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February 24, 2018 / molehunter

A new, firm and growing pink lump on a middle aged woman’s leg

I always teach that there are four steps to doing skin lesion recognition properly. Step one is for the learner to stock their brain with correct information about the natural history of common and important skin lesions. (*) The web makes it easier to do this than it has ever been before, and is why I blog here. If the doctor or nurse has mastered step one, the description at the top of this post will have grabbed their attention and they will be anxious before even seeing the spot, lump or mole.

(2)

Here we are, a pink lump on the front of a middle aged woman’s shin. What could it be? It has to be something. It looks around 8-10mm and is irregular. Will dermoscopy give us any additional information? Let’s have a look.

(1)

I can see a pink background (no news there) many shiny white structures of various shapes and sizes, and with care some irregular blood vessels. The overall appearance is chaotic, and there are clues to amelanotic melanoma. Also, (diagnosis of exclusion) there are no features pointing to any other kind of skin lesion (e.g. wart, haemangioma, benign naevus, BCC etc).

This was excised as fast as possible. I was sorry but not surprised that it was a nodular non-pigmented (amelanotic) melanoma. In fact, a text book case.

A distinguished dermatologist once told me that I should not waste my time teaching dermoscopy to GPs, ‘You should tell them about the dangers of the new, firm, growing pink nodule instead.’ he said. We had this conversation a few times, and I said ‘I’m going to take half of your advice.’

The new, firm, growing pink nodule (especially in sun exposed locations in older white patients) is a RED FLAG warning sign. non-pigmented melanomas are very dangerous as they don’t look like the ‘typical’ black and other colours mole we are expecting to see, and also as they are biologically more aggressive for genetic reasons I won’t go into here.

Seven times beware the perilous pink papule. Patients can die, doctors can get sued, because you should have known.

 

(*) step 2, listen to the patient’s description of the lesion’s development, step 3 is to examine it, step 4 is dermoscopy. Then put it all together to make a rational decision above all answering the question-is this lesion safe, or not.

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