Benign: 

Referral is not usually required for obviously benign lesions, Features which are generally reassuring and suggest a benign lesion include: 

• Regularity of colour, surface, and border. 
• Rapid growth over days rather than weeks – common with trauma or inflammation. 
• 'Stuck on' appearance with keratotic plugs on the surface (suggests a seborrhoeic keratosis). 
• A pigmented lesion in a child (melanoma is very rare in this age group). 

Risk evaluation: 

Risk evaluation indicating at risk people includes the following: 

• A personal history of skin cancer.  
• A family history of skin cancer.  
• Pale skin (Fitzpatrick Skin Type I and II) that burns easily.  
• Red, blonde or light-coloured hair. 
• Blue or green eyes. 
• History of sunburn, particularly blistering sunburn in childhood. 
• A large number of moles. 
• Unusually high sun exposure (living or spending frequent periods in hot countries). 
• Use of tanning beds or sun beds, particularly if 10 or more sessions.  
• Increasing age.  
• Immunosuppression 
• Pigmented lesions which 'stand out from the crowd' because they are different (the 'Ugly Duckling sign') are a cause for concern, especially if they are changing.  

The Weighted 7-point checklist may be used to assess pigmented skin lesions, and determine referral:  

o Major features of the lesion (2 points each): change in size, irregular shape or border, irregular colour. 

o Minor features of the lesion (1 point each): largest diameter 7 mm or more, inflammation, oozing or crusting of the lesion, change in sensation (including itch). 

o Suspicion is greater for lesions scoring 3 points or more. However, if there are strong concerns about cancer, any one feature is adequate to prompt urgent referral under Urgent Suspicion Of Cancer (USOC) arrangements.

The ABCD(E) system can also be used for pigmented lesion assessment (http://www.pcds.org.uk/clinical-guidance/melanoma-an-overview1) 

Refer using a Routine priority (as long as there is no index lesion of concern, where USOC needed) for risk estimation if people are at higher risk of melanoma, such as those with: 

• Giant congenital pigmented naevi (risk is highest for those measuring 20 cm in diameter or more). 
• A family history of 3 or more cases of melanoma and/or family history of pancreatic cancer— Those with two cases in the family may also benefit, especially if one of the cases had multiple primary melanomas or the atypical mole phenotype.  
• More than 100 normal moles. 

Atypical moles, see: https://www.pcds.org.uk/clinical-guidance/atypical-dysplastic-melanocytic-naevus  (particularly if multiple). 

Possible malignant: 

Urgently refer (using USOC, or similar, urgent pathway) to a dermatologist, plastic surgeon, or other suitable specialist with experience of melanoma diagnosis if: 

• The lesion is suggestive of malignant melanoma (including nodular and amelanotic melanoma). For example: 

• Lesions scoring 3 points or more (based on major features scoring 2 points each and minor features scoring 1 point each) on the 7-point checklist. However, any one feature is adequate to prompt urgent referral. 
• New nodules which are pigmented or vascular in appearance. 
• Nail changes, such as a new pigmented line in the nail or pigmentation under the nail that differs from other nails. 

• A skin condition is persistent or slowly evolving and unresponsive, with an uncertain diagnosis, and melanoma is a possibility. 
• A biopsy has confirmed the diagnosis of malignant melanoma. Note: normally such patients would be referred prior to excision. 

A copy of the pathology report should be sent with the referral correspondence, as there may be details (such as tumour thickness, excision margin) that will specifically influence further management.

Scottish Referral Guidelines for suspected cancer are available at the following link - https://www.cancerreferral.scot.nhs.uk/Home 

Benign: 

Manage in primary care. Consider scenarios 1 to 3 in Key messages. Review access to alternative providers for patient access to benign lesion treatments outside the NHS. 

Risk evaluation: 

Possible malignant: 

Refer using the USOC pathway for skin cancer. 

Scottish Referral Guidelines for suspected cancer are available at the following link - https://www.cancerreferral.scot.nhs.uk/Home 

Scottish Referral Guidelines for Suspected Cancer - https://www.cancerreferral.scot.nhs.uk/Home 

Scenario: Management | Management | Melanoma | CKS | NICE

NICE Pathways - Suspected cancer recognition and referral: site or type of cancer 

BAD Quality Standards for Teledermatology 

PCDS- Melanoma 

DermNet NZ- Melanoma 

SIGN- Cutaneous melanoma 

• Lesions change over time and a benign diagnosis at initial assessment may need to be reviewed if the lesion changes. Initial safety netting by check in 3 months against baseline photos is current NICE guidance for lesions with some measure of uncertainty. For itchy benign-appearing lesions causing uncertainty, see scenario 2 in Key Messages. 
• Photography is key for monitoring of lesions, sharing the diagnostic process and helping patients self-monitor. It improves the quality of the GP record and can be used for teledermatology. See scenarios below illustrating common dilemmas 

Scenario 1  

Low suspicion of malignancy: teledermatology may be used outside the USOC process, where locally available. Include a stable non-changing clinically benign skin lesion, but where the clinical diagnosis is uncertain and doesn’t satisfy 7 point checklist. Suitable photos are essential: 

take at least 3 images of the lesion, once indicated with an inked arrow or circle, including:  

• regional photograph with lesion indicated with ink.  
• macro image plane and at an angle.  
• dermoscopic image with and without gel/polarisation.  

Include core history: 

• see Risk Evaluation: e.g. evolution, symptoms, skin type, family history, eye colour, episodes of burning, high mole count.  

Scenario 2 

For a pigmented lesion which does not satisfy criteria for referral but is difficult to evaluate, consider the following: 

• Take a photograph (see scenario 1)  
• Ask a senior colleague with additional expertise/dermoscopy skills.  
• Where the lesion is itchy and suspicious for seborrhoeic keratosis take a photo, use emollient and moderate potency steroid for 3 weeks and review to ensure return to previous appearance. 

Scenario 3  

For someone with multiple pigmented lesions which appear benign but give rise to uncertainty: 

• Highlight with ink (number and arrow) those that warrant monitoring or assessment and take regional /macro/dermoscopy photos. Suggest patient participates in self-monitoring with Apps (review NHS Apps). Failure to number them in regional photo will risk misidentification. 
• If atypical see “risk evaluation” 

1. BAD Patient Information Leaflet - Melanoma stage 1-4 
2. Patient.info leaflet - Melanoma Skin Cancer 
3. BAD website description of ABCD 
4. NHS Conditions- Skin cancer (Melanoma) 
5. NHS Scotland Inform- Skin Cancer (Melanoma) 

Malignant 

ICD11 code - 2C30