June 10, 2024 • 25 mins
Do you use ABCD to diagnose malignant melanomas? You may be contributing to the 84% of obviously benign melanomas that are referred to secondary care. Or even worse, you could be missing over two thirds of melanoma.
Dr George Moncrieff and Dr Roger Henderson scrutinise ABCD in this podcast episode, working through each letter of the acronym to decipher the helpfulness of distinguishing malignant melanomas from benign lesions in primary care and explaining how much more useful E, F and G are.
When you finish this episode you’ll feel more confident in your diagnosis with Dr Moncrieff’s comprehensive diagnostic criteria. In addition, you’ll find out when you need to decide the next steps on a lesion immediately and where you have 3 to 4 months to make a decision.
Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence.
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Is there a dermatology topic you’d like us to explore? Email us at info@aproderm.com, and we’ll do our best to cover it.
Episode Resources:
- Survival with nonmelanoma skin cancer in Germany: https://pubmed.ncbi.nlm.nih.gov/26676514/
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:08):
Hello and welcome to this Rash Decisionspodcast, where we look at skin-related
issues, conditions and treatments inan interesting and informative way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I'venow retired from my practice and I
(00:29):
was one of the past Chairs of theDermatology Council for England.
So today, George and I are going tobe talking to you about the diagnostic
criteria of malignant melanomas.
And if you were with us for the firstpodcast, where we talked about the risk
factors involved with this particularcancer, we do hope you found it helpful.
(00:57):
So I'm going to kick off this week'spodcast, George, by looking at what
we should perhaps be thinking aboutwhen considering if a skin lesion
is a possible cause for concern.
So a patient comes in, sits down infront of us, shows you a skin lesion
and says, "What about it, Doc?"
Where should we be starting off with that?
(01:19):
Well, last time we focusedpredominantly on history.
The patient's experience of sunlight,episodes of sunbed use, episodes
of sunburn, immune suppression,family history, past history, etc.
I think there's a bit more history, whichis, if they've got a lesion which they say
is changing, I would take that seriouslyand I'd look at it very carefully.
(01:45):
So a changing lesion matters.
So that's the first thing to say.
But you need to look at the lesionand decide, does this lesion worry me?
Or sometimes I turn it on its headand say, does it not worry me?
Can I recognise anobviously benign lesion?
The giant comedo or, recently Isaw somebody who had a leg ulcer.
(02:07):
He was Asian, so his risknecessarily, was very, very low
risk for melanoma, at that site.
And there's a lot ofpost-inflammatory hyperpigmentation,
and that wasn't a melanoma.
Seborrhoeic keratosescause the most concern.
Um, they are pigmented, and oftenthey are ugly, and they are irregular,
(02:30):
and they can become inflamed.
Over a quarter of all our referralsto the two-week bureau turn out
to be seborrhoeic keratoses.
They're very, very common.
So they can be difficult, butcan you confidently diagnose
a seborrhoeic keratosis?
Dermatofibromas, they are oftenpigmented, the post-inflammatory
(02:50):
hyperpigmentation around the outside.
They give a clear history, usually, andthey're stable for months and years.
And haemangiomas, those can bevery, very tricky clinically.
So can I recognise an obviouslybenign lesion, or are there
features about this lesion thatI think are a bit more worrying?
I think the ugly ducklingis, one I always remember.
(03:13):
I think it's a really nice way, just to,sort of look at the one that stands out.
And as we've said so often, it'sjust that gut feeling, you might
not be quite sure why somethingbothers you, but it just bothers you.
And I suppose, as junior doctors, andmedical students still tell me this now,
if we were taught anything about lesionswhen we were training, it was ABCD.
(03:39):
It was probably the acronymthat we still remember the most.
So, as we all know, asymmetry, border,colour, diameter, really easy to
understand, but in my experience,as with so much of medicine, I've
learnt that medicine is not blackand white, it's all shades of grey.
(03:59):
I'm getting qualms about using ABCD.
I don't think it's perfect by any means.
In fact, I think it's probably imperfect.
And I suspect, it's an understatementof somewhat heroic proportions to
say that you have your views on this.
Would I be right about that?
Well, you are, I'm afraid.
(04:19):
Yes, I think this is a lot of the problemand the reason why we are making so many
referrals, of obviously benign lesions,is because we're relying on this.
So let's look at ABCD.
A stands for asymmetry, as yousay, the two halves are not
symmetrical or not identical.
Well, this just does not discriminatebenign lesions from malignant.
(04:39):
Yes, malignant lesions often areasymmetrical, not early ones.
Early ones are often quite symmetrical,but certainly, a well established
melanoma is likely to be asymmetrical.
But so are benign lesions.
Many, many benign lesions lose symmetry,so it doesn't usefully discriminate.
Border, irregular or ragged.
(05:01):
Again, that doesn't discriminate.
Many benign lesions have anirregular or ragged border.
In fact, far more important than theborder being irregular, or ragged is
whether the edge is sharply demarcated.
Benign things, so, for example,haemangiomas and seborrhoeic keratosis,
usually have a very nice, sharplydemarcated edge, whereas the melanoma
(05:25):
sort of blurs into the surrounding skin.
And perhaps more usefully than justthat, is whether the edge is irregularly
not discrete, or sharply demarcated.
If you have an edge that's, lookingfairly sharply demarcated, but other areas
where it's not, that's more worrying.
So looking at the bordercan be very useful.
