When to Refer a Mole to Dermatology
Refer urgently to dermatology when a pigmented lesion shows one or more major signs: change in size, change in shape, change in color, or diameter ≥7 mm. 1
Urgent Referral Criteria
Major Signs (Any One Warrants Referral)
- Change in size - progressive growth of the lesion 1
- Change in shape - alteration in the contour or outline 1
- Change in color - development of irregular pigmentation with different shades of brown and black 1
- Diameter ≥7 mm - lesions meeting or exceeding this threshold 1
Minor Signs (Support Referral When Combined with Major Signs)
- Inflammation - reddish tinge within the lesion 1
- Sensory change - increased awareness, mild itch 1
- Crusting, oozing, or bleeding 1
The revised seven-point checklist from the BMJ found that 94-95% of melanomas showed at least one major sign, and none failed to show at least one major sign. 1 This makes the major signs highly sensitive for melanoma detection.
Referral Timeline
Patients with lesions suspicious for melanoma must be seen by a dermatologist or surgeon/plastic surgeon with expertise in pigmented lesions within 2 weeks of receipt of the referral letter. 2
High-Risk Populations Requiring Enhanced Surveillance
Automatic Referral or Close Monitoring
- Previous melanoma - these patients are at moderately increased risk and should be taught melanoma recognition 2
- Atypical mole syndrome - requires ongoing surveillance 2
- Giant congenital pigmented naevi - need long-term follow-up due to increased melanoma risk 2
- Family history of melanoma - three or more cases warrant referral to Clinical Genetics for counseling; two cases may also benefit, especially if one had multiple primaries or atypical mole syndrome 2
- More than 50 moles with family history of melanoma - warrants enhanced surveillance 3
Clinical Assessment Tools
ABCDE Mnemonic
The ABCDE criteria help identify concerning melanocytic lesions: 4, 5, 6
- Asymmetry in shape
- Border irregularity
- Color variation
- Diameter greater than 6 mm
- Evolution over time
Ugly Duckling Sign
A pigmented lesion that appears distinctly different from the patient's other moles should raise suspicion. 4, 3 Benign moles tend to have similar appearances, whereas an outlier is more likely undergoing malignant change.
What NOT to Do in Primary Care
Do not perform shave or punch biopsies of suspected melanomas in primary care, as these make pathological staging impossible. 2, 7 Incisional biopsies are also not recommended except in specific circumstances (lentigo maligna on face, acral melanoma) and should only be performed by specialists. 2
Do not use laser or electro-coagulation for initial excision of suspicious lesions, as tissue destruction compromises diagnosis. 8, 9
Do not delay referral while waiting for additional testing or photography - urgent specialist evaluation takes priority. 7
Common Pitfalls
Clinical assessment alone has limited accuracy of approximately 85%, meaning 15% of clinically suspected melanomas are benign lesions. 7 This underscores why histopathological confirmation is mandatory and why suspicious lesions warrant referral rather than reassurance.
Avoid using definitive diagnostic terminology like "melanoma" or "malignant melanoma" before histopathological confirmation. 7 Instead, document as "pigmented lesion suspicious for melanoma" or "atypical pigmented lesion concerning for possible malignant melanoma." 7
Do not reassure patients that a suspicious lesion is "probably nothing" even when trying to reduce anxiety. 7 Maintain appropriate clinical concern while explaining the need for specialist evaluation.
Melanoma Detection Rates in Practice
In British pigmented lesion clinics where general practitioners make referrals, one melanoma is detected for every 20 non-melanoma lesions examined. 1 This demonstrates that British general practitioners exclude non-melanomas with considerable skill, achieving a much better ratio than self-referral clinics (1:250 in the US, 1:500 in Dutch beach campaigns). 1
The highest melanoma detection occurs in patients referred for a specific doubtful lesion or those with melanoma risk factors, not in those seeking general reassurance about their moles. 10