Dermatology: Skin lesions and skin cancer

• Assessment and benign lesions: Assessing a Skin Lesion | Moles (Melanocytic Naevi) | Seborrhoeic Keratoses and Other Benign Lesions | Cysts and Lumps | Vascular Lesions | Scars and Keloids
• Sun damage and pre-cancer: Sun Damage and Prevention | Actinic Keratosis | Bowen's Disease
• Skin cancer: Basal Cell Carcinoma | Squamous Cell Carcinoma | Melanoma — Recognition | Melanoma — Diagnosis and Treatment | Other Skin Cancers | Skin Cancer in Transplant Recipients | Referral Pathways | Skin Biopsy and Minor Procedures
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🔍 Skin lesions and skin cancer — skin cancer is the commonest cancer in the UK, and rates are rising. Basal cell carcinoma is the most common but rarely spreads; squamous cell carcinoma can metastasise; melanoma causes most skin cancer deaths. The key skills are telling benign lesions from suspicious ones (ABCDE, 7-point checklist, "ugly duckling"), referring appropriately, and advising on sun protection.
Your four questions for every lesion: Is it new or changing (size, shape, colour)? Does it look different from the person's other moles? What are their risk factors (sun, skin type, immunosuppression, family history)? Does it need urgent referral, routine referral, or reassurance?

Assessing a Skin Lesion

• History — how long; change (size, shape, colour, surface); symptoms (itch, bleeding, crusting, pain, not healing); previous skin cancer; family history of melanoma; sun exposure and sunburn, sunbed use; immunosuppression (transplant, drugs, HIV); skin type.
• Examination — size (measure), shape, colour, surface, border, elevation, ulceration; compare with other moles; examine the whole skin (scalp, soles, nails, genitals) and regional lymph nodes.
• ABCDE of melanoma:
  • Asymmetry.
  • Border irregularity.
  • Colour variation (several shades of brown, black, blue, red, white).
  • Diameter over 6 mm.
  • Evolution (change) — the most important.
• "Ugly duckling" sign — a mole that looks different from the person's other moles.
• Dermoscopy — magnified view of pigment patterns and vessels; improves accuracy; teledermatology services send dermoscopic photographs for specialist review.
• Photographs with a ruler help monitor lesions over time.
• Fitzpatrick skin types — I (always burns, never tans) to VI (never burns, deeply pigmented); types I–II have the highest skin cancer risk, but cancers in darker skin are often diagnosed later (acral and nail melanoma).

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Moles (Melanocytic Naevi)

• Common acquired naevi — appear in childhood and early adult life; most people have 10–50; usually small (under 6 mm), round, uniform colour, regular edge.
  • Junctional — flat, brown (children).
  • Compound — raised, brown centre.
  • Intradermal — dome-shaped, skin-coloured or pale (adults).
• Atypical (dysplastic) naevi — larger (over 5 mm), irregular edge or colour; many atypical moles ("atypical mole syndrome") or over 100 moles raises melanoma risk — sun protection, self-examination, photography, specialist follow-up if strong family history.
• Congenital naevi — present at birth; large or giant (over 20 cm predicted adult size) carry a higher melanoma risk and may involve the brain (neurocutaneous melanosis) — specialist review.
• Halo naevus — a mole with a white ring around it (immune reaction), common in teenagers; usually harmless (check the central mole and the rest of the skin).
• Blue naevus — blue-black, small, stable.
• Spitz naevus — pink or red-brown dome-shaped papule in children; can look like melanoma — refer.
• Self-examination — check moles monthly; report change.