Colour, yes, of course,colour does matter.
(05:47):
White light is actually made up ofall the colours of the rainbow, and
the way these are scattered by theatmosphere depends on their wavelengths.
When white light goes through anymedium, whether that's the sky or
water or indeed the skin, blue lightis scattered more and that results
in more blue light penetrating.
(06:10):
This is known as theTyndall or Rayleigh effect.
And that is why the sky looksblue and the sea looks blue.
Similarly, if you've got melanin,eumelanin, which is brown/black, sitting
up in the stratum corneum or in theepidermis, it'll be black or brown.
But if you've got melanin that'smuch, much deeper down in the
(06:33):
reticular dermis, you've lost the redend of the spectrum when the light
reflects back, and it looks blue.
Hence, you get blue nevi.
Stable nests and melanocytes deep inthe reticular dermis, perfectly benign.
And so that just looks blue.
If you cut that melaninout, it'd be brown or black.
But if you've got a lesion that'sgot several colours, then you're
(06:54):
getting a three dimensionalimpression of its sort of contours.
There are elements that aredeep, elements that are not.
So if you've got browns and reds andpinks and things, that's worrying.
Pink and brown makes me frown.
If you've got blacks and blues, you'vegot melanin up in the epidermis and
you've got melanin deep in the dermis.
That's a worry.
(07:15):
So, several colours, just like having anirregular edge, several colours is giving
you a third dimension of irregularity.
Just on that point actually, if you getmetastatic melanoma, often the metastases
are very deep and they're therefore blue.
So a blue naevus is fine ifit's been there for years and
it's stable and it's just a bluesmudgy naevus and good history.
(07:41):
But if you've got new blue nevi,particularly multiple, just bear in
mind they might be secondary deposits.
Diameter in the ABCD, Ithink it's six millimetres.
Frankly, I think that'sdangerously useless.
I've picked up many melanomas, justtwo, three, or even four millimetres.
So if you're waiting until it's sixmillimetres, you're going to miss
(08:02):
those really early melanomas whenyou can really alter the prognosis.
So why wait until it's six millimetres?
And I can think of very few seborrhoeickeratoses that are less than six
millimetres So there you have anirregular edged, non-symmetrical,
pigmented lesion of 8, 9, 10 millimetres.
(08:22):
It fails ABCD.
And so, no wonder we are beingalarmed by ABCD and are referring
84%, of obviously benign lesions.
Furthermore, if you just rely on ABCD,a guy called Giuseppe Argenziano, who is
the world expert on dermatoscopy, he'sfrom Naples and, more papers to his name
(08:43):
than anybody I've ever come across, andan absolute world authority on melanoma.
He estimates that over two thirds ofmelanoma would be missed, mostly early
melanomas, if you just rely on ABCD.
And at the same time, countless patientswill have been unnecessarily worried with
false positives because they do fail ABCD.
(09:06):
So it, it fails both ways.
So if we've got to think about movingaway from the simplistic ABCD, and
bearing in mind, I'm a bearer of verylittle brain, and I like to remember
very simple things in a busy surgery.
What would be your alternative toABCD to have in our heads to remember?
(09:30):
We're going to sort of keepploughing on down the alphabet.
Yeah, I think so.
Yep.
I think E, F, and G is much more useful.
I'll come on to that.
Yeah, remember E, F, and G.
Yeah, and you can remember C, actually.
I think you remember C as well.
C, E, F, G, if you like.
Well, I take seriously a new melanocyticnaevus in somebody over the age of 30.
(09:52):
Your acquired mole population shouldhave all been settled by the age of 30.
Usually mid-twenties at the latest.
So if somebody says, here's a photographof me on the beach last year, and I
didn't have that mole, and now I've gotthis mole here on my back, and it is
a melanocytic naevus, it's not a solarlentigo, or seborrhoeic keratosis,
or dermatofibroma, or anything else,then, if they're over 30, I would
(10:17):
want to watch that one closely.
If they're over 40, I'd be moreconcerned, and if they're over
50, I would say it needs to comeout, however benign it looks.
But a definite, new, acquiredmelanocytic naevus over the age of
50, I would say should come out.
The only exception to that perhapsis patients with multiple moles.
Interestingly, they're trickybecause they go on getting new
(10:40):
moles even into their 70s and 80s.
And we know that they are candidatesfor melanoma, that are higher risk.
And also when they get a melanoma, it'shard to spot sometimes because it's
hidden amongst all their other moles.
It's hiding there.
You mentioned the ugly duckling sign,and I think that's incredibly important.
The melanocytic lesion thatdoesn't look like it's brothers
(11:03):
and sisters, it stands out.
It's looking ugly and different.
Definitely be worried about that.
And I suppose to a small extent, Ithink about the back in men and the
leg in women, but frankly, both menand women can get melanomas anywhere.
So I don't think that'sterribly important, but no,
as you say, E, F, and G.
E for me is elevation.
(11:26):
If you've got a lesion that youcan feel, it's raised, you must
make a decision about that today.
Either you are confident, utterlyconfident it's benign and you can
dismiss it, or you need histology, i.e.
you need to refer it.
So, raised lesions, they'vealready got vertical growth.
(11:49):
The converse is really useful.
If you've got a macular lesion,you run your hand over it,
you can't feel it at all.
It's only got horizontal growth.
It's totally superficial.
You've got time.
You've certainly got three,four months to make a decision.
