The skin calls for the faculty of close observation and attention to detail.
LOUIS A DUHRING (1845–1913), VALEDICTORY ADDRESS, UNIVERSITY OF PENNSYLVANIA MEDICAL SCHOOL
The management of pigmented skin lesions is a constant concern for all practitioners and requires careful evaluation based on the natural history of these lesions and the increasing incidence of malignant melanoma in particular.
Most pigmented lesions are benign and include simple moles or melanocytic naevi, seborrhoeic keratoses, freckles and lentigines. Reassurance is all that is necessary in the management of these problems.
However, one-third of all melanomas arise in pre-existing naevi, many of which are dysplastic, and it is the recognition and removal of such naevi that is so important in the prevention of melanoma.1
Malignant melanoma is doubling in incidence each decade, which is an alarming statistic considering the public education programs about the hazards of sun exposure. Of equal interest is the fact that the cure rate for melanoma is also increasing, reflecting earlier diagnosis and treatment. The most important factor in management is early detection. It is most appropriate for GPs to acquire skills in dermoscopy, which significantly improves diagnostic accuracy for melanoma.2
A classification of pigmented skin lesions is given in TABLE 125.1.
Table 125.1Classification of pigmented skin lesions |Favorite Table|Download (.pdf) Table 125.1 Classification of pigmented skin lesions
Pigmented basal cell carcinoma
Foreign body granuloma
Talon noir (black heel)
Lentigo maligna (Hutchinson melanotic freckle)
Superficial spreading melanoma
Acral lentiginous melanoma
Key facts and checkpoints
The incidence of melanoma is greatest in white Caucasians and increases with proximity to the equator.
The early diagnosis and treatment of melanoma profoundly affects the prognosis.
Melanoma is extremely rare before puberty.
Currently the greatest rate of increase is in men >55 years.
Most people have 5–10 melanocytic naevi on average.
Multiple dysplastic naevi carry a higher risk of malignant change, which may occur in young adults. Such patients require regular observation (with photography).
Synonyms: granuloma, granuloma telangiectaticum, acquired haemangioma.
A pyogenic granuloma is a 5–10 mm soft vascular lesion (without pus) due to a proliferation of capillary vessels. It is considered to be an abnormal reaction to minor trauma (see FIG. 125.1).
Pyogenic granuloma showing bright red, friable tumour on face. It followed a puncture from a spiky plant in the garden.
Photo courtesy Robin Marks