Synopsis
Assess a pigmented lesion systematically, compare it with the patient’s mole pattern, use the weighted seven-point checklist correctly, and arrange urgent specialist assessment without unsafe destructive sampling.
- ABCDE prompts asymmetry, border irregularity, colour variation, diameter and evolution; evolution is often the most useful single feature.
- The ugly-duckling sign identifies a lesion that differs from the person’s background naevus pattern, even if it does not satisfy every ABCDE letter.
- Nodular melanoma may be symmetrical, uniformly coloured and initially small; use elevated, firm and growing over weeks to months as an additional warning pattern.
- NICE weighted seven-point major features—change in size, irregular shape and irregular colour—score 2 each; minor features score 1 each.
- Minor features are diameter 7 mm or more, inflammation, oozing and change in sensation; a total of 3 or more triggers urgent suspected-melanoma referral.
- Examine all skin, including scalp, nails, palms and soles, with informed consent and a chaperone where preferred; do not assume low risk from skin tone.
- Dermoscopy by a trained clinician improves diagnostic accuracy but does not make a changing suspicious lesion safe for routine review.
- Do not curette, cauterise, freeze or partially sample a possible melanoma in primary care; urgent specialist full-thickness excision planning preserves staging.
Key red flags
Evolution, an ugly-duckling lesion, nodular growth, bleeding, ulceration, irregular colour or shape, nail-unit pigment extending onto skin, or a weighted seven-point score of 3 or more requires urgent suspected-cancer referral.
A new elevated, firm and continuously growing papule or nodule over weeks to months can be melanoma without classic ABCD asymmetry.
An enlarging irregular palm or sole macule, broad changing nail band, nail dystrophy or pigment on adjacent skin requires urgent specialist review.
Investigation priorities
Standardise urgent-referral assessment of a suspicious pigmented lesion.
Management branches
The weighted checklist scores 3 or more, dermoscopy suggests melanoma, or an ugly-duckling, nodular, acral or nail warning exists.
- Document history, measurements, morphology, patient’s comparison pattern and relevant risk factors without attempting destructive treatment.
- Make an urgent suspected-cancer referral using the local pathway and attach consented images only when secure systems and policy allow.
- Explain referral urgency without declaring a diagnosis, safety-net further growth or bleeding and ensure the patient knows how the appointment will arrive.