So, with a flat pigmented lesion,if you think it looks alright, it
doesn't look that different to theother moles, it's not doing anything
(12:12):
very much as far as you can tell, Isuggest you take a quality photograph
and review in three or four months,and if it looks identical, it's stable.
But with a nodular lesion, youmust make a decision today.
The second thing is F for firmness.
All tumours are firm.
Yes, certainly some benign thingslike dermatofibromas are very firm.
(12:35):
But if it's firm and doesn't give atall, you need to be a bit more concerned.
Again, the converse is more useful.
If it's soft and wobbly, you can sortof wobble it around the place like
a skin tag or a lipoma or whatever.
If it's soft and wobbly,it isn't a tumour.
Tumours are firm.
They don't give.
And G for me is growth, i.e.
(12:56):
anything that is exhibitingdynamic features, particularly if
it's measuring over a few months,then I take that very seriously.
Tumours grow.
That's the big difference betweena tumour and a benign lesion.
Benign things stay the same.
Tumours change.
I did some work withCRUK about 10 years ago.
They were wanting to produce a toolboxfor recognising melanoma in primary care.
(13:19):
And all the lesions that theywere showing were nodules that
were ulcerated and bleeding.
And yeah, those were all melanomas.
But frankly, as far as I'm concerned,almost too late to be diagnosing
because they've all got invasivegrowth, they've probably metastasised
(13:39):
and by referring those you're savingyour reputation but not your patient.
So yeah, ulcerated bleeding nodules.
I think any ulcerated nodule,needs histology, every time.
Unless there's a really clear historythat it's a picker's nodule, or something
along those sorts of lines, where you'vegot a nodular prurigo or something.
(14:01):
If you've got a solitary nodule that'sulcerated, it needs urgent histology.
I think another thing to remember is thatif your patient is very fair-skinned,
it's quite likely they have the MC1R gene.
People with this typically have blondeor ginger hair, blue or green eyes.
(14:23):
They don't form an even tan andinstead they make lots of freckles.
Now, these individuals aresignificantly more likely to develop
a melanoma, several fold more likely.
And indeed, if they've gotmultiple moles as well, then they
have a 25-fold increased risk.
(14:43):
It could be a pink melanoma.
And by pink, I mean pink like strawberryblancmange, that sort of pink colour.
And these are pink melanomas'cause they're full of
pheomelanin, not black eumelanin.
They've got pink, pheomelanin.
So some people call them amelanotic,but they're not without melanin.
They've got pheomelanin, or you cancall them hypomelanotic if you like.
(15:06):
But if you've got a firm, pink nodule insomebody with type 1 Celtic skin, treat it
with the same respect you would a brown orblack nodule in somebody with darker skin.
On acral skin you can gettwo sorts of melanomas.
This is on fingerprinting skinI'm thinking about particularly.
You can get the pigmented melanomas,which actually are quite low grade.
(15:30):
They're lentiginous.
And they grow very slowly, but they havea bad prognosis because we miss them and
patients don't present with them either.
And they just grow very slowlyand therefore they have a bad
reputation for that reason, butthey're not inherently aggressive.
But there is a, a non-lentiginousmelanoma that occurs on acral skin,
(15:51):
which is typically very aggressive.
It's usually hypomelanotic, oftenwith no melanin to see at all, often
keratotic, which is very distracting.
You don't expect to see keratin ina melanoma and they ulcerate early,
and these are very tricky, so youmust bear them in mind at all times.
If you've got a ulcerated noduleon the leg, don't just put it
(16:14):
down to overgranulation tissueor ulcer or diabetic, whatever.
It could be a non-lentiginous melanomaand they have a very nasty reputation.
I think the final thing just to sayis that if you're concerned that
your patient could have a melanoma,or any skin cancer for that matter.
, but you've looked at their lesion andyou've said, no, that's fine, that's
(16:34):
benign, it doesn't mean that your patientisn't still a candidate for skin cancer.
Shockingly, a fifth of all the tumoursthat were excised in Oxford in 2018
were not the lesion that we'd referred.
And this worries me because we'removing into a new world where we're
being asked to take photographsand maybe dermatoscopy images of
lesions and just sending the lesion.
(16:56):
Secondary care will give the rightopinion and reassure, more often than
not, or maybe say they need to see thepatient, but when they reassure the
patient, that isn't the end of the story.
If no one's examined their skin.
It doesn't mean they haven't got askin cancer and uh, I sometimes say
I don't need to examine it today butI would like you to come back in the
next month or so when I can examinebetween your toes, in the natal cleft,
(17:21):
maybe in the armpits, between thefingers, on the scalp, behind the ears
and maybe even under the underclothes.
The patient can come back,prepared and expecting that.
You can have a chaperone if youwant, and you can do the job, and
do your job professionally, but Ithink, to miss a fifth of cancers
because we just referred a benignlesion, isn't the end of the story.
And would I be right in thinkingthat dermatoscopy is absolutely
(17:48):
key to successful picking up andpreventing inaccurate referrals?
Oh, it is my favourite topic.
Absolutely.
I could live without a stethoscope.
I could live without an auriscope,actually, but I could not have
practised without a dermatoscope.
I would say my dermatoscope changed,changed, my decision about lesions, half a
(18:10):
dozen times a day, whereas, my stethoscopepossibly changed my decision about
something a dozen times in my career.
So, yeah, dermatoscopy givesyou so much more information.
It's a brilliant way of recognising,with confidence, a seborrhoeic
(18:30):
keratosis or with confidence, ahaemangioma or a dermatofibroma.
It absolutely changes the landscapeand I would find it utterly impossible
to give any opinion on a pigmentedlesion without using dermatoscopy.
So it staggers me that thereare GPs who are struggling
(18:50):
without using a dermatoscope.
I don't know how they can do their job.
It must be terrifying.
Yeah.
No, I completely concur, and I wasthinking, when you were just talking
then, about that amazing statistic,about the skin cancers excised that
weren't the lesion that was referred.
I saw a chap not too long ago, asingle man came in with an obviously
benign lesion on his forearm, whichis what he wanted to see me about.
(19:14):
I must have had some time that daybecause I said, well, let's have
a little look at the rest of youto make sure everything's fine.
And sitting between his shoulder blades,that he couldn't obviously see himself,
and no one was living with him to tellhim about it, was this most obvious mother
of all melanomas sitting there, that hewas completely, you know, clueless about.
But if I just looked at his arm andsaid, "yep, you're fine, carry on."
(19:36):
You know, no one would have seenthat until it had metastasised, and
he got away with it, fortunately.
But I completely agree with you.
The one-stop, look at a photo,diagnose it correctly, yes, but you're
not sending in photographs of everysquare inch of that patient's skin.
So yes, we, have to look at thewhole of the patient's skin.
(19:57):
It is just one organ and we needto look at that whole organ.
We've covered an awful lot here,George, in a very short time.
So there's an awful lot for people tochew over, I think, here in primary
care, may have made them rethink howthey think about looking at melanomas.
So if I, can ask you a slightly unfairquestion, and try and pull lots of things
(20:19):
together, from a perspective point ofview, when we're thinking about melanomas.
What would be your, key take home pointsif you like, that we might not have
considered previously, which perhapswe should be just keeping in the back
of our minds, with our patients here?
Wow.
Well, I think, I think you're absolutelyright, we do need to keep this all
in perspective and at the end of theday, I'm, personally, not terribly
(20:44):
worried about squamous cell carcinoma,because it'll be pretty obvious.
It's a lesion that's rapidlychanging and it can be cut out and
they tend to behave themselves.
They don't have distantmetastases and things like that.
Yes, I do worry about melanoma.
But I also acknowledge that it ismostly down to genetic risk factors.
And again, something I want to diagnose,nice and early, and get it cut out and
(21:07):
make a big difference by prognosis.
What I am worried about though is dyingof a heart attack or a stroke, and I'm
68 times more likely to die from a heartattack or stroke than from skin cancer.
In fact, as a man, probablyeven more than that.
And whilst UV light does increase the riskof skin cancer, I can't say it doesn't.
(21:30):
It does.
It, also significantly reducesthe risk of heart attacks and
strokes by releasing nitric oxideand lowering your blood pressure.
So, I think to have lower bloodpressure and some of the other benefits
of sunlight is something that I givea lot of thought to, particularly
as I'm 68 times more likely to diefrom that than from skin cancer.
(21:51):
There are also twice as manydeaths from falls each year
as there are from melanoma.
So yes, there is a risk ofdying from melanoma, but we need
to keep that in perspective.
And the risk of dying from melanomaanyway, has dropped dramatically
recently because of new biologicalapproaches to managing it.
(22:12):
And what got me thinking about allthis some years ago was when I thought,
well, why did our ancestors, and myancestors had black skin, and when they
migrated out of Central Africa 50 to200,000 years ago, we're not quite sure
of the exact date, and they moved tolatitudes where the sunlight was weaker.
Why did they evolve to have weakermelanin, where the sunlight became weaker?
(22:35):
What was the evolutionary drive to allowmore sunlight to get through our skin?
Because evolution doesn't do somethingwithout there being a good reason.
And I think that says it all to me.
That there are benefits of sunlight.
Yes, there are risks, and yes, going outin the sun, my skin will age and so on.
(22:55):
But I think that I need to balancethose risks and then make sure I
diagnose melanoma and other skincancers competently, and early.
But the risks to your health fromnon-burning UV exposure in adulthood, I
think, has been seriously overemphasised.
I acknowledge it will cause my skinto age faster and I get a greater
(23:19):
risk of the keratotic cancers fromthis cumulative life risk, but,
that doesn't worry me as much.
And there's a fascinating studyfrom Germany, in 2016, in the
British Journal of Dermatology.
They looked at a population, I think itwas 33 million, and they found that those
individuals who'd had a non-melanomaskin cancer, which obviously would be
(23:41):
usually a BCC, were enjoying three tofour years longer life expectancy than
individuals who'd not had a skin cancer.
Okay, a lot of confounding factors there.
Might have had more holidaysabroad and all sorts of other
things and better quality of life.
But if you've had a BCC, you're in acohort of individuals who live longer.
(24:02):
But I suppose one of the importantmessages here today, aggressive
skin cancers, like melanoma, change.
They grow, they become moreugly, but they start small.
So don't wait, like ABCD might encourageyou to, for it to reach six millimetres
diagnose it early, ideally with adermatoscope, demonstrating the features.
(24:22):
And by ugly, I mean it doesn'tlook like the other moles.
It's becoming more and more asymmetrical.
It's getting several colours, it's gettingan edge that's doing all sorts of things.
If you wait for them to become hardraised nodules and then ulcerate,
you're not doing a patient any favours.