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Seborrhoeic Keratoses and Other Benign Lesions

• Seborrhoeic keratosis ("seborrhoeic wart", "basal cell papilloma") — extremely common in older adults:
  • Well-defined, "stuck-on" raised, warty, greasy-looking papules or plaques; skin-coloured, brown or black; often many on the trunk and face.
  • Surface "crypts" and "milia-like cysts" on dermoscopy.
  • Harmless — reassure; cryotherapy or curettage if catching or itchy (cosmetic removal isn't usually funded); biopsy if in doubt (can mimic melanoma).
  • Sudden eruption of many — Leser–Trélat sign (rarely associated with internal malignancy).
• Skin tags (acrochordons) — soft, pedunculated papules in the neck, armpits and groin; obesity, diabetes, pregnancy; snip, cryotherapy or tie off if troublesome.
• Dermatofibroma — firm, brown-pink nodule, usually on the legs (often after an insect bite); dimples inward when pinched ("dimple sign"); harmless.
• Cherry angioma (Campbell de Morgan spots) — small, bright red, dome-shaped papules on the trunk; common with age; harmless.
• Solar lentigines ("age spots", "liver spots") — flat brown patches on sun-exposed skin (backs of hands, face); differentiate from lentigo maligna (irregular, darker, growing — refer).
• Sebaceous hyperplasia — small yellow papules with a central dip on the face (can resemble BCC).
• Milia — tiny white cysts (newborns, or after blistering).
• Keratoacanthoma — a rapidly growing (weeks) dome-shaped nodule with a central keratin plug on sun-exposed skin; may regress, but can't be reliably distinguished from SCC — treat as SCC (urgent referral and excision).
• Chondrodermatitis nodularis helicis — painful nodule on the ear rim (worse lying on it); pressure-relieving pillow; exclude SCC.

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Cysts and Lumps

• Epidermoid cyst (often called "sebaceous cyst") — a firm, round, mobile lump in the skin with a central punctum; contains cheesy keratin; may become inflamed or infected. Excise the whole cyst (with its wall) if troublesome — incision and drainage only if infected (warm compresses, antibiotics if cellulitis).
• Pilar (trichilemmal) cyst — on the scalp; no punctum; often familial.
• Lipoma — soft, mobile, painless, slowly growing fatty lump under the skin; harmless; refer urgently (sarcoma pathway) if over 5 cm, growing, painful, deep to the fascia, or recurring after excision.
• Ganglion — firm, smooth cyst near a joint or tendon (wrist); often resolves; aspiration or excision if troublesome.
• Dermoid cyst — present from birth along lines of embryological fusion (outer eyebrow); may extend deeply — imaging before removal.
• Pilonidal sinus — natal cleft; hair-containing sinus; abscesses; surgery.
• Enlarged lymph nodes — think of reactive nodes, infection, lymphoma and metastases (e.g. from melanoma or SCC).

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Vascular Lesions

• Infantile haemangioma ("strawberry mark"):
  • Appears in the first weeks of life; grows rapidly (mostly in the first 3–5 months), then slowly shrinks over years (most by school age); more common in girls, preterm and low birth weight babies.
  • Bright red raised (superficial) or bluish (deep) lesion.
  • Refer urgently if — near the eye (amblyopia), nose, lip or ear (disfigurement), "beard" area (airway haemangioma — stridor), ulcerating, large facial segmental lesions (PHACE syndrome — brain, heart, eye anomalies), lumbosacral (spinal anomalies), or more than five (liver haemangiomas — ultrasound).
  • Treatment — most need no treatment; oral propranolol (specialist — hypoglycaemia, bradycardia, bronchospasm) for problematic lesions; topical timolol for small superficial ones.
• Port-wine stain (capillary malformation) — flat, red-purple patch present at birth, doesn't fade, grows with the child and may darken and thicken; on the ophthalmic area of the face — consider Sturge–Weber syndrome (seizures, glaucoma); pulsed dye laser.
• Salmon patch ("stork mark") — pink patch on the nape or eyelids of newborns; common, fades (forehead and eyelid ones fade quickly).
• Pyogenic granuloma — a rapidly growing, bright red, bleeding nodule after minor trauma (fingers, lips, gums), common in pregnancy; curettage and cautery, with histology (amelanotic melanoma can look identical).
• Spider naevi — central arteriole with radiating vessels that blanch; a few are normal (children, pregnancy); many — liver disease, oestrogen excess.
• Venous lake — soft, dark blue papule on the lip or ear in older people; compressible.
• Hereditary haemorrhagic telangiectasia — telangiectasia on lips, tongue and fingers; nosebleeds; GI bleeding; AVMs.

