What is the appropriate dermatology referral description for a 5–10 mm raised, rough, firm papule/nodule on the forehead with an irregular dark pigmented center?

Medical Description for Dermatology Referral

This lesion should be described as a 5–10 mm raised, firm papule/nodule on the forehead with an irregular dark pigmented center, exhibiting features concerning for possible melanoma or other malignant skin neoplasm, requiring urgent evaluation within 2 weeks.

Structured Referral Description

Lesion Morphology

• Size: Specify exact diameter in millimeters (5–10 mm meets the ≥7 mm threshold, which is a major sign for melanoma) 1, 2
• Elevation: Document as "raised" or "elevated papule/nodule" to indicate vertical growth 1
• Surface texture: Describe as "rough" or "hyperkeratotic" surface 1
• Consistency: Note "firm" texture on palpation 1

Pigmentation Pattern

• Central pigmentation: Specify "irregular dark pigmented center" or "central dark pigmentation with irregular borders" 1
• Color heterogeneity: Document any variation in pigmentation (brown, black, blue, red) as this represents a major sign 1

Anatomic Location

• Precise site: State "forehead" with laterality if applicable (right/left) 1
• Sun exposure: Note this is a sun-exposed site, relevant for differential diagnosis 1

Major Warning Signs to Document

The revised seven-point checklist identifies three major signs that mandate urgent referral 1, 2:

• Change in size: Any progressive enlargement (94% of melanomas show this) 1
• Change in shape: Alteration in contour or development of asymmetry (95% of melanomas) 1
• Change in color: Development of irregular pigmentation (89% of melanomas) 1
• Diameter ≥7 mm: This threshold has replaced the older 6 mm criterion 1, 2

No melanoma lacks at least one major sign, making these criteria highly sensitive at 94–95% 2.

Minor Signs to Include if Present

Document any of these four minor features 1, 2:

• Inflammation: Surrounding erythema (present in 51% of melanomas) 1
• Crusting or bleeding: Surface changes (31% of melanomas) 1
• Sensory change: Itching or altered sensation (46% of melanomas) 1
• Diameter ≥7 mm: Also serves as both major and minor criterion 1

Differential Diagnosis Considerations

High-Priority Malignant Lesions

The dark pigmented center with raised morphology raises concern for:

• Nodular melanoma: Characterized by vertical growth phase, often presents as raised lesion with irregular pigmentation 1
• Pigmented basal cell carcinoma: Can mimic melanoma with dark pigmentation 3
• Squamous cell carcinoma: May present as firm, hyperkeratotic nodule on sun-exposed sites 1

Benign Mimics

• Seborrheic keratosis: Often rough-surfaced with dark pigmentation, but these frequently itch and are referred more commonly in Britain than Australia 1, 3
• Pigmented actinic keratosis: Rough-textured lesion on sun-damaged skin 1

Critical Referral Requirements

Urgency Timeline

• Patients with lesions meeting major sign criteria must be evaluated by a specialist within 2 weeks of the referral letter 2
• This applies to any pigmented lesion with one or more major signs 2

Referral Destination

• Direct to dermatologist or surgeon/plastic surgeon with expertise in pigmented lesions 2, 4
• Ensure the receiving specialist has capability for excisional biopsy and histopathologic processing 1

What NOT to Do in Primary Care

Prohibited Procedures

• Do not perform shave or punch biopsy: These partial sampling techniques prevent accurate pathological staging and Breslow thickness measurement 2, 4
• Do not use laser or electro-coagulation: Tissue destruction compromises definitive histopathologic diagnosis 1, 2
• Do not perform incisional biopsy: Reserved exclusively for specialists in select circumstances (e.g., lentigo maligna on face, acral melanoma) 2, 4
• Do not delay referral for additional imaging, photography, or ancillary testing 2

Appropriate Primary Care Action

The correct approach is urgent referral without biopsy 4. Even when melanoma is strongly suspected, the family physician should refer without performing any biopsy procedure 4.

Diagnostic Accuracy Context

• Clinical assessment alone achieves approximately 85% accuracy, meaning 15% of clinically suspicious lesions are ultimately benign 2
• In British pigmented-lesion clinics with GP referrals, 1 melanoma is identified for every 20 non-melanoma lesions examined, demonstrating much higher detection efficiency than self-referral programs 2
• This high pre-test probability justifies the urgent referral pathway despite the false-positive rate 2

Sample Referral Language

"I am referring this patient urgently for evaluation of a suspicious pigmented lesion on the [right/left] forehead. The lesion measures approximately [X] mm in diameter, is raised and firm to palpation, with a rough surface texture and an irregular dark pigmented center. The patient reports [change in size/shape/color over X timeframe]. This lesion exhibits [number] major signs concerning for possible melanoma: [list specific major signs]. [Include any minor signs if present]. Request evaluation within 2 weeks per melanoma referral guidelines."

Common Pitfalls to Avoid

• Underestimating amelanotic melanoma: These usually have a peripheral rim of pigment and are excised due to change in size or shape 1
• Dismissing lesions <7 mm: Many primary melanomas today have diameter <5 mm 1
• Failing to document temporal changes: Evolution (dynamics) is a critical major sign 1
• Attempting biopsy to "confirm" before referral: This delays definitive care and compromises staging 2, 4