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November 18, 2017 / molehunter

A nasty nodule

As I was teaching some medical students this week, most of the time when you see a melanoma, you immediately think ‘YECH! that needs to be in a jar-fast!’ This is an example. Just take one look at it-dermoscopy is not necessary.

3.7 melanoma 7 mitoses 1302196 (2)

Everything about this skin tumour is wrong. Let’s apply the ABCDE rule.


B-border irregular

C-colour mixed-in particular there is pink, brown, black and blue

D-diameter you can’t tell on this projection but it was over 1cm.

E-for ERYTHEMA. I know that’s non standard, but the more melanomas I see, the more I am worried about pinkness.

But before all that there is the ‘one glance’ test, the ugly duckling sign. This is a mole you would hopefully, stop a stranger in the supermarket and beg them to get checked.

Anyway, here’s the dermoscopy.

3.7 melanoma 7 mitoses 1302196 (1)

NB the little pepper grain dots everywhere are an artefact, some form of external dirt.

To be honest, the dermoscopy doesn’t add very much, and it certainly doesn’t change our clinical decision. We can see, faintly, some linear-irregular vessels in the pink nodule, a blue-white veil becomes apparent just above and left of centre, and the off-centred black and brown area looks more irregular than we saw on naked eye. But who cares-we already decided it needed excision at one glance. But it’s always worth dermoscopy just to build up your knowledge base of dermoscopic signs of melanoma.

Histology confirmed a nodular melanoma, to nobody’s surprise. A dangerous tumour over 3mm thick that may end this poor person’s life, what a pity it wasn’t caught earlier.

learning point beware the new pink lump, or ‘perilous pink papule’. If this pink nodule had appeared on its own, without the other deeper colours, it would still have been 100% melanoma, just harder to diagnose.



June 15, 2017 / molehunter

draft patient skin cancer information leaflet page 1

draft skin cancer patient leaflet page 1 Just trying to post this here to see what it looks like. Anyone feel free to comment-this is an ongoing project.


June 7, 2017 / molehunter

PDF of June 7th presentation for GPs at RSH

This PDF is for the benefit of the doctors who attended the short presentation at the Royal South Hants’ department of dermatology on Wednesday 8th June. Hayes June 2017 short introduction to dermoscopy

Good hunting!

June 3, 2017 / molehunter

Integrated skin lesion recognition and dermoscopy course dates 9th March and 8th June 2018

Following our 7th successful year of running this course we have now fixed the dates for 2018. Same venue and format, just every increasing experience and more new images and cases. We have had to increase prices by around 10%, first increase since 2014, due to our rising expenses but still believe this to be the best value dermoscopy course in the UK, if not Europe! Booking is now open, reduced priced for bookings before 1st December 2017 and for nurses.



Integrated skin lesion recognition & dermoscopy course

Two Friday afternoons 9th March and 8th  June 2018

An interactive course suitable for all health professionals who have to evaluate suspicious moles. Ideal for GPs, dermatology and plastic surgical trainees, elderly care and occupational health doctors, specialist and practice nurses. No prior knowledge of dermoscopy is assumed. We believe this to be the best value UK dermoscopy course, combining expert presentations, a virtual textbook including all presentations on memory drive and 12 weeks of on -line case discussions.

South Coast Dermoscopy Associates

Dr Stephen Hayes, Associate Specialist in Dermatology, Southampton

Dr Catriona Henderson, Dermatologist, Southampton

Dr Birgit Pees, Dermatologist, Southampton

Between us we have been practicing, studying and teaching dermoscopy for a combined total of well over 50 years and attended numerous international conferences and courses. Over the last 2 years SH has taught dermoscopy in Jersey, Belfast, Kilkenny (with number 1 UK dermoscopy expert Jonathan Bowling), Birmingham, London, St Andrews and various other UK destinations. On 26th April 2017 the South Coast Dermoscopy team taught the first dermoscopy course for dermatology trainees at Willan House in London, HQ of the British Association of Dermatologists.


9th March and 8th June 2018 Holiday Inn, Fareham, Hampshire + e-learning

Friday afternoons 13.30-17.00                 Hot lunch in restaurant from 12.30 + coffee included

Dermoscopy (dermatoscopy, surface skin microscopy) is an internationally validated technique which is increasingly seen as essential in the evaluation of pigmented and other skin lesions.  Peer review evidence from meta analysis (1) confirms that dermoscopy outperforms naked eye examination of pigmented skin lesions.

A one day dermoscopy course for GPs was shown in a prospective randomised trial to reduce avoidable referrals while missing far fewer skin cancers, only 6 compared with 25 for the control group (2) .

