Hello, and welcome to this Skin Deep podcast, where we look at skin-related issues, conditions and treatments in an interesting and informative way. I'm Dr Roger Henderson. I'm a GP with a long-standing interest in this area of health. And I'm Dr George Moncrieff, I was also a GP, although I've now retired from my practice. And I was the past Chair of the Dermatology Council for England. Today, George and I will be talking about the diagnosis of malignant melanomas.
And if you were with us for our first one, where we talked about the risk factors involved with this particular type of cancer, we do hope you found it helpful. So to kick off this week's podcast, George, let's look at what we should be perhaps thinking about when considering if a skin lesion is a possible cause for concern. So if a patient comes and sits in front of us and says, "would you have a look at this skin lesion doc, I'm a bit worried about it."
What should we be thinking about initially? Well, having taken into account whether you believe your patient's a risk candidate, high-risk candidate for a melanoma, which is clearly important, looking at the individual lesion, does the lesion worry you?
Well, if you can get a history of change, the patient says, "this mole wasn't here before" or, "unlike my other moles, which look the same as they did last year, this one is now growing or developing new colours, becoming more raised" or whatever. Any change, history of change is, we talked about history last time, it is so important. So, any history of change would alert me.
Obviously benign things also can change, they can become inflamed if you catch them or they get infected and things like that. But, I think it's as important as saying, "does it worry me?" Can I turn it on the head and say, "can I recognise it's an obviously benign lesion?" I mentioned last time that dermatologists see the cases that we refer to the cancer bureau for suspected skin cancer and they say that, over 8 out of 10 are not just benign, they're obviously benign.
And they're things like a patch of post-inflammatory increased pigmentation from a leg ulcer or, a giant blackhead, you can get these giant thick blackheads sometimes, or, simply just a blood vessel, that [to the] naked eye can look worrying. And so, unless you look at it very carefully, you might miss these obviously benign lesions. So first of all, decide, am I absolutely confident it's a benign lesion, and I'll come on to the sort of features that distinguish those two as we go on.
And is it a lesion that's changing? A history of change in somebody at higher risk would definitely make me stop in my track and look at it very carefully. So, if we have got a patient in front of us and we think, hmm, yes, I need to look at this in a bit more detail. Let's think about the alphabet, by which I mean ABCD. Now, if we were taught anything about dermatology as junior doctors, we were probably taught this acronym ABCD.
And it's still one of the most commonly remembered by GPs and by medical students. And for those who don't know, this stands for asymmetry, B for border, C for colour, and D for diameter. So it's really easy to remember. And I used to think this was the bee's knees, but as with so much of medicine, the more you do, the more you realise it's shades of grey, not black and white.
So I've started to have some slight qualms about the almost over simplification of ABCD and having spoken with you about your views on this, I think it would be an understatement of somewhat heroic proportions to say that you've got some issues with ABCD as well. So, why? Well, I think this underpins, over referral of obviously benign lesions. Let's look at them. Asymmetry. The two halves of the lesion are not identical. Well, yeah, that is a feature of melanoma, but so too are benign lesions.
Many benign lesions are irregular in that way. So the lack of symmetry doesn't safely distinguish a malignant lesion from a benign lesion. When they talk about border, they're talking about an irregular or a ragged border. Well, again, that doesn't discriminate, obviously, benign lesions from the melanomas. Yes, melanomas are likely to have an irregular border, but so too can benign lesions.
In fact, regarding the border, it's the nature of the border that matters more than whether it's irregular. Benign lesions tend to have a very sharply demarcated edge. They end abruptly. Whereas tumours tend to, spread into the surrounding tissue a little bit. And in fact, if you look around the border, if part of the border is discrete and another part of the border is vague, that would be worrying.
But if all the way around the edge of the lesion, it's sharply demarcated, that's pretty reassuring. C for colour does matter. Yes. When white light goes through any medium, whether it be the sky or water or even the skin. The blue light is scattered more. That's why the sky looks blue, that's why the sea looks blue. Similarly, when white light penetrates the skin, the deeper it goes into the skin before it's reflected, the more red light you've lost. And so, melanin, which is...
I'm talking here about eumelanin, there are different melanins, but there's eumelanin which is brown/black. When that's up on the surface of the skin, in the top layers of the skin, in the epidermis, it's going to be black or brown. But if you've got melanin that's migrated deeper into the skin and then the light is reflecting from that, say really down deep in the skin, it can come back looking blue. Cut that bit of blue melanin out, it will be black.
