The Consultation
As soon as the patient presents with a pigmented lesion the pressure is there not to miss a melanoma.
Fair skin, history of sun burn, immune compromise, sunbed use in the patient history? A family history of skin cancer? A new or changing lesion (possibly with itching or bleeding)?

Multiple colours, asymmetry, irregular border?
Size is not always a useful criteria as small lesions should not be ignored.
Differential diagnoses such as seborrhoeic keratoses, haemangiomas and benign naevi are common

The Problem
Melanoma is the fifth most common cancer for both men and women. Cases are increasing. According to the figures from the American Cancer Society (2018) the average age that Melanoma is diagnosed is 63 years of age but it is not uncommon in young adults. The earlier it is it detected the better the outlook.
More than two thirds of melanoma arises de novo as a new skin lesion rather than arising in a pre-existing naevus (Pampena et al 2017). New lesions are particularly suspicious as a patient enters middle age.

GP use of Dermoscopy
Dermoscopy can be used in primary care. There are one day courses that are a good start to learning how to use a dermatoscope.
The first stage is to see the features of the benign lesions. Once you can reliably identify what the lesion is, this is good evidence of what it is not. The features indicating melanoma are clearer too but if in doubt it is always worth referring on.

Patient Education
Sun protection, vitamin D supplementation and self examination (a ruler and home digital photography can be used) are recom-mended. Sun exposure is the main cause of skin cancer.
Sunbed use or ‘indoor tanning’ is to be strongly discouraged – it increases the risk of skin cancers both melanoma and non-melanoma. Women who have ever used indoor tanning are six times more likely to be diagnosed with melanoma in their 20s than those who have never tanned indoors. More than 10 000 melanoma cases each year were attributable to indoor tanning in the United States, Europe, and Australia. (Wehner et at 2014).

This is still happening around us in the UK, here in Kent, and we need to do more to protect our young people. Brazil and Australia have now banned commercial indoor tanning but the UK is yet to take that action via public policy.

Referral to secondary care
As a specialist, I regularly use dermoscopy and have easy access to excision and histopathology pathways (with rapid feedback). I can often ‘see and treat’ which can help to alleviate the anxiety associated with waiting for removal of a suspected cancer.

Excision for removal and diagnosis/ biopsy in Secondary Care
The suspect pigmented lesion should be removed in secondary care.
It should not be punched, shaved or curetted but excised in entirety with a 2mm margin and cuff of fat under the skin.
The full thickness of the skin needs to be taken so that the ‘Breslow thickness’ of a melanoma can be measured by the histo-pathologist – this measurement is the main determinant used for staging and to predict prognosis.
Ideally the whole lesion should be taken and presented to the dermatopathologist (pathologist specialising in skin). If it is only partially taken it is possible that the thickest Breslow thickness may be in the part left behind. (Although we do sometimes biopsy larger patches of pigment that would be difficult to excise).
Breslow thickness is used to help plan what further investigations, treatment and follow up are to be offered after MDT (multidisciplinary team) discussion.
It is also important to know for cancer staging whether the lesion is ulcerated on pathological examination.
A 2mm a margin should be take initially and no wider. A wider margin and therefore a larger scar could later make sentinel node inaccurate (if that is later offered). Melanoma patients are usually recommended to undergo a further wide excision as a second procedure – even though the melanoma should be initially completely excised – as statistically it reduces the risk of local recur-rence.

Summary
I am always happy to see any lesion and look forward to helping your patients. It is not just pigment-ed lesions to refer – I see and treat many basal cell carcinomas and squamous cell carcinomas. It is worth bearing in mind that a pink lesion can turn out to be an amelanotic melanoma or Merkel cell tumour so they should be seen quickly too. If in doubt, please refer. I will always feedback opinions and results.