Skip to main content
  1. Right Decisions
  2. Back
  3. Dermatology pathways
  4. Melanoma
Announcements and latest updates

Right Decision Service newsletter: May 2024

Welcome to the Right Decision Service (RDS) newsletter for May 2024.

Issues with RDS and Umbraco access

A fix was deployed on Thursday 30th May to address the stability issues experienced with the Right Decision Service over recent weeks. These arose principally when multiple toolkits were built simultaneously or successively to the mobile app  We are hopeful that the stability issues are now resolved. If you encounter any problems with this newly deployed site, please email ann.wales3@nhs.scot and onivarova@tactuum.com immediately as well as raising an Urgent support ticket.

Thank you again for your patience while we have been resolving these issues.

New editor request form

A form to request creation of new editors, or updates to existing editor details, is available in the Standard Operating Procedures toolkit  .

Redesign and improvements to RDS

The timeline for this work has been slightly delayed because effort has been diverted to addressing the recent stability issues.  However, the redesign of search, browse, archiving and version control have now been through a second round of testing and Tactuum is beginning to work on amendments.  We now plan to go out to user acceptance testing in July 2024 and will let you know when we are ready to do this.

Deep linking direct to individual toolkits on the mobile app

We are awaiting clarification from Tactuum on the time and effort required for this development. We should hear this week and I will let you know as soon as information is available.

New feature requests

Once we have completed the current redesign and deep linking we will be able to take stock of outstanding new feature requests and update you on what can be achieved within available resource.

Training

Introductory webinars for new RDS editors will be held on the following dates:

  • Thursday 27 June 11 am – 12 pm
  • Wednesday 3rd July 3.15 pm – 4.15 pm

To book to attend one of these webinars, please contact Olivia.graham@nhs.scot , stating your name, job title, health board and preferred date for training.

The RDS Learning working group is also progressing work on “train the trainer” resources for RDS editors and toolkit leads. These resources include:

  • A module on clinical and care governance for RDS content
  • A step by step introduction to the toolkit development process.
  • Video learning bytes to introduce key editorial features and functions.

We aim to have initial content available on the RDS Learning area by end of June/early July.

Evaluation

Thanks to Fergus Donachie in NHS Dumfries and Galloway and Sheila Grecian in NHS Lothian, who have shared the results of user surveys for their referral management and diabetes & endocrinology toolkits. The results provide excellent insights into how RDS is improving practice and saving time for clinicians. And there are also helpful suggestions for improving the service.

This all provides valuable material to support the business case to Scottish Government for the next stages of RDS development. If you have carried out local evaluation we would be very pleased to hear from you.

New toolkits

The following RDS toolkits are now live:

The Right Decisions toolkit for SIGN 171: Management of diabetes in pregnancy.

SIGN 168: Assessment, diagnosis, care and support for people with dementia and their carers. This toolkit is live and just awaiting final editorial review to remove the “in development” status.

Living well with dementia - for everyone. We recommend that you use the mobile version of this toolkit, as the web version contains only informational resources. The mobile app provides access to the Dementia wellbeing diary, which enables people in early post-diagnostic stages and their carers to keep track of their wellbeing outcomes. Each wellbeing outcome is linked to resources and services supporting that outcome. The mobile toolkit also provides a digital version of the “Getting to know me” form, and a range of resources and tools for people living with dementia and their carers. Four HSCPs have localised this app to include directories of local support services, but this generic app is available for anyone in any location to use.

The following toolkits are due to go live imminently:

  • SARCS (Sexual Assault Response Coordination Service)
  • Child protection procedures (North Lanarkshire)
  • NHS Lothian neonatal guidelines

Toolkits in development

Some of the toolkits the RDS team is currently working on:

Waiting Well – national toolkit for healthcare professionals. This toolkit is being developed for the Scottish Government Waiting Well team in collaboration with NHS GGC knowledge services staff. It provides healthcare teams in NHS Boards and HSCPs with guidance and tools to develop and implement their action plans to support people on waiting lists with access to information, signposting to local community assets and services, and to professional support and services.

NHS Borders RefHelp – referral guidance for NHS Borders. Work is about to start on a similar toolkit for NHS Tayside.

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit

Thank you to everyone who has completed the retrospective Quality Assurance checklist. I am pleased to say that the latest report was well-received within Healthcare Improvement Scotland, with positive comments on the commitment shown by NHS Boards and other organisations to ensuring the quality and safety of their content on the RDS.

 

Implementation projects

A knowledge exchange session to share learning about implementation of patient and public-facing RDS apps is scheduled for 28th June 11 am – 12 pm.  This will include sharing key points from a recent literature review, and the results of early tests of change of implementing the ‘Being a partner in my care’ app, which aims to help citizens to become active partners in Realistic Medicine. 

If you would like to attend this session and have not yet received an invitation, please contact ann.wales3@nhs.scot .

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

Melanoma

Warning

Cutaneous Melanoma: A skin cancer of the melanocytes in the skin. Melanoma is the third most common skin cancer in the UK. It accounts for more cancer deaths than all other skin cancers combined. Although melanoma is more often diagnosed in older people, it is increasingly affecting younger people. It is the second most common cancer in adults aged between 25 and 49. Most melanomas occur in people with pale skin. Precursor lesions include acquired and large congenital melanocytic naevi (moles), and dysplastic naevi but at least 50% appear with no preceding lesion. Several histologic variants have been recognized, including superficial spreading melanoma, acral lentiginous melanoma, nodular melanoma, and lentigo maligna melanoma.  

 

Please see key messages with scenarios outlining common situations where people have benign lesions that cause some concern and need additional evaluation over time. 

 

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

Not all treatment options may be listed in this guidance. Please refer to local formulary for a complete list.

Treatment/ therapy

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 

Referral Management

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 

Clinical tips

  • 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” 

ICD search categories

Malignant 

ICD11 code - 2C30 

Editorial Information

Last reviewed: 24/05/2023

Next review date: 24/05/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society.

Approved By: Scottish Dermatological Society