Since we began this annual course in 2011 the skin cancer problem has got steadily worse. Despite steadily  increasing numbers of urgent skin cancer referrals, dangerous skin cancers are still being missed. Missed melanoma as well as the potential tragedy for each patient continues to be the number one reason for doctors in dermatology being sued. Doctors who have done our course have fed back to us that they have picked up melanomas they would otherwise have missed, while reducing their overall referral rates.  This is in line with international published research which shows that GPs’ performance is significantly increased by one day of dermoscopy training. (1)

Our course is designed and delivered by an experienced former GPSI (SH, currently working as a specialty doctor in lesion recognition) and 2 senior skin cancer specialists. Learners should gain excellent skin lesion diagnostic skills, enabling them to safely reassure and advise the great majority of patients worried about harmless lesions and refer questionable lesions to the right person first time.

The course ran successfully each year from 2011 to 2016 with high levels of satisfaction from over 300 participants so far. We have improved the course following feedback. Approval is sought for 7 hours CME.  The 3 teachers attended the 3 day world dermoscopy congress in Vienna in April 2015 and have incorporated up to date evidence based insights from this global event into our teaching. We are booked to attend the 5th world congress in Thessaloniki in June 2018.

Our course begins by stressing the natural history of common and important skin lesions, basics of history taking, inspection and palpation of lesions before going on to what dermoscopy can add.

FREE VIRTUAL TEXTBOOK. learners receive an 8GB memory drive containing all presentations, 100 image based case discussions, PowerPoint presentations of virtual clinics which go through the essentials of skin lesion recognition and demonstrations of how to use various diagnostic algorithms. Some videos will also be included. This amounts to a virtual text book of dermoscopy to enable learning re-enforcement. You can work through it at your leisure and claim additional learning credits.

ON LINE CASE DISCUSSIONS. Participants will join a private Google email group for on line case discussions. Plain and dermoscopic lesion images will be emailed out 2 or 3 times a week for interactive discussion guided by Dr Hayes. Learners can raise any difficulties or questions and even post their own lesion images for discussion. We expect to do at least 30 case discussions, covering all kinds of skin lesion which occur in UK practice. Please, no addresses as the security blocks images. Hotmail and  Gmail are suitable free alternatives that work well.

SESSION 2 will recapitulate the whole course including a reprise of the case discussions plus difficult cases and any particular learner issues that come up in the case discussions.


  • Natural history and basic rules of recognition of benign and malignant skin lesions. What to do before you pick up the dermoscope e.g. history, inspection, palpation.
  • Benign naevi. Natural history and development, various types, flat and raised moles. How to make a safe and positive diagnosis of benignity. Various network and globular patterns, vessels that point to benignity. Red flags and question marks
  • Seborrhoeic keratoses. Recognising their wide range of appearances. Dermoscopic features which allow a safe diagnosis. Traumatised warts-the sheep in wolf’s clothing-
  • Haemangiomas, recognising their dermoscopic features.
  • Melanomas-the range of presentations. Red flag features not to miss. Key dermoscopic features including abnormal networks, streaks, globules, blue grey veil, regression structures. Hypopigmented and amelanotic melanomas, ‘featureless’ melanomas, the deadly and deceitful pink nodule.
  • Basal cell cancers, vessels, pigmented structures, micro ulcers and other features.
  • Miscellaneous skin lesions including Bowen’s disease, dermatofibromas, scabies etc.
  • Diagnostic algorithms including 2 step, 3 point, 7 point, heuristic method, pattern analysis and an introduction to the new descriptive dermoscopic terminology of Harald Kittler.
  • Mole mapping and skin monitoring for high risk patients e.g. the dysplastic mole syndrome.
  • All presentations plus other material will be included on the memory drive. We decided to trust you on this as we believe it will be a better learning experience, but must ask you to respect our copyright on this material. We don’t mind you using the presentations for bona fide, in-house professional education with colleagues at your place of work, but you must not publish, copy, distribute or use any part of them in any other way.


We believe the above is a balanced and comprehensive curriculum which addresses all the important Primary Care issues about skin cancer triage, diagnosis and referral, but if other issues are raised by learners they can be addressed due to the nature of this course which runs on line over 12 weeks.

For all enquiries contact Dr Stephen Hayes at

Learners may also be interested in my blog at where case discussions, links to other on line learning resources and details about the course may be found.

COST £220 for doctors, £150 for nurses if booked by 1st December 2017, £280/£170 thereafter.

Refund on application less £30 admin fee if requested before 10th February 2018, none thereafter. Discretionary deferment (minus £30 admin fee) to the 2019 course for bereavement, injury etc occurring after the above cancellation period.  People who cannot make one or other of the Friday sessions and declare this at the time of booking will receive £25 discount.

payment by BACS  30-90-85, 21513968 or cheque to South Coast Dermoscopy Associates,

96 Winchester Street,


Hampshire SO30 2AA.


Dr Stephen Hayes                                              South Coast Dermoscopy Associates


(1) as in the meta-analysis by Vestergaard et al (British Journal of Dermatology. 2008; 159:35-48.)






















APPLICATION FORM  please type or write clearly and post or email to


Dear Dr Stephen Hayes

I wish to apply for a place on the South Coast Dermoscopy Associates skin lesion and dermoscopy course 2018. I have read, understood and accept the above terms. In particular, I will not make any use whatever of the images and other learning material in the memory drive or discussion group other than as permitted above.