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Scars and Keloids

• Hypertrophic scar — raised, red scar within the boundary of the original wound; appears within weeks; often improves over 1–2 years.
• Keloid scar — raised, firm, shiny scar that extends beyond the original wound; may appear months later after minor injury (ear piercing, acne, vaccination, chest surgery); itchy or painful; more common in skin of colour; sites — earlobes, chest, shoulders, upper back; often recurs after excision.
• Treatment — silicone gel sheets, pressure; intralesional triamcinolone injections; cryotherapy; surgery combined with steroid injections or radiotherapy (high recurrence after surgery alone); avoid elective procedures (piercings, cosmetic surgery) in people prone to keloids.
• Marjolin ulcer — SCC developing in an old burn scar or chronic ulcer — biopsy any non-healing area in a scar.

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Sun Damage and Prevention

• UV radiation — UVB (burning, the main cause of skin cancer) and UVA (ageing, also contributes to cancer; passes through glass).
• Risk factors for skin cancer — fair skin (types I–II), red or fair hair, freckles, blue or green eyes; many or atypical moles; sunburn (especially blistering in childhood); intermittent intense exposure (holidays — melanoma); cumulative exposure (outdoor workers — SCC, BCC); sunbeds; older age; immunosuppression; previous skin cancer; family history of melanoma; xeroderma pigmentosum; arsenic; radiation therapy.
• Sun protection advice:
  • Shade between 11 am and 3 pm in the UK summer; never burn.
  • Cover up — clothing, wide-brimmed hat, UV-protective sunglasses.
  • Sunscreen — at least SPF 30 with high UVA protection (4 or 5 stars), applied generously (about 6–8 teaspoons for an adult body) 15–30 minutes before going out and reapplied every 2 hours and after swimming.
  • Keep babies under 6 months out of direct sun.
  • Avoid sunbeds — illegal for under 18s in the UK.
• Vitamin D — people who avoid the sun (or with darker skin, covered skin, housebound) may need vitamin D supplements (10 micrograms a day in autumn and winter for everyone in the UK).
• Photosensitising drugs — doxycycline, thiazides, amiodarone, NSAIDs, retinoids, voriconazole (SCC risk), St John's wort.
• Skin self-examination — monthly, particularly in high-risk people.

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Actinic Keratosis

• What it is: A pre-cancerous patch of sun-damaged skin — a rough, scaly, red or skin-coloured patch, better felt than seen ("sandpaper"), on sun-exposed skin (bald scalp, face, ears, backs of hands, forearms); older, fair-skinned people; often many ("field change").
• Risk — each lesion has a small risk of becoming SCC (signs of change — thickening, tenderness, bleeding, rapid growth, ulceration — refer).
• Management:
  • Sun protection and emollients for everyone; mild, asymptomatic lesions can be left and monitored.
  • Topical treatments (for single lesions or field change):
    • 5-fluorouracil cream (e.g. twice daily for 3–4 weeks) — marked redness and soreness expected.
    • Imiquimod cream (immune response modifier) — inflammation.
    • Diclofenac 3% gel — mild lesions; well tolerated (3 months).
    • Tirbanibulin ointment (5-day course for face and scalp).
  • Cryotherapy — for individual lesions.
  • Photodynamic therapy (specialist) — field treatment.
  • Curettage or excision for thick lesions or diagnostic doubt.
• Actinic cheilitis — the lower lip version: dry, scaly, pale lip; risk of SCC.

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Bowen's Disease

• What it is: Squamous cell carcinoma in situ (confined to the epidermis) — a slowly enlarging, well-defined, red, scaly plaque, often on the lower legs of older women, or sun-exposed areas.
• Mimics — psoriasis, eczema, tinea, superficial BCC (which is shinier with a raised edge).
• Risk — about 3–5% progress to invasive SCC (higher on genitals — penile intraepithelial neoplasia, vulval disease linked to HPV).
• Treatment — 5-fluorouracil or imiquimod cream, cryotherapy, photodynamic therapy, curettage, or excision; on the lower legs, healing can be slow (avoid aggressive treatment).

