Melanoma - recognise and refer

melanoma · malignant melanoma · changing mole · suspicious pigmented lesion · acral melanoma · subungual melanoma

Recognise and refer - this is not a diagnostic tool. The UK referral criterion is the weighted 7-point checklist, not ABCDE.

URGENT DERMBand D

Red flags

A weighted 7-point checklist score of 3 or more - suspected cancer pathway referral
A pigmented or non-pigmented lesion suggesting nodular melanoma - NICE says consider a suspected cancer pathway referral regardless of the checklist score
A new or changing pigmented band in a single nail, or pigment extending onto the nail fold. Do not attribute nail pigment to an injury and discharge. Patients frequently recall or assume a trauma that did not cause it, and CKS treats associated nail damage as making a new pigmented nail line more suspicious, not less. A subungual haematoma migrates distally and grows out with the nail over weeks; melanoma does not, and pigment on the nail fold is never a haematoma. If you cannot demonstrate it growing out, refer
Bleeding, ulceration or a rapidly growing lesion
Any lesion the patient is worried about that you cannot confidently explain - refer rather than reassure

Recognise

On light skin

An asymmetric pigmented lesion with an irregular border and variegated colour, changing in size, shape or colour, often on sun-exposed skin; nodular melanoma may be uniform, raised, firm and rapidly growing.

On brown and black skin

Melanoma is much less common in people with brown and black skin but is diagnosed later and has substantially worse outcomes, and this entry exists because of where it occurs rather than what colour it is. A 2026 review of melanoma in skin of colour, defined there as Fitzpatrick IV to VI, attributes the higher melanoma-specific fatality despite lower incidence to later-stage diagnosis, to differences in subtype distribution, and to systemic barriers to care. Non-Hispanic Black patients in particular have a higher proportion of acral lentiginous and mucosal melanomas, which arise in areas that are not sun-exposed. So the concern is acral lentiginous melanoma, on the palms, soles and nail beds - sites that are not sun-exposed, are routinely not examined, and are not what patients are told to watch. Examine the soles, the palms, between the toes and the nails of anyone presenting with a pigmented lesion. A new, widening or irregular pigmented band in a nail, especially a single nail, and particularly with pigment spreading onto the surrounding nail fold (Hutchinson sign), needs referral - though be aware that benign longitudinal melanonychia is common in people with darker skin, so this is a reason for specialist assessment rather than alarm. Reassurance based on skin tone, or on the absence of sun exposure, is not safe.

In any skin tone

Change is the central concept - in size, shape, colour or sensation
The UK criterion is NICE's weighted 7-point checklist, with a score of 3 or more triggering a suspected cancer pathway referral
ABCDE (asymmetry, border, colour, diameter, evolution) is a useful aide-memoire but is not the NICE referral standard
Nodular melanoma may break all the usual rules - uniform in colour, symmetrical, and simply growing quickly
A lesion that looks different from the patient's other moles - the ugly duckling
The checklist was not developed in children and NG12 gives no paediatric variant of it. Melanoma is rare in childhood, but a low score in a child is not a reason to withhold referral - refer a changing, bleeding or rapidly growing lesion on clinical concern alone
Examine palms, soles and nails, particularly in patients with brown and black skin

Distribution

Anywhere. In people with brown and black skin, disproportionately on the palms, soles, nail beds and mucosae rather than sun-exposed sites.

Photographs

A melanoma surrounded by that person's ordinary moles - which is the most useful way to look at one. It is asymmetric, its border is ragged and notched, and its colour runs from mid-brown to near-black within a single small lesion, while every naevus around it is small, round and one even shade. **That is the ugly duckling sign.** In brown and black skin melanoma is far more often acral - on the sole, the palm or under a nail - so examine those sites rather than relying on sun-exposed areas. The only openly licensed photograph found for this entry shows light skin. **That is a limitation of this page, not of the disease** - a darker-skin photograph is still being sought.
Fitzpatrick I (Fitzpatrick type estimated from the photograph, not stated by the source) · Simone Trovato Monastra · Wikimedia Commons - Melanoma in adult woman.jpg · CC BY-SA 4.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Basal cell and squamous cell carcinoma - recognise and refer — Non-melanoma skin cancers have different referral urgencies - SCC is a suspected cancer pathway referral, BCC is non-urgent
Molluscum contagiosum — Benign dome-shaped lesions with central umbilication, in clusters, usually in children

What to do in the ED

This is a recognition and escalation aid only. Do not attempt to diagnose or exclude melanoma from an appearance, and never reassure a patient that a lesion is benign.
Score the lesion against the weighted 7-point checklist and refer on a suspected cancer pathway if it scores 3 or more
Refer regardless of score if the lesion suggests nodular melanoma, or if dermoscopy performed by someone competent suggests melanoma
Examine the palms, soles and nails, particularly in patients with brown or black skin
Do not excise, shave, biopsy or cauterise a suspicious pigmented lesion in the ED
Document exactly what you saw, the site, the size, and the checklist score, and make the referral rather than advising the patient to see their GP
Give the patient a clear account of what happens next and by when

Score

Weighted 7-point checklist — the calculator is in the interactive tool.

Disposition

URGENT DERM

Suspected cancer pathway referral for a checklist score of 3 or more, for suspected nodular melanoma, or where dermoscopy suggests melanoma. Make the referral; do not delegate it to the patient.

Safety-netting

You are being referred because this needs a specialist to look at it, not because we know what it is. Do not wait to see whether it changes. If you do not hear about an appointment within two weeks, contact us or your GP. In the meantime do not pick at, scratch or try to remove the lesion. Check your palms, soles and nails as well as sun-exposed skin.

Local variation

Whether the ED can refer directly onto a suspected cancer pathway, or must route via the GP, varies by trust - know which applies, because a referral the patient has to chase is a referral that fails.

Sources

Open this entry in the interactive tool