The degree and depth of skin trauma may be greater at the donor site, which may be responsible for the Koebner phenomenon . Many questions arise out of this observation. Is the degree of trauma important in pre- cipitating the phenomenon? Is the activity lesion spe- cific or generalized? What are the factors responsible for the survival of transplanted melanocytes? Are these pa- tients vulnerable to recurrence or loss of pigment in the lesions treated with MKT? Long-term follow-up and col- laborative research with immunologists and dermatopa- thologists may be helpful to elucidate the events and shed more light on the pathogenesis of vitiligo. Correspondence: Dr Mulekar, National Center for Viti- ligo and Psoriasis, Tahlia Street, PO Box 300320, Ri- yadh, 11372, Saudi Arabia (mulekar@gmail.com). Financial Disclosure: None reported. Acknowledgment: We thank Smita S. Mulekar for help- ing with data compilation. 1. Falabella R, Arrunategui A, Barona MI, Alzate A. The minigrafting test for viti- ligo: detection of stable lesions for melanocyte transplantation. J Am Acad Dermatol. 1995;32:228-232. 2. Mulekar SV. Melanocyte-keratinocyte cell transplantation for stable vitiligo. Int J Dermatol. 2003;42:132-136. 3. Malakar S, Lahiri K. Spontaneous repigmentation in vitiligo: why it is important? Int J Dermatol. 2006;45:478-479. COMMENTS AND OPINIONS Fast-Growing and Slow-Growing Melanomas W e read with great interest the article by Liu et al 1 and the accompanying editorial by Lipsker 2 on rapidly growing melanomas. Both articles point out that different types of melanomas ex- ist in relation to their biological propensity to grow and metastasize. Based on patient recall, Liu et al 1 calculated the rate of growth of 404 invasive melanomas (median tumor thickness, 1.3 mm) and found that almost a third of them grew 0.5 mm per month or more. These rapidly growing melanomas are more likely thick tumors asso- ciated with a high mitotic rate and more frequently found in older men with fewer melanocytic nevi and freckles. Furthermore, they usually lack the clinical ABCD fea- tures of melanoma (A, asymmetry; B, border irregular- ity; C, color variegation; D, diameter 5 mm), being fre- quently symmetric and amelanotic nodules. The authors conclude that the lack of the most important risk fac- tors for melanoma (ie, large number of nevi and freck- les) and the lack of the typical melanoma features (ie, ABCD criteria) make it more difficult for the physician to identify this subtype of rapidly growing melanoma. To overcome these difficulties, Lipsker 2 suggests a simple rule: each growing skin tumor that cannot be clearly diagnosed clinically must be rapidly excised. We applaud this message as being the simplest rule to apply in daily practice so as not to miss those melanomas that are responsible for most deaths attributable to mela- noma. But will this recommendation be sufficient to de- crease melanoma mortality? We do not believe so. In our view there are 3 avenues to approach the task of reducing melanoma deaths: the first is to alter the tu- mor itself, particularly the subtype described by Liu et al 1 ; the second is to modify patient behavior; and the third is to concentrate on what the physician can do. On which of the 3 actors should we concentrate our efforts? Unfor- tunately, nothing can be done to change the aggressive be- havior of some melanomas, and it would be very difficult to teach the whole population how to recognize fast- growing melanomas early enough to prevent growth and metastases. Thus, the only way to reduce melanoma deaths is to focus our attention on the third actor, the physician; but our challenge is not only the recognition of fast- growing melanoma once we see it but, indeed, to get the chance to see it! How many times do we perform full- body skin examination when the patient is coming to us for hand dermatitis or cosmetic procedures? As a derma- tologist, I have to confess, the answer is very rarely! It is actually proven that although most patients with melanoma have at least 1 medical consultation in the year before diagnosis, only 20% report receiving a skin can- cer examination. 3 In a previous randomized trial, our re- search group 4 demonstrated that a group of general phy- sicians using dermoscopy performed 25% better triage of suggestive skin tumors than physicians who used na- ked-eye examination alone. At the beginning of that study, just a short dermoscopy course (only 2 hours) was given to general physicians. Thus, our research group specu- lated that the increased dedication of physicians to the patients, a sine qua non condition to perform dermos- copy, was in itself one of the main reasons for the in- creased detection rate of suspected skin malignancies. In summary, we would like to propose a modification of the simple message of Lipsker 2 : full-body skin examination should routinely be performed to detect growing skin tu- mors, which must be rapidly excised if they cannot be clearly diagnosed clinically. Another point of discussion is the existence of differ- ent forms of melanoma as outlined by Lipsker 2 : (1) thin, slow-growing melanomas, with a strong increase in in- cidence across time and associated with intermittent sun exposure, a large number of nevi, and BRAF mutations; (2) thick, fast-growing melanomas, with stable inci- dence and presumably not associated with sun expo- sure, a large number of nevi, and BRAF mutations; and (3) classic lentigo maligna melanoma, with a more slowly increasing incidence and associated with continuous sun exposure but not with a large number of nevi and BRAF mutations. This categorization seems very plausible from an epidemiologic and biologic point of view. As noted by Lipsker, 2 the striking increase in number of thin mela- nomas contrasts with the stable incidence of thick mela- nomas, and it is surprising that increased excision of thin melanomas had no effect on the number of thick mela- nomas in a region not subjected to significant popula- tion migration. Sanjeev V. Mulekar, MD Marwan Asaad, MD Bassel Ghwish, MD Ahmed Al Issa, MD Abdullah Al Eisa, MD (REPRINTED) ARCH DERMATOL/ VOL 143, JUNE 2007 WWW.ARCHDERMATOL.COM 802 ©2007 American Medical Association. All rights reserved. Downloaded From: http://archderm.jamanetwork.com/ by a Seconda Universita Studi Napol User on 02/07/2016