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Basal Cell Carcinoma

• The commonest cancer in the UK; slow-growing, locally invasive ("rodent ulcer") — very rarely metastasises.
• Risk factors — sun exposure (especially intermittent), fair skin, older age, immunosuppression, radiotherapy, Gorlin syndrome (basal cell naevus syndrome — many BCCs from a young age, jaw cysts, palmar pits).
• Sites — mostly head and neck (nose, inner canthus, around the eyes, ears), then trunk.
• Types:
  • Nodular (the commonest) — a pearly or translucent papule or nodule with a rolled edge and telangiectasia on the surface; may ulcerate centrally ("rodent ulcer") and bleed or crust repeatedly.
  • Superficial — a flat, pink-red, slightly scaly plaque with a fine thread-like pearly edge (trunk); like Bowen's or eczema.
  • Morphoeic (infiltrative) — scar-like, pale, firm plaque with poorly defined edges — extends further than it looks.
  • Pigmented — brown or black areas (can resemble melanoma; more common in darker skin).
• Referral (NICE NG12) — usually a routine referral (or treatment in the community by trained GPs for low-risk lesions); 2-week wait only if there's concern that a delay could have a significant impact because of its site or size (e.g. near the eye or nose).
• Treatment:
  • Surgical excision with a margin — the standard (about 4 mm for low-risk lesions).
  • Mohs micrographic surgery — for high-risk sites (central face, around eyes, nose, lips, ears), recurrent, morphoeic, or ill-defined lesions — margins checked during surgery; best cure rates, saves tissue.
  • Superficial BCC — imiquimod, 5-fluorouracil, photodynamic therapy, cryotherapy, curettage.
  • Radiotherapy — older people or where surgery is unsuitable.
  • Advanced or metastatic (rare) — hedgehog pathway inhibitors (vismodegib, sonidegib — teratogenic), cemiplimab.
• Follow-up — risk of further BCCs; sun protection; self-examination.

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Squamous Cell Carcinoma

• What it is: A malignant tumour of keratinocytes — the second commonest skin cancer; can metastasise (lymph nodes, then distant), especially high-risk tumours.
• Risk factors — cumulative sun exposure (outdoor workers), older age, fair skin, actinic keratoses, immunosuppression (organ transplant recipients — up to 100 times higher risk), chronic wounds and scars (Marjolin ulcer), radiotherapy, HPV (genital and periungual SCC), lichen sclerosus and lichen planus (genital and oral), smoking (lip), arsenic, voriconazole, xeroderma pigmentosum.
• Features — a tender, keratotic (scaly or crusted), firm nodule or non-healing ulcer on sun-exposed skin (face, ears, scalp, lips, backs of hands, lower legs); grows over weeks to months; may bleed.
• High-risk features — on the lip or ear, over 2 cm, thickness over 4 mm, poorly differentiated, perineural invasion, recurrent, in a scar or chronic wound, in immunosuppressed people.
• Referral — suspected cancer pathway (2-week wait) for a lesion suspicious of SCC (NICE NG12).
• Treatment:
  • Surgical excision with clear margins (at least 4 mm for low-risk, 6 mm or more for high-risk); Mohs surgery at some sites.
  • Radiotherapy — adjuvant for high-risk features, or primary if surgery isn't possible.
  • Lymph node assessment — examine and image if high risk; neck dissection for nodal disease.
  • Advanced, inoperable or metastatic — cemiplimab (PD-1 inhibitor immunotherapy).
  • Follow-up for recurrence, nodes and new skin cancers.