Pick up these melanomas early.
(24:43):
So I think they're the messages.
Excellently done, George, because there'san awful lot to try and pull together
and just remember that ugly duckling,and I think that's a really nice place to
bring this particular episode to a close.
So, George and I do hope youfound it interesting and helpful,
and as always, thank you so muchfor your time listening to us.
(25:03):
Roger and I hope you'll join us nexttime, where we'll be looking at the
way forward in the early recognitionof melanoma in primary care.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
So until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
Hello and welcome to this Rash Decisionspodcast, where we look at skin-related
issues, conditions and treatments inan interesting and informative way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I'venow retired from my practice and I
(00:29):
was one of the past Chairs of theDermatology Council for England.
So today, George and I are going tobe talking to you about the diagnostic
criteria of malignant melanomas.
And if you were with us for the firstpodcast, where we talked about the risk
factors involved with this particularcancer, we do hope you found it helpful.
(00:57):
So I'm going to kick off this week'spodcast, George, by looking at what
we should perhaps be thinking aboutwhen considering if a skin lesion
is a possible cause for concern.
So a patient comes in, sits down infront of us, shows you a skin lesion
and says, "What about it, Doc?"
Where should we be starting off with that?
(01:19):
Well, last time we focusedpredominantly on history.
The patient's experience of sunlight,episodes of sunbed use, episodes
of sunburn, immune suppression,family history, past history, etc.
I think there's a bit more history, whichis, if they've got a lesion which they say
is changing, I would take that seriouslyand I'd look at it very carefully.
(01:45):
So a changing lesion matters.
So that's the first thing to say.
But you need to look at the lesionand decide, does this lesion worry me?
Or sometimes I turn it on its headand say, does it not worry me?
Can I recognise anobviously benign lesion?
The giant comedo or, recently Isaw somebody who had a leg ulcer.
(02:07):
He was Asian, so his risknecessarily, was very, very low
risk for melanoma, at that site.
And there's a lot ofpost-inflammatory hyperpigmentation,
and that wasn't a melanoma.
Seborrhoeic keratosescause the most concern.
Um, they are pigmented, and oftenthey are ugly, and they are irregular,
(02:30):
and they can become inflamed.
Over a quarter of all our referralsto the two-week bureau turn out
to be seborrhoeic keratoses.
They're very, very common.
So they can be difficult, butcan you confidently diagnose
a seborrhoeic keratosis?
Dermatofibromas, they are oftenpigmented, the post-inflammatory
(02:50):
hyperpigmentation around the outside.
They give a clear history, usually, andthey're stable for months and years.
And haemangiomas, those can bevery, very tricky clinically.
So can I recognise an obviouslybenign lesion, or are there
features about this lesion thatI think are a bit more worrying?
I think the ugly ducklingis, one I always remember.
(03:13):
I think it's a really nice way, just to,sort of look at the one that stands out.
And as we've said so often, it'sjust that gut feeling, you might
not be quite sure why somethingbothers you, but it just bothers you.
And I suppose, as junior doctors, andmedical students still tell me this now,
if we were taught anything about lesionswhen we were training, it was ABCD.
(03:39):
It was probably the acronymthat we still remember the most.
So, as we all know, asymmetry, border,colour, diameter, really easy to
understand, but in my experience,as with so much of medicine, I've
learnt that medicine is not blackand white, it's all shades of grey.
(03:59):
I'm getting qualms about using ABCD.
I don't think it's perfect by any means.
In fact, I think it's probably imperfect.
And I suspect, it's an understatementof somewhat heroic proportions to
say that you have your views on this.
Would I be right about that?
Well, you are, I'm afraid.
(04:19):
Yes, I think this is a lot of the problemand the reason why we are making so many
referrals, of obviously benign lesions,is because we're relying on this.
So let's look at ABCD.
A stands for asymmetry, as yousay, the two halves are not
symmetrical or not identical.
Well, this just does not discriminatebenign lesions from malignant.
(04:39):
Yes, malignant lesions often areasymmetrical, not early ones.
Early ones are often quite symmetrical,but certainly, a well established
melanoma is likely to be asymmetrical.
But so are benign lesions.
Many, many benign lesions lose symmetry,so it doesn't usefully discriminate.
Border, irregular or ragged.
(05:01):
Again, that doesn't discriminate.
Many benign lesions have anirregular or ragged border.
In fact, far more important than theborder being irregular, or ragged is
whether the edge is sharply demarcated.
Benign things, so, for example,haemangiomas and seborrhoeic keratosis,
usually have a very nice, sharplydemarcated edge, whereas the melanoma
(05:25):
sort of blurs into the surrounding skin.
And perhaps more usefully than justthat, is whether the edge is irregularly
not discrete, or sharply demarcated.
If you have an edge that's, lookingfairly sharply demarcated, but other areas
where it's not, that's more worrying.
So looking at the bordercan be very useful.
Colour, yes, of course,colour does matter.
(05:47):
White light is actually made up ofall the colours of the rainbow, and
the way these are scattered by theatmosphere depends on their wavelengths.
When white light goes through anymedium, whether that's the sky or
water or indeed the skin, blue lightis scattered more and that results
in more blue light penetrating.
(06:10):
This is known as theTyndall or Rayleigh effect.
And that is why the sky looksblue and the sea looks blue.
