Evaluation of a Rugged, Bumpy, and Itchy Scalp Mole
This lesion requires urgent dermatologic evaluation with biopsy to rule out melanoma, as the combination of irregular surface texture, elevation, and new-onset pruritus are concerning features for malignant transformation.
Key Concerning Features
The clinical presentation you describe raises significant concern for melanoma based on established diagnostic criteria:
- Irregular surface texture ("rugged" and "bumpy") suggests an irregular border and surface changes, which are major features in melanoma recognition 1
- Pruritus (itching) is recognized as a sensory change that characterizes early invasive melanoma, often described as greater awareness of the lesion or mild itch 1
- Any changing mole in an adult is often indicative of melanoma development, particularly when multiple features are present 1
Diagnostic Approach
Immediate Clinical Assessment
The revised seven-point checklist for melanoma should guide your evaluation, with major features including:
- Change in size (growth of the lesion) 1
- Irregular shape/border (the "rugged" appearance you describe) 1
- Irregular color (different shades of brown and black) 1
Minor features to assess:
- Diameter ≥7mm 1
- Inflammation (reddish tinge within the lesion) 1
- Oozing, crusting, or bleeding 1
- Sensory change (the itching symptom present here) 1
Melanomas typically have three or more of these features, making urgent referral appropriate 1.
Critical Pitfall to Avoid
Do not dismiss this as a benign condition without tissue diagnosis. Scalp melanomas can present as large, ulcerated lesions that may be misdiagnosed as eczema or other inflammatory conditions, leading to dangerous delays 2. The scalp location is particularly concerning as melanomas in this area may be detected later due to hair coverage 1.
Differential Diagnosis (Less Likely but Consider)
While melanoma is the primary concern, other scalp conditions can present with bumpy, itchy lesions:
- Seborrheic keratosis - benign but often itchy; however, these typically have a "stuck-on" appearance rather than concerning melanoma features 1
- Tinea capitis (fungal infection) - can present with inflammatory variants including diffuse pustular patterns with itching, but typically shows scaling and possible alopecia 1, 3
- Inflammatory dermatoses - various conditions can cause scalp pruritus with lesions 4
Immediate Management
Refer urgently to dermatology for examination and biopsy - do not wait for the lesion to change further 1, 2.
- Biopsy is mandatory to establish diagnosis, as clinical examination alone is insufficient 2
- If melanoma is confirmed, prognosis depends critically on Breslow thickness at diagnosis - lesions <1mm have ~90% five-year disease-free survival, while delayed diagnosis significantly worsens outcomes 1
- The scalp location requires particular attention as surgical margins and reconstruction may be more complex 2
Do not attempt to treat empirically with topical steroids or antifungals without tissue diagnosis when melanoma features are present, as this delays potentially life-saving intervention 1, 2.