Skin Physical Examination Template for Mole Evaluation
Use the ABCD criteria systematically when documenting pigmented lesions, as this framework is guideline-recommended for identifying suspicious lesions that require excision or urgent referral 1, 2, 1.
SKIN EXAMINATION - PIGMENTED LESION EVALUATION
Patient History:
- Duration of lesion: ___________
- Recent changes: □ Size □ Color □ Shape □ None
- Symptoms: □ Itching □ Bleeding □ None
- Personal history of melanoma: □ Yes □ No
- Family history of melanoma: □ Yes □ No
- Sun exposure history: □ Frequent sunburns □ Tanning bed use □ Occupational exposure
Risk Factors Present:
- □ Fair skin/photosensitivity
- □ Red or blond hair
- □ Freckling
- □ >20 nevi on arms
- □ Atypical/dysplastic nevi
- □ Giant congenital nevi
LESION DOCUMENTATION:
Location: ___________
Size: Maximum diameter _____ mm
Elevation: □ Flat □ Palpable □ Nodular
A - ASYMMETRY: □ Symmetric □ Asymmetric (one half unlike the other)
B - BORDER: □ Regular, well-defined □ Irregular, poorly defined, notched
C - COLOR: □ Uniform (single color) □ Heterogeneous (multiple colors - specify: □ tan □ brown □ black □ red □ white □ blue) □ ≥3 colors present
D - DIAMETER: □ <5 mm □ ≥5 mm □ ≥10 mm
E - EVOLUTION/DYNAMICS 1, 2: □ Stable □ Changing (size, color, elevation, or symptoms)
"UGLY DUCKLING" ASSESSMENT 1: □ Lesion resembles other nevi on patient □ Lesion does NOT fit patient's nevus pattern (concerning)
ADDITIONAL FEATURES:
- Ulceration: □ Present □ Absent
- Regression: □ Present □ Absent
- Satellitosis: □ Present □ Absent
DERMOSCOPY PERFORMED: □ Yes □ No (If yes, describe findings): ___________
REGIONAL LYMPH NODES:
- Cervical: □ Normal □ Enlarged
- Axillary: □ Normal □ Enlarged
- Inguinal: □ Normal □ Enlarged
Complete skin examination performed: □ Yes □ No Additional suspicious lesions identified: □ Yes □ No
CLINICAL IMPRESSION: □ Benign-appearing nevus □ Atypical/dysplastic nevus □ Suspicious for melanoma □ Other: ___________
PLAN: □ Reassurance, routine follow-up □ Photographic monitoring □ Excisional biopsy with 1-3 mm margins □ Urgent dermatology/surgical referral □ Patient education on self-examination
Key Documentation Principles:
When to refer urgently 3: Any lesion with ABCD-positive features (asymmetry, irregular borders, color heterogeneity, diameter >5mm), any changing lesion, lesions with ≥3 colors, itching/bleeding lesions, or lesions that don't fit the patient's nevus pattern.
Critical pitfall: Many primary melanomas now present with diameter <5mm 1, so do not rely solely on the "D" criterion. Evolution (change) and the "ugly duckling" sign are equally important 1.
Dermoscopy note: If trained in dermoscopy, this enhances diagnostic accuracy 1, but visual examination alone using ABCD criteria is sufficient for determining need for biopsy or referral.
Complete skin examination 3, 2: Always examine the entire skin surface including scalp and all regional lymph nodes when evaluating any pigmented lesion, as this identifies additional primaries and metastases.