Similarly, if you've got melanin,eumelanin, which is brown/black, sitting
up in the stratum corneum or in theepidermis, it'll be black or brown.
But if you've got melanin that'smuch, much deeper down in the
(06:33):
reticular dermis, you've lost the redend of the spectrum when the light
reflects back, and it looks blue.
Hence, you get blue nevi.
Stable nests and melanocytes deep inthe reticular dermis, perfectly benign.
And so that just looks blue.
If you cut that melaninout, it'd be brown or black.
But if you've got a lesion that'sgot several colours, then you're
(06:54):
getting a three dimensionalimpression of its sort of contours.
There are elements that aredeep, elements that are not.
So if you've got browns and reds andpinks and things, that's worrying.
Pink and brown makes me frown.
If you've got blacks and blues, you'vegot melanin up in the epidermis and
you've got melanin deep in the dermis.
That's a worry.
(07:15):
So, several colours, just like having anirregular edge, several colours is giving
you a third dimension of irregularity.
Just on that point actually, if you getmetastatic melanoma, often the metastases
are very deep and they're therefore blue.
So a blue naevus is fine ifit's been there for years and
it's stable and it's just a bluesmudgy naevus and good history.
(07:41):
But if you've got new blue nevi,particularly multiple, just bear in
mind they might be secondary deposits.
Diameter in the ABCD, Ithink it's six millimetres.
Frankly, I think that'sdangerously useless.
I've picked up many melanomas, justtwo, three, or even four millimetres.
So if you're waiting until it's sixmillimetres, you're going to miss
(08:02):
those really early melanomas whenyou can really alter the prognosis.
So why wait until it's six millimetres?
And I can think of very few seborrhoeickeratoses that are less than six
millimetres So there you have anirregular edged, non-symmetrical,
pigmented lesion of 8, 9, 10 millimetres.
(08:22):
It fails ABCD.
And so, no wonder we are beingalarmed by ABCD and are referring
84%, of obviously benign lesions.
Furthermore, if you just rely on ABCD,a guy called Giuseppe Argenziano, who is
the world expert on dermatoscopy, he'sfrom Naples and, more papers to his name
(08:43):
than anybody I've ever come across, andan absolute world authority on melanoma.
He estimates that over two thirds ofmelanoma would be missed, mostly early
melanomas, if you just rely on ABCD.
And at the same time, countless patientswill have been unnecessarily worried with
false positives because they do fail ABCD.
(09:06):
So it, it fails both ways.
So if we've got to think about movingaway from the simplistic ABCD, and
bearing in mind, I'm a bearer of verylittle brain, and I like to remember
very simple things in a busy surgery.
What would be your alternative toABCD to have in our heads to remember?
(09:30):
We're going to sort of keepploughing on down the alphabet.
Yeah, I think so.
Yep.
I think E, F, and G is much more useful.
I'll come on to that.
Yeah, remember E, F, and G.
Yeah, and you can remember C, actually.
I think you remember C as well.
C, E, F, G, if you like.
Well, I take seriously a new melanocyticnaevus in somebody over the age of 30.
(09:52):
Your acquired mole population shouldhave all been settled by the age of 30.
Usually mid-twenties at the latest.
So if somebody says, here's a photographof me on the beach last year, and I
didn't have that mole, and now I've gotthis mole here on my back, and it is
a melanocytic naevus, it's not a solarlentigo, or seborrhoeic keratosis,
or dermatofibroma, or anything else,then, if they're over 30, I would
(10:17):
want to watch that one closely.
If they're over 40, I'd be moreconcerned, and if they're over
50, I would say it needs to comeout, however benign it looks.
But a definite, new, acquiredmelanocytic naevus over the age of
50, I would say should come out.
The only exception to that perhapsis patients with multiple moles.
Interestingly, they're trickybecause they go on getting new
(10:40):
moles even into their 70s and 80s.
And we know that they are candidatesfor melanoma, that are higher risk.
And also when they get a melanoma, it'shard to spot sometimes because it's
hidden amongst all their other moles.
It's hiding there.
You mentioned the ugly duckling sign,and I think that's incredibly important.
The melanocytic lesion thatdoesn't look like it's brothers
(11:03):
and sisters, it stands out.
It's looking ugly and different.
Definitely be worried about that.
And I suppose to a small extent, Ithink about the back in men and the
leg in women, but frankly, both menand women can get melanomas anywhere.
So I don't think that'sterribly important, but no,
as you say, E, F, and G.
E for me is elevation.
(11:26):
If you've got a lesion that youcan feel, it's raised, you must
make a decision about that today.
Either you are confident, utterlyconfident it's benign and you can
dismiss it, or you need histology, i.e.
you need to refer it.
So, raised lesions, they'vealready got vertical growth.
(11:49):
The converse is really useful.
If you've got a macular lesion,you run your hand over it,
you can't feel it at all.
It's only got horizontal growth.
It's totally superficial.
You've got time.
You've certainly got three,four months to make a decision.
So, with a flat pigmented lesion,if you think it looks alright, it
doesn't look that different to theother moles, it's not doing anything
(12:12):
very much as far as you can tell, Isuggest you take a quality photograph
and review in three or four months,and if it looks identical, it's stable.
But with a nodular lesion, youmust make a decision today.
The second thing is F for firmness.
All tumours are firm.
Yes, certainly some benign thingslike dermatofibromas are very firm.
(12:35):
But if it's firm and doesn't give atall, you need to be a bit more concerned.