Email address

GMC/CNG number

If you are a nurse please state your place of work and employer

Position (e.g. GP, specialist, specialist registrar, specialist nurse, APN, practice nurse etc.)

please tick one box. If applying for more than one person, please print multiple copies.

Doctor, early booker discount pre 1.12.17 £220
Nurse  as above £150
Doctor, post 1.12.17 £280
Nurse as above £170



To reduce costs, a receipt will be sent by email only and no reminders will be sent.

for directions see

Please note, the venue is 15 minutes by taxi from Southampton Airport, which is well served with flights from Dublin, Belfast, Paris, Amsterdam, Glasgow, Edinburgh, Manchester and several other major European cities.

May 17, 2017 / molehunter

NEC Birmingham presentation on mole mapping with dermoscopy

This (link at foot of this post) is a PDF of a presentation I will be giving today at the NEC. It is an edited version of a presentation given at the British Association of Dermatologists’ dermoscopy course for trainees on 26th April. It is intended for delegates but may be of interest to other dermatology doctors. My sincere thanks to Professor Harald Kittler of the University of Vienna for the use of his excellent images.

The main point of this presentation is that people who have had a previous melanoma, have 100 or more moles, who have some atypical moles (atypical moles =naevi over 5mm diameter which are somewhat irregular in shape and colour but have no clear signs of melanoma) are at increased risk of getting a new melanoma, and that monitoring with photography has been shown by good published scientific studies to pick up their new melanomas at an early, therefore curable, stage. The risk is additive, so if you have 100 moles, several over 5mm and looking a bit odd, and have already had a melanoma-you really should be mole mapped and monitored. One of the studies I cite in the presentation showed that melanoma patients in Florence, Italy, who were monitored, when they developed new melanomas they were picked up earlier and were A THIRD OF THE THICKNESS (0.36mm versus 1.22mm) compared with non monitored people. This could literally be the difference between life and death.

In my opinion, based on the evidence I have seen, mole mapping and monitoring should be getting more attention that it currently is. In particular, I think there is a good case for low risk people (i.e. most white people with 40 or fewer moles) to self-monitor using their own tablet computer or similar device. It’s not complicated-just photograph your back, front, sides, arms, legs, head and neck and get a family member of friend to check you over against the photos every 3 months and report any significant change. Not as good as digital mole mapping and regular review with a dermatologist, in fact we don’t have much published evidence it works, but it’s common sense, harmless and affordable. As things are, only people with high risk factors for a melanoma can expect to be regularly monitored by a dermatologist-especially in the UK where we have far too few dermatologists.

Watch this space for further developments in the area of skin screening for melanoma!


NB the PDF contains several links to published data which may be useful.

Birmingham NEC registrars monitoring

May 3, 2017 / molehunter

Subtle melanoma

This pigmented lesion on a middle aged woman’s upper arm had been present for several years. There was some doubt as to whether or not it had changed recently. It was flat to palpation and mildly asymmetrical in shape, outline and colour as the image shows.

thin melanoma very subtle (4) - Copy

A full skin check showed it was the biggest mole on her whole body, the ‘ugly duckling‘ Dermoscopy was performed.

thin melanoma very subtle (2)

This is not a very dramatic image, no colour but brown but 2 very distinct patterns. The upper half, taking a line from about 2 o’clock to 8 o’clock, was a mix of reticular and featureless (not photographed very well) but the lower half is made up of globules (=‘clods’ in the modern descriptive terminology). They are of roughly similar size and colour, but the distribution is highly asymmetrical. On balance, the mole was removed for histology.

It proved to be a thin melanoma, 0.5mm Breslow thickness with zero mitoses so almost certainly cured. 

Learning point: as ever, take a holistic view, and err on the side of caution. Some of the melanoma images I post here are so obviously bizarre that a bright child of  6 or 7 could see they needed cutting out, but not always. The goal is to catch them early. As the melanoma develops, it becomes easier to diagnose but harder to cure.

Also, never forget the ugly duckling sign. This catches more melanomas than any other single factor. The mole that looks different, in any way, from all your other moles deserves attention, especially if it is new or changing.

PS note also the many freckles (solar lentigines/lentigos) on the person’s upper back. These are a sure sign of past sun damage, therefore the risk of a melanoma is somewhat higher than in a person of the same age and skin colour without a load of freckles.




March 22, 2017 / molehunter

Urgent skin cancer referral pathway

This is the PDF (click on link below) of a presentation I am giving this afternoon (22nd March 2017) for Southampton GPs about how to make best use of the 2 week wait urgent skin cancer pathway.

Please note, while we sometimes can remove skin cancers on the day, and will try to do so in the case of nodular melanomas, we can’t guarantee to do this, so don’t tell patients to expect it. Many tumours, e.g. SCCs on the scalp or BCCs on the noseCCG 2 week wait, require a skin graft which is 90 minutes in Day Theatre with a highly experienced skin surgeon, common sense dictates we can’t just provide this off the peg in a busy clinic setting.

CCG 2 week wait