Malignant melanomaBMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b3078 (Published 04 September 2009) Cite this as: BMJ 2009;339:b3078
- Stella Ivaz, senior house officer—plastic surgery1,
- Hawys Lloyd-Hughes, senior house officer—plastic surgery1,
- Pippa Oakeshott, reader in general practice2,
- Saima Shah, senior teaching fellow in general practice2
- 1Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College NHS Trust, London W6 8RF
- 2Community Health Sciences, St George’s, University of London, London SW17 0RE
- Correspondence to: S Ivaz
- Accepted 1 May 2009
A 40 year old white woman is worried about a 5 × 7 mm brown and black lesion on her arm that has been getting darker over the past few months and has begun to itch. It has a regular border but is slightly raised. She has no axillary lymphadenopathy.
What issues you should cover
Is this a rapidly growing new mole or a long standing one that is changing in size, shape, colour, or sensation—for example, newly bleeding or itching?
What is the history of sun exposure? Ask about sunny holidays, occupational and recreational exposure, use of sun beds, and episodes of sunburn—particularly in childhood.
Photoprotection measures, for example, sunscreen use.
Personal history of malignant melanoma or other skin cancer.
Family history of malignant melanoma.
What you should do
Examine the mole and look for the ABCDE suspicious features (see box). Note whether the patient has sun sensitive skin (red or blonde hair, blue eyes, and particularly freckles), an above average mole count (more than 100 common naevi), naevi in unusual places, such as breast, buttock, scalp, ears, dorsum of feet, or under a nail. If relevant, examine for lymphadenopathy.
Refer to your local skin cancer multidisciplinary team any patient with ABCDE suspicious features, such as:
A new mole that is growing quickly in an adult
A long standing mole that is changing in shape, colour, or size
A mole that has three or more colours or has lost its symmetry
Any new lesion or nodule persisting more than eight weeks that is growing and is pigmented or vascular in appearance
A new pigmented line in a nail, especially where there is nail damage
Any lesion growing under a nail.
Explain that this mole has some suspicious features and needs specialist assessment and possible excision for accurate diagnosis and decisions about further management. Ask about concerns, and offer support and follow-up.
Do not biopsy or excise the lesion in general practice; initiate a fast track two week referral according to your local guidelines.
Bear in mind that no treatment other than wide local excision has been shown to be effective. Prognosis of primary melanoma is determined by invasion (Breslow thickness) and the presence or absence of microscopic ulceration. Approximate five year survival ranges from 95% to 100% (Breslow thickness <1 mm) to 50% (Breslow thickness >4 mm).
For patients with no suspicious features, explain the ABCDE warning signs and suggest they take photos every two months, holding a ruler next to the lesion. Ask patients to come back if they are worried. Advise about avoiding sun exposure and about wearing a hat and sunscreen. Consider referring patients with more than 100 moles routinely to a dermatologist for risk estimation and education.
ABCDE warning signs of malignant melanoma
A Asymmetry of lesion
D Diameter—more than 6 mm or increasing rapidly
Bataille V, de Vries E. Melanoma—part 1: epidemiology, risk factors, and prevention. BMJ 2008;337:a2249
BMJ Clinical Evidence (www.clinicalevidence.bmj.com)— Latest evidence based information on management of malignant melanoma
British Association of Dermatologists (www.bad.org.uk)—Patient information and leaflets
Royal College of Physicians. Prevention, diagnosis, referral and management of melanoma of the skin: concise guideline no 7. 2007. www.rcplondon.ac.uk/pubs/contents/f36b1656-cc74-4867-8498-cc94b378312a.pdf
Cite this as: BMJ 2009;339:b3078
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
Funding: None declared.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally reviewed.