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Melanoma — Recognition

• What it is: A malignant tumour of melanocytes — the fifth commonest cancer in the UK; causes most skin cancer deaths; about a quarter of cases are in people under 50.
• Risk factors — sunburn (especially in childhood), intermittent intense UV exposure, sunbeds, fair skin, red hair, freckles, many moles (over 100) or atypical moles, previous melanoma, family history (CDKN2A mutations), large congenital naevi, immunosuppression.
• Types:
  • Superficial spreading (the commonest) — a flat, irregular, multicoloured lesion growing outwards, later raised; trunk in men, legs in women.
  • Nodular — a rapidly growing, raised nodule, often dark but can be pink or red (amelanotic), may bleed; grows downward quickly — poor prognosis. Use "EFG" — Elevated, Firm, Growing for over a month.
  • Lentigo maligna (melanoma) — slowly enlarging, irregular, brown-black flat patch on the sun-damaged face of older people; lentigo maligna is the in-situ form.
  • Acral lentiginous — on the palms, soles and under nails (subungual — Hutchinson's sign); the commonest type in people with darker skin; often diagnosed late.
  • Mucosal (mouth, nose, genitals, anus) and ocular (uveal) melanoma.
• Weighted 7-point checklist (NICE NG12) — refer on the suspected cancer pathway if the score is 3 or more:
  • Major features (2 points each) — change in size, irregular shape, irregular colour.
  • Minor features (1 point each) — largest diameter 7 mm or more, inflammation, oozing, change in sensation (e.g. itch).
  • Also refer if dermoscopy suggests melanoma, or for any pigmented or non-pigmented lesion suspicious of melanoma, even with a low score.

⚠️ Safety Pearl: Not all melanomas are dark. A pink or red, firm, growing nodule (amelanotic or nodular melanoma), or a dark streak under one nail, can be melanoma. If a lesion is elevated, firm and growing for over a month — refer urgently.

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Melanoma — Diagnosis and Treatment

• Diagnosis — excision biopsy of the whole lesion with a 2 mm margin (don't shave or partially remove suspected melanoma) by the specialist team.
• Prognosis depends mainly on Breslow thickness — depth from the top of the granular layer to the deepest tumour cells (in mm); also ulceration, mitotic rate, lymph node and distant spread (AJCC staging).
  • In situ — confined to the epidermis — excellent prognosis.
  • Under 1 mm — about 95% or more 5-year survival; thicker tumours and nodal spread lower survival.
• Treatment:
  • Wide local excision — margins based on Breslow thickness (e.g. 0.5 cm for in situ; about 1 cm for thin melanoma; 2 cm for thicker tumours).
  • Sentinel lymph node biopsy — offered for stage IB and above (Breslow over 0.8 mm or with ulceration) — for staging and guiding adjuvant treatment.
  • BRAF mutation testing (about half have BRAF V600 mutations) for stage III and IV disease.
  • Adjuvant treatment (after surgery for high-risk stage IIB–III) — immunotherapy (pembrolizumab, nivolumab) or BRAF/MEK inhibitors (dabrafenib with trametinib) for BRAF-mutant stage III.
  • Advanced or metastatic melanoma — immune checkpoint inhibitors (nivolumab with ipilimumab, pembrolizumab, nivolumab, nivolumab with relatlimab) or BRAF/MEK inhibitors; surgery or stereotactic radiotherapy for limited metastases; brain metastases are common.
• Immunotherapy side effects (immune-related adverse events) — colitis (diarrhoea), hepatitis, pneumonitis, thyroiditis, hypophysitis (headache, adrenal insufficiency), type 1 diabetes, myocarditis, rash — urgent assessment; steroids (see the Oncology chapters).
• Follow-up (NICE NG14) — regular skin and lymph node examination; imaging for higher stages; teach self-examination; sun protection; check vitamin D at diagnosis; psychological support; genetic referral if multiple primaries or strong family history.

