Large congenital nevi present the biggest treatment difficulty because of the high rate of malignant transformation. If possible, serial excisions to remove large nevi are the best option. Tissue expanders are often used to help decrease the need for skin grafting. The goal should be 100% removal, although in some cases this is not feasible. If the nevi cover 10% to 30% or more of body surface area, they become almost impossible to remove. In these cases, as in all the others, the importance of lifelong surveillance needs to be taught to the parents, the afflicted individuals, and the participating physicians. The goal in these cases is to biopsy and remove any changing areas of the nevi in an effort to prevent metastasis if a melanoma were to develop.
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