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Endgames Picture Quiz

A darkly pigmented lesion with recent changes

BMJ 2011; 343 doi: (Published 09 September 2011) Cite this as: BMJ 2011;343:d5375
  1. U Sarwar, specialist trainee year 2, plastic surgery1,
  2. W A Townley, specialist trainee year 6, plastic surgery1,
  3. M Nicolaou, specialist trainee year 4, plastic surgery1,
  4. M S Khan, consultant plastic surgeon1
  1. 1Department of Plastic Surgery, Salisbury District Hospital, Salisbury, UK
  1. Correspondence to: U Sarwar u.sarwar{at}

A 65 year old retired construction worker was urgently referred by his general practitioner to the dermatology clinic. He had noticed that a darkly pigmented painless lesion on his back, which had been present for two years, had recently begun to increase in size and weep blood. He had never had any similar lesions before and he was otherwise healthy.

On examination, he was noted to have a 2 cm irregular lesion on his back with dark pigmentation (figure). There was no lymphadenopathy and further skin examination was normal. All other systems examinations were unremarkable.

Pigmented skin lesion


  • 1 How should a clinician assess a patient presenting with a pigmented skin lesion?

  • 2 What are the differential diagnoses and the most likely diagnosis in this patient?

  • 3 How would you confirm the diagnosis?

  • 4 What further procedure and investigations are useful in determining prognosis in this condition?

  • 5 What is the overall prognosis in this condition?


1 How should a clinician assess a patient presenting with a pigmented skin lesion?

Short answer

Take a thorough history. Ask about the natural course of the lesion including change in size, shape, oozing, bleeding, pain, and change in sensation. Risk factors for melanoma should also be elicited by asking about exposure to ultraviolet radiation, family or personal history of melanoma, and immunosuppression. Perform a head to toe examination of the skin and other systems.

Long answer

The natural history of a lesion can give vital clues to the likely diagnosis. Any pigmented mole that has been subject to recent change should alert suspicion. The seven point checklist (box 1) provides a more formal assessment tool to determine the likelihood of a suspicious lesion being melanoma and should form the basis of the history.1 The checklist emphasises the importance of any change in size, shape, and colour of a pre-existing pigmented lesion (major features). Symptoms such as bleeding, itching, and …

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