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Other Skin Cancers

• Merkel cell carcinoma — rare, aggressive neuroendocrine tumour; a fast-growing, painless, red-purple nodule on sun-exposed skin of older or immunosuppressed people (Merkel cell polyomavirus); spreads early — urgent referral; surgery, radiotherapy, avelumab or other immunotherapy.
• Kaposi sarcoma — purple patches, plaques or nodules on the skin and mouth; caused by HHV-8; HIV (AIDS-defining), transplant recipients, older men of Mediterranean or Jewish heritage, endemic African form; test for HIV; antiretroviral therapy, chemotherapy, radiotherapy.
• Cutaneous T-cell lymphoma (mycosis fungoides) — persistent, scaly, pink patches and plaques in sun-protected areas (buttocks, trunk) mimicking eczema or psoriasis for years; biopsy (often several); skin-directed treatment (steroids, phototherapy); later tumours and Sézary syndrome (erythroderma, abnormal T cells in blood).
• Dermatofibrosarcoma protuberans — slow-growing, firm, scar-like plaque that becomes nodular (trunk); locally aggressive; wide or Mohs excision.
• Extramammary Paget's disease — persistent, itchy, red, eczema-like plaque in the genital or perianal area; may be linked to underlying cancer (rectal, bladder).
• Paget's disease of the nipple — eczema-like nipple that doesn't respond to steroids — breast cancer (see the Breast and Gynaecological Cancers chapter).
• Skin metastases — firm nodules (breast, lung, kidney, colorectal cancers, melanoma); Sister Mary Joseph nodule (umbilicus — intra-abdominal cancer).

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Skin Cancer in Transplant Recipients

• Organ transplant recipients and others on long-term immunosuppression have a very high risk of skin cancer — SCC up to 65–100 times higher, also BCC, melanoma, Merkel cell carcinoma and Kaposi sarcoma; often many tumours, more aggressive.
• Risk factors — duration and intensity of immunosuppression (azathioprine, ciclosporin, tacrolimus), sun exposure, fair skin, older age at transplant, HPV.
• Prevention and care:
  • Education before transplant; strict sun protection; monthly self-examination.
  • Regular dermatology surveillance (dedicated transplant skin clinics).
  • Early treatment of actinic keratoses and Bowen's disease (field treatments).
  • Switching to mTOR inhibitors (sirolimus, everolimus) can reduce new SCCs; reduce immunosuppression where possible.
  • Nicotinamide and acitretin for chemoprevention in high-risk patients.
• Also higher risk with other immunosuppression — HIV, chronic lymphocytic leukaemia, long-term methotrexate or biologics, voriconazole.

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Referral Pathways

• Teledermatology — dermoscopic photographs are increasingly used to triage referrals.
• Don't remove a suspicious pigmented lesion in primary care (unless trained and accredited) — refer.
• If a lesion is removed and turns out to be cancer, ensure histology is reviewed and the patient is referred.

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Skin Biopsy and Minor Procedures

• Consent — explain purpose, scarring (all procedures leave a mark), infection, bleeding, nerve damage, recurrence, need for further surgery; photographs.
• Local anaesthetic — lidocaine (with adrenaline to reduce bleeding — traditionally avoided on fingers, toes, penis, ears, although now considered safe in many settings); maximum dose by weight.
• Types of biopsy:
  • Punch biopsy (3–6 mm) — rashes, inflammatory conditions; a full-thickness core.
  • Shave biopsy — raised superficial lesions (seborrhoeic keratosis); not for suspected melanoma.
  • Incisional biopsy — part of a large lesion.
  • Excisional biopsy — the whole lesion with a margin (suspected melanoma — 2 mm margin).
• Other procedures — curettage and cautery (seborrhoeic keratosis, pyogenic granuloma, superficial BCC), cryotherapy (liquid nitrogen — warts, actinic keratoses; blistering, hypopigmentation especially in darker skin), electrosurgery.
• Histology — always send removed lesions for histology (except obviously benign cryotherapy targets); include clinical details.
• Wound care — keep dry 24–48 hours; suture removal (face 5 days, scalp 7 days, trunk 10–14 days, limbs 10–14 days).

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 34-year-old woman has a mole on her calf that has grown over 3 months. It is 8 mm across, has an irregular edge and several shades of brown, and has started to itch.
Answer: Suspected melanoma (7-point score: size change 2, irregular shape 2, irregular colour 2, diameter 1, sensation 1 = 8).

