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The skin calls for the faculty of close observation and attention to detail.


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 117.1.

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).

Table 117.1Classification of pigmented skin lesions

Talon Noir (‘Black Heel’)

Talon noir is a black spotted appearance on the heel and is common in sportspeople. A similar lesion (probably smaller) is often found on the other heel.

‘Black heel’ is formed by small petechiae caused by the trauma of the sharp turns required in sport: shearing stress on the skin of the heel produces superficial bleeding. The diagnosis can be confirmed by gentle paring of the callus to reveal the multiple small petechial spots in the epidermis; these are then pared away. If there is doubt about the diagnosis (malignant melanoma is the ...

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