Borders Ref Help Toolkit
Refer a person with any of the following according to the local skin cancer pathway as a USC:
- Skin or nail lesion suspicious for melanoma
- Skin or nail lesion suspicious for squamous cell carcinoma (SCC)
- Skin lesion suspicious for a basal cell carcinoma (BCC) invading a potentially dangerous area e.g. peri-ocular, auditory meatus, nerve, or major blood vessel
- Skin lesion whose features raise concern for malignancy (see – other skin lesions that are concerning for malignancy)
- Unexplained or concerning skin lesion in an immunocompromised person
- A biopsy proven melanoma, SCC, or high-risk BCC (infiltrative, micronodular, or basosquamous)
Melanoma:
A mole* with any of the following features (ABCDE criteria):
Asymmetry
Border (irregular, scalloped or poorly defined)
Colour (irregularity or darkening)
Diameter more than 6 millimetres (they can be smaller)
Evolution in shape, size, or colour (especially if quickly)
A mole which stands out from those around it (the ‘ugly duckling’ sign)
A new mole developing in a person aged 40 or over
*See good practice section below for the assessment of pigmented lesions
Subungual melanoma:
Nail pigmentation which evolves but remains in contact with and/or involves the nail fold (fold of skin that borders the bottom and sides of the nail)
Squamous cell carcinoma (SCC):
If a person with a skin lesion has one or more of the following features:
- Hyperkeratotic (scaly) nodule or indurated (thickened) lesion
- Ulcerated nodule that may bleed easily
- Lesion is painful or tender on palpation
- Lesion grows over weeks to a few months
- There is background of actinic keratosis
Squamous cell carcinoma (SCC) of the nail apparatus:
A lesion growing underneath the nail that may be associated with local tissue destruction
A change such as a nodule growing in an established periungual wart
Basal cell carcinoma (BCC):
If a skin lesion has one or more of the following characteristics:
- Ulcer with a raised rolled edge, a nodule on the skin (waxy or pearly), a reddish plaque, scar-like with tethering or contraction
- Prominent fine blood vessels within the lesion
- History of spontaneous bleeding
- Maycontainpigmented areas
- Rarely painful
Other skin lesions that are concerning for malignancy:
The following skin changes should raise concern for a malignant lesion (including Merkel's tumour, sarcoma, or amelanotic melanoma):
- Nodule grows quickly (over weeks)
- A new change (growth, pigmentation, or pain) in a long-standing ulcer, scar, traumatic or inflamed area of skin
- Non-healing and/or destructive atypical ulcer
- Progressive unexplained scar-like area
An unexplained skin lesion with loco-regional lymphadenopath
Good Practice Guidelines
Pigmented lesions:
Not all pigmented skin lesions are melanomas. Seborrheic keratoses are common, benign, pigmented lesions that can change in colour, size, and shape. They have a classical ‘stuck on’ appearance and can easily be distinguished with a dermatoscope. It is important to recognise these benign lesions as application of the ABCDE criteria may result in over-referral for suspected melanomas. Lesions which are suspicious for melanoma should not be removed in primary care.
Subungual melanoma:
This is rare compared with other causes of nail discolouration and change including fungal infection and haematoma. A subungual haematoma will grow out distally resulting in normal nail proximally between the nail pigmentation and the nail fold.
Other considerations:
- Any skin lesion removed should be sent for pathological examination
- Referrals should be accompanied by an accurate description of the lesion – including size (with measurements), pain, and tenderness
- A photograph of the lesion should be sent with the referral to secondary care wherever possible. This allows for accurate and timely triage increasing the efficiency of care for patients with skin cancer. Please follow local pathways.
- Please visit the Right Decision Service for CfSD primary care management of skin lesions not referred as a USC
- GPs with a special interest in dermatology can often safely manage SCCs and BCCs in primary care, including excision
- Dentists play a key role in the identification of cancers on the skin, in particular of the face and neck. There should be systems in place for USC referral pathways for dentists
- Lesions suspicious of basal cell carcinomas (BCC) may not require urgent referral, except those invading potentially dangerous areas