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Probability diagnosis

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Naevi: congenital and acquired

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Seborrhoeic keratoses

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Solar keratoses

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Freckles

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Lentigines

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Serious disorders not to be missed

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Pigmented squamous cell carcinoma

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Pigmented basal cell carcinoma

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Melanoma:

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  • lentigo maligna

  • superficial spreading melanoma

  • nodular melanoma

  • acral lentiginous melanoma

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Other disorders

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Haemangioma (thrombosed)

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Dermatofibroma

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Pyogenic granuloma

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Foreign body granuloma

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Talon noir (black heel)

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Becker naevus

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Common melanocytic naevi:

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  • congenital

  • acquired

    • — junctional → compound → intradermal

    • — halo

    • — blue

    • — spitz

    • — dysplastic melanocyte

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Key history

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Establish the history of the lesion and associated features. Family history, especially of melanoma. Determine history of past residential (geographic) areas, sun exposure, history of sunburn and the practice of preventive measures.

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Key examination

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  • Systematic examination of the skin especially searching for melanoma

  • Starting at the head, examine the hairline, backs of the ears, neck, back and backs of the arms. Pull down the underwear to expose the buttocks, examine the backs of the legs and feet. Then examine the front of the body including the anterior surfaces of the legs

  • Apply the ABCDE system to a suspicious lesion: Asymmetry, Border, Colour, Diameter, Evolution and/or Elevation

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Key investigations

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  • Photography to monitor dysplastic naevi

  • Dermoscopy

  • Excision biopsy

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Diagnostic tips

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  • Most pigmented lesions are benign but one-third of all melanomas arise in pre-existing naevi, many of which are dysplastic.

  • Melanoma is extremely rare before puberty.

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