Again, the converse is more useful.
If it's soft and wobbly, you can sortof wobble it around the place like
a skin tag or a lipoma or whatever.
If it's soft and wobbly,it isn't a tumour.
Tumours are firm.
They don't give.
And G for me is growth, i.e.
(12:56):
anything that is exhibitingdynamic features, particularly if
it's measuring over a few months,then I take that very seriously.
Tumours grow.
That's the big difference betweena tumour and a benign lesion.
Benign things stay the same.
Tumours change.
I did some work withCRUK about 10 years ago.
They were wanting to produce a toolboxfor recognising melanoma in primary care.
(13:19):
And all the lesions that theywere showing were nodules that
were ulcerated and bleeding.
And yeah, those were all melanomas.
But frankly, as far as I'm concerned,almost too late to be diagnosing
because they've all got invasivegrowth, they've probably metastasised
(13:39):
and by referring those you're savingyour reputation but not your patient.
So yeah, ulcerated bleeding nodules.
I think any ulcerated nodule,needs histology, every time.
Unless there's a really clear historythat it's a picker's nodule, or something
along those sorts of lines, where you'vegot a nodular prurigo or something.
(14:01):
If you've got a solitary nodule that'sulcerated, it needs urgent histology.
I think another thing to remember is thatif your patient is very fair-skinned,
it's quite likely they have the MC1R gene.
People with this typically have blondeor ginger hair, blue or green eyes.
(14:23):
They don't form an even tan andinstead they make lots of freckles.
Now, these individuals aresignificantly more likely to develop
a melanoma, several fold more likely.
And indeed, if they've gotmultiple moles as well, then they
have a 25-fold increased risk.
(14:43):
It could be a pink melanoma.
And by pink, I mean pink like strawberryblancmange, that sort of pink colour.
And these are pink melanomas'cause they're full of
pheomelanin, not black eumelanin.
They've got pink, pheomelanin.
So some people call them amelanotic,but they're not without melanin.
They've got pheomelanin, or you cancall them hypomelanotic if you like.
(15:06):
But if you've got a firm, pink nodule insomebody with type 1 Celtic skin, treat it
with the same respect you would a brown orblack nodule in somebody with darker skin.
On acral skin you can gettwo sorts of melanomas.
This is on fingerprinting skinI'm thinking about particularly.
You can get the pigmented melanomas,which actually are quite low grade.
(15:30):
They're lentiginous.
And they grow very slowly, but they havea bad prognosis because we miss them and
patients don't present with them either.
And they just grow very slowlyand therefore they have a bad
reputation for that reason, butthey're not inherently aggressive.
But there is a, a non-lentiginousmelanoma that occurs on acral skin,
(15:51):
which is typically very aggressive.
It's usually hypomelanotic, oftenwith no melanin to see at all, often
keratotic, which is very distracting.
You don't expect to see keratin ina melanoma and they ulcerate early,
and these are very tricky, so youmust bear them in mind at all times.
If you've got a ulcerated noduleon the leg, don't just put it
(16:14):
down to overgranulation tissueor ulcer or diabetic, whatever.
It could be a non-lentiginous melanomaand they have a very nasty reputation.
I think the final thing just to sayis that if you're concerned that
your patient could have a melanoma,or any skin cancer for that matter.
, but you've looked at their lesion andyou've said, no, that's fine, that's
(16:34):
benign, it doesn't mean that your patientisn't still a candidate for skin cancer.
Shockingly, a fifth of all the tumoursthat were excised in Oxford in 2018
were not the lesion that we'd referred.
And this worries me because we'removing into a new world where we're
being asked to take photographsand maybe dermatoscopy images of
lesions and just sending the lesion.
(16:56):
Secondary care will give the rightopinion and reassure, more often than
not, or maybe say they need to see thepatient, but when they reassure the
patient, that isn't the end of the story.
If no one's examined their skin.
It doesn't mean they haven't got askin cancer and uh, I sometimes say
I don't need to examine it today butI would like you to come back in the
next month or so when I can examinebetween your toes, in the natal cleft,
(17:21):
maybe in the armpits, between thefingers, on the scalp, behind the ears
and maybe even under the underclothes.
The patient can come back,prepared and expecting that.
You can have a chaperone if youwant, and you can do the job, and
do your job professionally, but Ithink, to miss a fifth of cancers
because we just referred a benignlesion, isn't the end of the story.
And would I be right in thinkingthat dermatoscopy is absolutely
(17:48):
key to successful picking up andpreventing inaccurate referrals?
Oh, it is my favourite topic.
Absolutely.
I could live without a stethoscope.
I could live without an auriscope,actually, but I could not have
practised without a dermatoscope.
I would say my dermatoscope changed,changed, my decision about lesions, half a
(18:10):
dozen times a day, whereas, my stethoscopepossibly changed my decision about
something a dozen times in my career.
So, yeah, dermatoscopy givesyou so much more information.
It's a brilliant way of recognising,with confidence, a seborrhoeic
(18:30):
keratosis or with confidence, ahaemangioma or a dermatofibroma.
It absolutely changes the landscapeand I would find it utterly impossible
to give any opinion on a pigmentedlesion without using dermatoscopy.
So it staggers me that thereare GPs who are struggling
(18:50):
without using a dermatoscope.
I don't know how they can do their job.
It must be terrifying.
Yeah.
