GPAtlas🧭 When to suspect
Melanoma is a malignant tumour of melanocytes and the most lethal of the common skin cancers; UK incidence has risen faster than that of almost any other major cancer over recent decades. Most patients present first in primary care, where the task is to distinguish a rare melanoma from the many benign pigmented lesions seen every week – and to refer suspicious lesions promptly without attempting to treat them.
Use the ABCDE features (Asymmetry, Border irregularity, Colour variation, Diameter > 6 mm, Evolving) to flag a suspicious mole, but remember that change – in size, shape or colour – is the single most important sign. Formal triage uses the weighted 7-point checklist (the Glasgow checklist): a score of 3 or more, or dermoscopy suggesting melanoma, warrants a suspected cancer pathway referral (for an appointment within 2 weeks). Crucially, strong clinical suspicion overrides a low score – refer any lesion that worries you.
Nodular melanoma breaks the usual rules: it grows fast, is often symmetrical and uniform in colour, may be amelanotic (pink, red or skin-coloured), and can score low on ABCDE and the checklist. Apply the EFG rule (Elevated, Firm, Growing) and refer such lesions on suspicion alone.
| Subtype | Key features |
|---|---|
| Superficial spreading | The commonest subtype in the UK; a pigmented macule or plaque enlarging and changing in shape or colour; any site, often trunk (men) or legs (women). |
| Nodular | Rapidly growing raised nodule that may bleed or ulcerate; frequently amelanotic; poorer prognosis owing to early vertical growth; think EFG. |
| Lentigo maligna / lentigo maligna melanoma | Slow-growing pigmented macule on chronically sun-damaged skin (typically the face) in older patients; lentigo maligna is in situ and becomes invasive once dermal invasion occurs. |
| Acral lentiginous | Arises on palms, soles and nail beds; not sun-related; the commonest subtype in people with darker skin; often presents late. Subungual disease shows a pigmented nail streak with Hutchinson's sign. |
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⚠️ Common pitfall – trusting the checklist to exclude melanoma The weighted 7-point checklist and ABCDE are built around the common superficial spreading melanoma; they are far less sensitive for nodular and amelanotic lesions, which may be uniform, symmetrical and lack pigment. A firm, raised lesion growing over weeks – even if pink or skin-coloured and scoring under 3 – should still be referred. A score below the threshold never excludes melanoma. |
Source: NICE NG12 · NICE NG14
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