What is the recommended management for a 48‑year‑old female with a brown, raised, rough, pruritic plaque on the left lateral lower back that has recently enlarged and darkened?

Management of Suspected Melanoma

This patient requires urgent full-thickness excisional biopsy with 2-5 mm margins performed by a dermatologist or surgeon with expertise in pigmented lesions, with referral arranged to be seen within 2 weeks. 1, 2, 3

Clinical Features Raising Concern for Melanoma

This 48-year-old woman presents with multiple alarming features that mandate urgent evaluation:

• Recent change in size and color (evolution) – the most critical warning sign for melanoma 1, 3
• Brown, raised, rough texture – suggests possible nodular or thick melanoma 1, 3
• Pruritus – while nonspecific, can indicate deeper dermal involvement 2, 3
• Location on lower back – a common site for melanoma in women 1

The combination of a changing pigmented lesion in a middle-aged woman on the trunk represents a high-risk presentation that cannot be managed conservatively. 2, 3

Urgent Referral Requirements

Refer immediately to a dermatologist or surgeon/plastic surgeon with expertise in pigmented lesions, with systems ensuring the patient is seen within 2 weeks of referral receipt. 1, 2, 3

Your referral letter must include:

• Specific concerning features: recent darkening, enlargement, pruritus, raised/rough texture 2, 3
• Exact anatomical location and approximate size 1, 3
• Patient's level of concern 2
• Documentation as "pigmented lesion suspicious for melanoma" or "atypical pigmented lesion concerning for possible malignant melanoma" – never use definitive diagnostic terminology like "melanoma" before histopathological confirmation 2, 3

What NOT to Do in Primary Care

Do not attempt any of the following procedures in primary care: 1, 2, 4

• Shave biopsy – makes pathological staging impossible 1, 4
• Punch biopsy – prevents accurate Breslow thickness measurement and risks sampling error 1, 4
• Incisional biopsy – inadequate for staging and not recommended in primary care 1
• Attempted excision without proper training – requires full-thickness technique with subcutaneous fat 1, 4

These inadequate sampling techniques can lead to understaging, inappropriate treatment planning, and potentially worse outcomes. 4

Required Biopsy Technique (Specialist Only)

The specialist must perform a full-thickness elliptical excisional biopsy that includes: 1, 3, 4

• Entire lesion with 2-5 mm clinical margin of normal skin laterally 1, 4
• Cuff of subcutaneous fat deep to the lesion 1, 4
• Orientation planned for potential re-excision (longitudinal on extremities, along skin tension lines) 1, 4
• Preservation of lymphatic drainage patterns for potential sentinel node biopsy 1

Essential Pathology Requirements

The pathology report must document: 1, 3, 4

• Breslow thickness in millimeters – the single most important prognostic factor 1, 3
• Presence or absence of ulceration – critical for staging 1, 3
• Mitotic rate (mitoses per mm²) – independent prognostic factor 1
• Clark level of invasion – particularly important for thin melanomas 1, 3
• Surgical margin status – determines need for re-excision 3, 4
• Histological subtype and presence of regression 3

Common Pitfalls to Avoid

Do not delay referral while waiting for photography, dermoscopy, or additional testing – urgent specialist evaluation takes priority. 2, 3

Do not reassure the patient that "it's probably nothing" even if attempting to reduce anxiety. Instead, maintain appropriate clinical concern while explaining the need for specialist evaluation. 2

Do not use definitive diagnostic language in documentation before histopathological confirmation, as clinical assessment alone has only 85% accuracy even among experienced clinicians. 2

If Melanoma is Confirmed

Following histopathological confirmation, the patient will require: 1, 3

• Wide local excision with margins based on Breslow thickness (1 cm for ≤1 mm, 1-2 cm for 1.01-2 mm, 2 cm for >2 mm) 1
• Consideration of sentinel lymph node biopsy for lesions >0.8-1.0 mm thickness or with high-risk features 1
• Annual full-body skin examinations for life, as risk of second primary melanoma is significantly elevated 1
• Patient education on self-examination and sun protection 1