But because it's got the artefact of going through the skin, the red light's been scattered and you're just left with blue light. So when you see lots of different colours in the lesion, one of the explanations for that can be that the light is reflecting from elements of the lesion, some are superficial and some are deep. And of course, melanomas are tumours that invade and they go down deep and so you get deeper elements. So colour is very important. Yeah, I like C for colour.
And then D for diameter. People have sort of used various diameters, I think currently it's six millimetres. That, I think, is dangerously wrong. I have diagnosed many melanomas that are only two or three millimetres. Tiny. Yes, they're melanomas. Yes, it's good to get them out. But they were only two or three millimetres. Why wait for it to grow up to six millimetres? And majority of benign lesions are also over six millimetres. So diameter does not discriminate.
So A, B, and D, I think, are dangerously wrong. And a chap called Giuseppe Agenziano from Naples, who is one of the absolute world experts in this field, and has done more work and research onto melanoma than anybody else I've ever come across. He said that relying on ABCD alone would mean that over two thirds of melanoma would be missed. Admittedly, they're going to be the smaller ones, but I'd rather have my melanoma removed when it's small.
And countless patients will be facing really totally unnecessary worry with having failed the ABCD with their large, benign lesions. Being referred on to secondary care, overloading secondary care. Costing the nation a fortune, causing them unnecessary anxiety and causing the GP also more work. So I think ABCD seriously lets us down. It does not discriminate. Right. There's your headline for the podcast, right there, George. Fantastic stuff.
Now I'm a bearer of very little brain and I like simple things to remember, especially in a busy surgery. So, if I'm not going to reach for my ABCD, what would be your alternative, simply, as an alternative to ABCD? Well, I suppose I could say E, F, and G. But before I say that, yeah, I think in the history. If you've got evidence that this is a new mole, they've got a photograph on the beach last year, and it wasn't there, now it's there.
And you feel it is a mole, a melanocytic naevus, and if they're over 30, I would be a little anxious. If they're over 40, I'd be more anxious, and if they're over 50... I would need very, very good reasons not to advise that this mole, however innocent it looks, ought to come out. So there are a lot of other things that are pigmented, that are new, that we develop as we get older. Sunspots and pigmented seborrhoeic keratoses, and the list can go on.
But if somebody's got a new mole, and they're over 30, I'd prefer them not to have it. And if they're over 50, I would say no choice. So that's the first thing. The second thing would be the lesion that just doesn't look like its brothers and sisters. They've got lots of moles. But here's this one that just doesn't look like the others. It's called the ugly duckling sign.
If they've got an ugly duckling, I would say, "look, why don't we just get it out and not worry about it?" And that, for us as GPs, inevitably means referral to secondary care. But I think referring an ugly duckling, I think, is reasonable. Clearly site matters a little bit, so I'm a little bit more cautious about the back in men, but that doesn't mean to say I'm not also anxious about other areas of their skin and the leg in women, but the differences aren't that huge.
But yeah, E, F, and G. E, for me, stands for elevation. If you run your hand over the lesion and you can't feel it, it's completely flat. It's only got horizontal growth at worst and we measure the prognosis of a melanoma by how deep it's going. So if it's completely flat, you've got plenty of time, you can take a close up photograph in focus and perhaps look at it again in a few months. If it's changing, then that matters.
The converse is that if it's raised, you run your hand over it and it's a bump, you can feel it's raised. It's already got vertical growth and you therefore must make a decision about that, today. You can't afford to say to the patient, let's see if it's doing anything. It's already potentially got vertical growth. If you're certain it's a benign lesion, and many benign lesions are raised. That's fine. You can reassure the patient and relax.
But if you aren't certain it's benign and it's raised, then I think that needs to be cut out. The second thing is F for firmness. All tumours are firm. Yes, some benign things are firm. Some are even more firm than tumours. But if it's, the converse is, if it's soft and it's wobbly, it is not a tumour. So if you can sort of wobble it around, little sort of fleshy, lumpy, soft, fatty lump or something. So if it's soft and wobbly, you've got nothing to worry about.
If it's firm and it doesn't give, then that could be something to worry about. And I keep G for growth, i.e. it's changing, so dynamic features. So I think new moles, ugly ducklings, and E, F, and G, are the important ones. I did some work with CRUK some years ago, they wanted to produce a toolkit for GPs to help them to diagnose melanoma. And all the lesions that they were asking us to use in this toolkit were nodules, (bumps).
