From the Guidelines
The proper method for documenting skin lesions involves a systematic approach that includes several key elements, prioritizing a visual skin examination using the "ABCDE" rule to assess for asymmetry, border irregularity, nonuniform color, diameter greater than 6 mm, and evolution over time, as recommended by the US Preventive Services Task Force in 2023 1. When documenting skin lesions, it is essential to record the location of the lesion using anatomical landmarks and body regions for precise identification.
- Next, measure the size of the lesion in centimeters, noting both length and width, and for raised lesions, include the height.
- Document the lesion's morphology by describing its primary characteristics such as macule, papule, nodule, plaque, vesicle, or pustule.
- Note the color of the lesion, including any variations or patterns within it.
- Describe the lesion's borders (regular, irregular, well-defined, or poorly defined) and surface characteristics (smooth, rough, scaly, crusted).
- Include any associated symptoms like pain, itching, or tenderness.
- When relevant, document the arrangement of multiple lesions (clustered, linear, annular) and their distribution pattern across the body.
- Taking clinical photographs with a scale marker provides valuable visual documentation for monitoring changes over time, as supported by the most recent guidelines 1.
This comprehensive documentation approach is essential for accurate diagnosis, treatment planning, and monitoring the progression or resolution of skin conditions, as well as facilitating clear communication between healthcare providers. Although biopsy is a crucial step in diagnosing skin cancer, as noted in earlier studies 1, the initial documentation of skin lesions should focus on a thorough visual examination and description, as outlined in the most recent recommendation from 2023 1.
From the Research
Documenting Skin Lesions
To properly document skin lesions, several factors must be considered, including the type of lesion, its location, and the method of documentation.
- The accuracy of clinical diagnosis of skin lesions is crucial for treatment selection and prioritization 2, 3.
- Studies have shown that misdiagnosis of skin lesions can result in delays in treatment and may increase the rate of incomplete excision 2.
- Photogrammetry provides a useful tool for taking precise measurements from photographs, and video recording has the potential to record a larger amount of image data faster 4.
- Manual measurements are more precise than automatic measurements and equally time-consuming 4.
Methods of Documentation
Different methods can be used to document skin lesions, including:
- Clinical diagnosis, which involves visually examining the lesion and making a diagnosis based on its appearance 2, 3.
- Dermoscopy, which involves using a special microscope to examine the lesion in more detail 5.
- Photogrammetry, which involves taking precise measurements from photographs 4.
- Video recording, which can record a larger amount of image data faster 4.
Importance of Accurate Documentation
Accurate documentation of skin lesions is essential for: