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 you must distinguish a rare melanoma from the many benign pigmented lesions seen every week – and refer suspicious lesions promptly without attempting to treat them.
Use the asymmetry, border irregularity, colour variation, diameter, evolving (ABCDE) features to flag a suspicious mole:
• Asymmetry
• Border irregularity
• Colour variation
• Diameter > 6 mm
• Evolving
Change – in size, shape or colour – matters most.
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.
Refer any lesion that worries you: strong clinical suspicion overrides a low score.
Nodular melanoma breaks the usual rules:
• Grows fast
• Often symmetrical and uniform in colour
• May be amelanotic (pink, red or skin-coloured)
• 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 or 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 |
|
⚠️ Common pitfall – trusting the checklist to exclude melanoma • The weighted 7-point checklist and ABCDE are built around the common superficial spreading melanoma. • The checklist and ABCDE 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. |
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