• Refer on the suspected skin cancer pathway (2-week wait).
• Specialist excision biopsy with a 2 mm margin — don't shave it off.
• If melanoma — Breslow thickness guides wide excision and sentinel node biopsy.

2. A 70-year-old retired farmer has a 6 mm pearly nodule with telangiectasia on his cheek that has grown slowly for a year and bleeds occasionally.
Answer: Nodular basal cell carcinoma.

• Routine referral to dermatology (2-week wait only if site or size means delay would matter).
• Surgical excision (Mohs if high-risk facial site).
• Sun protection advice; check for other skin cancers.

3. A 58-year-old man with a kidney transplant has a tender, crusted, rapidly growing nodule on the back of his hand.
Answer: Suspected squamous cell carcinoma in an immunosuppressed patient.

• Suspected cancer pathway referral; excision with clear margins.
• Examine lymph nodes and the rest of the skin.
• Transplant skin surveillance; discuss with the renal team about switching to an mTOR inhibitor; chemoprevention.

4. A 75-year-old woman has many rough, scaly patches on her forehead and scalp. None is thickened or tender.
Answer: Actinic keratoses (field change).

• Sun protection, hat and emollients.
• Field treatment — 5-fluorouracil cream (expect redness), imiquimod or diclofenac gel; cryotherapy for individual lesions.
• Refer any lesion that becomes thick, tender, bleeds or grows (possible SCC).

5. A 6-week-old baby has a rapidly growing bright red lump on her upper eyelid that is starting to close the eye.
Answer: Infantile haemangioma threatening vision.

• Urgent referral to paediatric dermatology and ophthalmology (amblyopia risk).
• Oral propranolol under specialist supervision.
• Reassure that most haemangiomas shrink over time, but this one needs treatment.

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Key Points

• ABCDE: asymmetry, border, colour, diameter over 6 mm, evolution (the most important); look for the "ugly duckling".
• Weighted 7-point checklist: major (2) — size, shape, colour change; minor (1) — 7 mm+, inflammation, oozing, sensation change; refer if 3 or more.
• Nodular melanoma: elevated, firm, growing — may be pink (amelanotic).
• Acral melanoma is the commonest type in darker skin — palms, soles, nails.
• Suspected melanoma: excision biopsy with 2 mm margin; never shave.
• Breslow thickness is the main prognostic factor; sentinel node biopsy for stage IB and above.
• Melanoma treatments include immunotherapy and BRAF/MEK inhibitors; watch for immune-related side effects.
• BCC: pearly, rolled edge, telangiectasia; rarely spreads; routine referral; surgery or Mohs.
• SCC: tender, keratotic, growing nodule or non-healing ulcer; can spread; 2-week wait referral.
• Treat keratoacanthoma as SCC.
• Transplant recipients have a huge SCC risk — surveillance, sun protection, mTOR inhibitors.
• Actinic keratosis and Bowen's disease: 5-FU, imiquimod, cryotherapy, PDT.
• Seborrhoeic keratoses are "stuck-on" and harmless.
• Lipoma over 5 cm, deep, growing or painful — sarcoma pathway.
• Infantile haemangiomas near the eye, airway or with ulceration — urgent referral; propranolol.
• Keloids extend beyond the wound; more common in skin of colour.
• Sun protection: shade, clothing, SPF 30+ with 4–5 star UVA, no sunbeds (illegal under 18).

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Guidelines and Further Reading

• NICE NG12: Suspected cancer — recognition and referral (skin cancers)
• NICE NG14: Melanoma — assessment and management
• NICE CSG8: Improving outcomes for people with skin tumours including melanoma
• British Association of Dermatologists: Guidelines for BCC, cutaneous SCC, actinic keratosis, Bowen's disease and melanoma
• NICE CKS: Actinic keratosis; Seborrhoeic keratosis; Infantile haemangioma; Keloid scars
• Cancer Research UK and British Association of Dermatologists: Sun safety information
• NICE NG34: Sunlight exposure — risks and benefits
• Primary Care Dermatology Society: Dermoscopy and skin lesion guidance
• BNF — for current doses