Too Much Pink Should Make Our Hearts Sink…

Summer is finally here and as we’re strolling through the park listening to ‘Everybody’s Free To Wear Sunscreen’ you realise not everyone has received this memo. ‘Lobster red’ appears to be the colour de jour.  Late spring to autumn see an increase in presentations of skin lesions, which correlates with increased detection of melanoma and non-melanoma skin cancers [Front Public Health:2016;4:78]. And so it is that Harry, fresh from basking in the European heatwave, comes to see you with a new suspicious evolving lesion. In this NB Blog, we review how to approach this consult and what we may find.

Incidence of melanoma has reached an ‘all time high’ with 17,500 cases now being diagnosed in the UK per year (BMJ 2023;382:85-126), with NICE expecting this to increase by a further ~10% over the next 10 years. Early diagnosis is crucial to good outcomes, so we need to ask ourselves: “can we confidently diagnose this is a benign lesion?” 

RISK FACTORS are a good place to start. Non-modifiable RF include Fitzpatrick skin types I/II, increasing age, a personal or family history of skin cancer, immunosuppression and a high number of common or atypical naevi (this is the most significant phenotypic risk factor). Modifiable risk factors include sunbed use and outdoor occupations but the most important risk factor, thought to contribute to ~85% of melanoma skin cancers, is overexposure to UV radiation.

CHANGE is clearly important - 30% of melanomas arise from a pre-existing naevus but we should be suspicious of any lesion with ongoing change.

DERMOSCOPY would be ideal to assess a lesion but if this isn’t available pattern recognition tools can be useful. NICE recommends the weighted 7-point checklist,  the ABCD(EFG) checklist is also useful, even the simple ‘ugly duckling sign’ – is this mole different from the others? 

What about two melanoma subtypes that are very easy to miss? 

Amelanotic melanoma: accounts for 8% of all melanomas, and this is what Harry presents with today. They often present on limbs and at acral sites, as a rapidly growing uniform pink-erythematous or skin coloured lesion. They initially present as a macule which tends to progress rapidly into a nodule which is friable and often bleeds easily due to ulceration. They tend to be more symmetrical than other melanoma subtypes and often mimic both benign and malignant skin tumours including pyogenic granulomas and BCCs. 

Acral lentiginous melanoma (ALM): accounts for ~1/3 to 2/3 of melanomas which occur in Fitzpatrick skin types V and VI. They occur on the palms, soles and can affect the nail unit (known as a subungual melanoma). ALM’s start as a slowly enlarging pigmented macule which increases in size with colour, border and surface irregularities, and often develops into a nodule, which can ulcerate and bleed. 

If you want to know more, join us for our interactive webinar on Common Dermatology Conditions Seen in Primary Care on Saturday 9^th September where we discuss clinical cases including more common melanoma subtypes, other benign and malignant skin lesions, psoriasis, eczema, urticaria and common skin infections we see in primary care with practical tips on how to manage these conditions. See you then!