What information should be included in a referral to dermatology for a patient with a suspicious dark freckle on the back of their leg, considering their medical history and risk factors for melanoma?

What to Include in a Dermatology Referral for a Suspicious Dark Freckle

Your referral letter should concisely state which specific features of the lesion prompted the referral using the major and minor signs checklist, the patient's degree of concern, and clearly indicate whether you suspect early melanoma or are seeking reassurance.

Essential Components to Document

Specific Clinical Features Present

Document any major signs present (these alone warrant referral): 1

• Change in size - specify timeframe if known
• Change in shape - describe the evolution
• Change in colour - note what changes occurred
• Diameter ≥ 7 mm - provide measurement

Document any minor signs present (these strengthen the case for referral): 1

• Inflammation around the lesion
• Sensory change (itching, tenderness, altered sensation)
• Crusting or bleeding
• Diameter between 5-7 mm (note: many melanomas are now <5 mm) 1, 2

Critical Context Information

State your clinical suspicion explicitly: 1

• "Suspected melanoma - urgent assessment requested"
• "Seeking reassurance - patient anxious but low clinical suspicion"
• This allows proper triage at busy dermatology clinics

Include the anatomical location precisely: 1

• "Posterior aspect of left lower leg"
• Note: The back of the leg in men is a common melanoma site where patients may not notice changes themselves 1

Document who noticed the lesion: 1

• Whether patient, relative, or friend first observed it
• This is particularly relevant as patients often aren't aware of changes, especially on the back or posterior leg

Patient Risk Factors

Include relevant melanoma risk factors: 3, 4

• Personal or family history of melanoma
• History of UV exposure or indoor tanning
• Skin type (especially skin that always burns, never tans)
• Presence of multiple atypical nevi
• Immunosuppression status

What NOT to Do

Avoid vague descriptions: 1

• Don't write "suspicious mole" without specifying which features make it suspicious
• Don't omit the patient's level of concern - this affects triage decisions

Never delay referral for lesions causing anxiety: 1

• Any lesion causing concern should be referred regardless of checklist criteria
• The guidelines are aids, not absolute exclusion criteria

Common Pitfalls

The "ugly duckling" concept may be more valuable than ABCDE criteria for certain melanoma subtypes like nodular melanoma, which can present symmetrically with regular borders: 2

• If the lesion doesn't fit the patient's overall nevus pattern, mention this explicitly

Don't assume diameter >6mm is required: 1, 2

• Many primary melanomas today are <5mm in diameter
• Approximately 38% of melanomas are ≤6mm 2

Evolution (change over time) is critical: 1, 2

• This can identify rapidly growing amelanotic melanomas that lack other classic features
• Always document the timeframe of any changes observed