melanoma precursors remains uncertain and is not sufficient to guide histopathologic management or justify systematic re-excision in the absence of additional risk factors. The strong influence of legal considerations observed in this study raises concerns about the appropriateness and sustainability of current clinical practices. A limitation of our study is that the questionnaire did not explore clinical factors potentially influencing re-excision decisions, such as diagnostic uncertainty or margin status, which future studies should address. This nationwide survey on DN management among Italian dermatologists highlights the urgent need for evidence-based, shared guidelines to reduce variability and mitigate defensive medicine. This anonymous, non-interventional survey did not involve patient data and did not require ethical approval. The authors have nothing to report. The patients in this manuscript have given written informed consent to the publication of their case details. This study follows the ethics guidelines. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.