A nodule is a raised lumpy lesion and they were all ulcerated and bleeding. Well, yeah, they were obvious melanomas, but frankly, if you're going to wait till your melanomas reach that point, it's just too late. I think that's not clever. You need to be diagnosing melanomas well before they become ulcerated and bleeding nodules.
Another important fact to remember is that if you're very fair-skinned, with blonde or ginger hair, blue or green eyes, that sort of genetic makeup, you're significantly more likely to develop a melanoma with that sort of skin type. And indeed, if you've got multiple moles as well, then you have a 25-fold increased risk. It could be a pink melanoma. And by pink I mean they really are a real pink, like raspberry or strawberry blancmange, that sort of pink colour.
But if you've got a firm, pink nodule, in particular if it's changing, in somebody with Celtic type skin, be just as alarmed about that as you would if it was brown or black. When you've got Celtic skin, you're making some eumelanin, this brown/black melanin I spoke about, but you're also making a pink melanin called pheomelanin. And so when you get a melanoma, it can be a melanoma made up of pheomelanin. Some people call them amelanotic, but A means without, and they're not without melanin.
They've got pheomelanin, so I call them pheomelanotic melanomas. Some people call them hypomelanotic, meaning reduced melanin. I think that's reasonable. So hypomelanotic melanomas. But just be aware of the pink, firm nodule in somebody with fair skin. Treat it with respect. Unless you know what it is. On the foot and the hand, what we call acral skin, you obviously can get normal melanomas, pigmented melanomas, and they do behave a bit different to melanomas elsewhere on the body.
These are the ones that are just as common in dark skin as they are in light skin. They've got nothing to do with ultraviolet light. They tend to have a bad prognosis, not because they're aggressive, they're actually very nonaggressive, but they're often missed for a very long time, and they present and are diagnosed quite late. So, those do matter, but the ones that frighten me more are the ones that are not pigmented.
They're often scaly, which is unusual for a melanoma, and they ulcerate early, and these are really nasty, aggressive ones, they're called non-lentiginous. They're very tricky to diagnose, and unless you keep them in your mind, you will miss them.
So if you've got a nodule or a raised lesion on the foot, or the hand that is not healing, scaly, changing and you don't know for certain that it's something benign, you must assume that, that could be one of these aggressive, difficult melanomas on the foot, called non-lentiginous. And they can, they grow very fast and they are nasty.
I think the final thing to say is that if somebody comes to you worried about a mole and you've decided that they are a potential candidate for a melanoma, i.e. they're a human being, but you've looked at the lesion they were concerned about and you reassured them that it is actually completely innocent and you're certain about that. It doesn't mean that they're not still a candidate for a skin cancer.
They've presented to you, or you've raised the concern because you've seen a lesion, and you're worried they could have a melanoma, well they could have a melanoma. And unless you look at their skin properly, you could miss that skin cancer that matters. And one thing that worries me about the way in which the health service is changing, we're moving into an era where we are not referring the patient, we're referring a picture of the lesion.
Yes. And specialists are going to look at that lesion and say, that lesion doesn't worry me. But you were sufficiently worried to send that picture and the patient hasn't been examined. So if, in general practice, we're not examining their skin properly, we'll miss their cancers.
And in Oxfordshire, a few years ago, they did some work and they found that a fifth of all the cancers that they needed to excise from patients who'd come up to their hospital to be seen with a lesion that the GP was worried about, a fifth of the cancers that were cut out were not the lesion that we'd sent up. We've sent patients who are risky patients, with a benign lesion, but we hadn't spotted the cancer that was in their armpit or under their pants or between their toe webs.
So I think to do a proper skin check and sometimes I say to patients, "look, this needs to be done. Would you like to come back when I can put some time aside, I can get a chaperone if necessary. And I would like to look between your toe webs, in your natal cleft, that's between the buttocks.
Maybe in the genital area, look behind your ears, look in your scalp, in the hair, and do a proper thorough skin check to reassure me and you that you haven't got the cancer there that we're concerned you could have." Final thing I'd like to say though, and I can't stress this enough. I could not give an opinion on a lesion, on the skin at all without using a device called a dermatoscope. And this is not something that is taught at medical school.
It's not something that every GP has access to, but I think to try to give an opinion on a pigmented lesion in particular without this special device, which is a very simple device to have. It takes some learning how to recognise what you're seeing. It gives so much more information. But I think to try and do it without a dermatoscope is a fool's game. It can utterly transform what you're seeing. Yeah, I think that's one of the top three pieces of GP kit, in my tool bag.