No, I completely concur, and I wasthinking, when you were just talking
then, about that amazing statistic,about the skin cancers excised that
weren't the lesion that was referred.
I saw a chap not too long ago, asingle man came in with an obviously
benign lesion on his forearm, whichis what he wanted to see me about.
(19:14):
I must have had some time that daybecause I said, well, let's have
a little look at the rest of youto make sure everything's fine.
And sitting between his shoulder blades,that he couldn't obviously see himself,
and no one was living with him to tellhim about it, was this most obvious mother
of all melanomas sitting there, that hewas completely, you know, clueless about.
But if I just looked at his arm andsaid, "yep, you're fine, carry on."
(19:36):
You know, no one would have seenthat until it had metastasised, and
he got away with it, fortunately.
But I completely agree with you.
The one-stop, look at a photo,diagnose it correctly, yes, but you're
not sending in photographs of everysquare inch of that patient's skin.
So yes, we, have to look at thewhole of the patient's skin.
(19:57):
It is just one organ and we needto look at that whole organ.
We've covered an awful lot here,George, in a very short time.
So there's an awful lot for people tochew over, I think, here in primary
care, may have made them rethink howthey think about looking at melanomas.
So if I, can ask you a slightly unfairquestion, and try and pull lots of things
(20:19):
together, from a perspective point ofview, when we're thinking about melanomas.
What would be your, key take home pointsif you like, that we might not have
considered previously, which perhapswe should be just keeping in the back
of our minds, with our patients here?
Wow.
Well, I think, I think you're absolutelyright, we do need to keep this all
in perspective and at the end of theday, I'm, personally, not terribly
(20:44):
worried about squamous cell carcinoma,because it'll be pretty obvious.
It's a lesion that's rapidlychanging and it can be cut out and
they tend to behave themselves.
They don't have distantmetastases and things like that.
Yes, I do worry about melanoma.
But I also acknowledge that it ismostly down to genetic risk factors.
And again, something I want to diagnose,nice and early, and get it cut out and
(21:07):
make a big difference by prognosis.
What I am worried about though is dyingof a heart attack or a stroke, and I'm
68 times more likely to die from a heartattack or stroke than from skin cancer.
In fact, as a man, probablyeven more than that.
And whilst UV light does increase the riskof skin cancer, I can't say it doesn't.
(21:30):
It does.
It, also significantly reducesthe risk of heart attacks and
strokes by releasing nitric oxideand lowering your blood pressure.
So, I think to have lower bloodpressure and some of the other benefits
of sunlight is something that I givea lot of thought to, particularly
as I'm 68 times more likely to diefrom that than from skin cancer.
(21:51):
There are also twice as manydeaths from falls each year
as there are from melanoma.
So yes, there is a risk ofdying from melanoma, but we need
to keep that in perspective.
And the risk of dying from melanomaanyway, has dropped dramatically
recently because of new biologicalapproaches to managing it.
(22:12):
And what got me thinking about allthis some years ago was when I thought,
well, why did our ancestors, and myancestors had black skin, and when they
migrated out of Central Africa 50 to200,000 years ago, we're not quite sure
of the exact date, and they moved tolatitudes where the sunlight was weaker.
Why did they evolve to have weakermelanin, where the sunlight became weaker?
(22:35):
What was the evolutionary drive to allowmore sunlight to get through our skin?
Because evolution doesn't do somethingwithout there being a good reason.
And I think that says it all to me.
That there are benefits of sunlight.
Yes, there are risks, and yes, going outin the sun, my skin will age and so on.
(22:55):
But I think that I need to balancethose risks and then make sure I
diagnose melanoma and other skincancers competently, and early.
But the risks to your health fromnon-burning UV exposure in adulthood, I
think, has been seriously overemphasised.
I acknowledge it will cause my skinto age faster and I get a greater
(23:19):
risk of the keratotic cancers fromthis cumulative life risk, but,
that doesn't worry me as much.
And there's a fascinating studyfrom Germany, in 2016, in the
British Journal of Dermatology.
They looked at a population, I think itwas 33 million, and they found that those
individuals who'd had a non-melanomaskin cancer, which obviously would be
(23:41):
usually a BCC, were enjoying three tofour years longer life expectancy than
individuals who'd not had a skin cancer.
Okay, a lot of confounding factors there.
Might have had more holidaysabroad and all sorts of other
things and better quality of life.
But if you've had a BCC, you're in acohort of individuals who live longer.
(24:02):
But I suppose one of the importantmessages here today, aggressive
skin cancers, like melanoma, change.
They grow, they become moreugly, but they start small.
So don't wait, like ABCD might encourageyou to, for it to reach six millimetres
diagnose it early, ideally with adermatoscope, demonstrating the features.
(24:22):
And by ugly, I mean it doesn'tlook like the other moles.
It's becoming more and more asymmetrical.
It's getting several colours, it's gettingan edge that's doing all sorts of things.
If you wait for them to become hardraised nodules and then ulcerate,
you're not doing a patient any favours.
Pick up these melanomas early.
(24:43):
So I think they're the messages.
Excellently done, George, because there'san awful lot to try and pull together
and just remember that ugly duckling,and I think that's a really nice place to
bring this particular episode to a close.
So, George and I do hope youfound it interesting and helpful,
and as always, thank you so muchfor your time listening to us.
(25:03):
Roger and I hope you'll join us nexttime, where we'll be looking at the
way forward in the early recognitionof melanoma in primary care.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
So until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
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