As you were talking there, I was just thinking, I just remembered this chap who came in with an obviously benign lesion on his arm, and he was really worried about this. I was very happy to reassure him. But did what you did, I must have had a bit of time that day and I said, "well, just slip your top off and let me have a good look at you" you know, arms, legs, trunk and everything. And he was a single man. So, no one was there in his house to tell him this.
And he turned around and he had the mother of all melanomas right between his shoulder blades. But he had no idea it was there. And if I'd sort of just looked at his arms and said, "yes, you're fine, off you go." You know, he'd have been pushing up daisies, and fortunately we got it in time, but yes, that's a fantastic statistic. That 20% of cancers excised weren't the lesion that was referred. That's remarkable. It's shocking, isn't it? Yeah. Incredible.
I mean, we've covered an enormous amount in a very short time here George, and really given people food for thought. So looking at perspective, let's try and sort of pull this together a little bit, from all our experience. What would be your key take home points to remember that we might not have considered previously about melanomas? Just to really get it lined up in perspective and not worry unnecessarily, but also just to bear in mind for future reference. I think that's a great thing to do.
Thank you. Yeah. I think at the end of the day, I say, I wouldn't be too worried about this. I'm not worried about melanoma. You're 68 times more likely to die of a heart attack or a stroke than from any skin cancer. Right. Wow. And ultraviolet light, whilst it does increase your risk, definitely, of squamous cell carcinoma, and the risk in adults of ultraviolet light, non-burning ultraviolet light, I think is controversial as far as melanoma is concerned.
It does significantly reduce your risk of heart attacks and strokes. So here's something that you're 68 times more likely to die from and you can go out in the sun and you can reduce that risk. So you don't need to reduce that risk by a huge percentage before you can make your chances of survival massively greater. And to put it into some context, there are twice as many deaths from falls each year than there are from melanoma. And the modern treatments of melanoma are quite revolutionary.
Even metastatic disease where it's spread, we've now got treatments that can transform that landscape. And it got me thinking well, our ancestors, when they moved out of Central Africa, I think sometime between 50,000 and 200,000 years ago, they had dark black skin, my ancestors. Why, when they migrated to northern and southern latitudes, where the ultraviolet light was weaker, did they evolve to have less black skin?
What was the driving factor to lose dark skin that protects you from this cancer? Evolution doesn't do something without there being a good reason and the reason is that sunlight has benefits. Yes, it has risks, and we need to be sensible about those risks, and we need to put them into context. But I'm much more scared of dying of a heart attack or a stroke. When sunlight reduces that risk, maybe evolution has something to do with all that.
The story about sunlight is far more than just vitamin D, and vitamin D is far more than just your calcium, metabolism, and bones. So, as I've been saying, the risk to your health from non-burning UV exposure in adulthood is overemphasised. Yes, it will cause my skin to age more, and I'll look older. Yes, I'll get these keratotic cancers. But in an immune competent adult, those are relatively low risk. And I think that it's only melanoma that behaves badly on the whole.
So I think that we need to get these things in balance. And then a final figure is that a diagnosis of a non-melanoma skin cancer, which is usually called a basal cell carcinoma, which is a very low grade. Wait for this. If you have a diagnosis of non-melanoma skin cancer, in a big study from Germany, looking at 33 million population, was associated with a three to four year longer life expectancy than individuals who had not given themselves a non-melanoma skin cancer.
Okay, a lot of confounding factors there. They'd more like to present to the doctor, perhaps have more holidays abroad and so on. I think the important message to remember is that aggressive skin cancers, like melanomas, change. They grow, they become more ugly, but they start small. So don't wait for a melanoma to get to six millimetres before you do something about it. You can diagnose it when it's small, if you know it's changing.
They become ugly, and by that I mean they don't look like their brothers and sisters. They look different to their other moles. They're increasing loss of symmetry, increasing number of different colours, but don't wait for them to become hard, raised nodules which then ulcerate. That's not good for anyone. Yeah, so think about the ugly duckling. That's what we're saying. Excellently done, George. That was a fantastic précis.
I've learnt a lot, as I always do in these podcasts, but that was fantastic. And I think that's a great place to bring this particular episode to a close. And as always, thank you so much for listening. George and I really do appreciate it. And we do hope you found this particular podcast interesting and helpful. So Roger and I hope you'll join us again, when we'll be discussing more skin-related conditions.
And we'd like to thank our sponsor, AproDerm®, for all their help in putting these Skin Deep podcasts together. We couldn't have done it without them. So, as always, until the next time, it's goodbye from George. Goodbye. And it's goodbye from me. Goodbye.