SUSPICIOUS PIGMENTED LESION ON CHEEK

This lesion had been present for over 5 years and there was no story of recent change. The patient had not been concerned, but a health care professional was worried, and an urgent referral was made as a suspected melanoma.

pigmented lesion on face of older white person.

The lesion is about 1cm diameter, on a background of elderly, white, sun-damaged skin. There are several smaller brown lesions in the field of vision. The lesion itself is angular in shape, very dark brown to black, with a light brown section on the lower left. It scores positive on the ABCD rule as Asymmetrical, irregular border, 2 colours and diameter over 6mm. It needs dermoscopy.

a seborrhoeic wart.

Dermoscopy confirms that the border is irregular in outline but very well defined. This is typical of some seborrhoeic keratoses. Non-polarising contact dermoscopy reveals abundant comedo-like openings and a few milia-like cysts. The latter feature are less well visualised in the following polarised image. It often helps to toggle between polarising and non-polarising dermoscopy, most better scopes e.g. Heinie D20 and Dermlite DL3/DL4allow this, typically with a small button on the side of the scope just below the lens.

I see no dermoscopic clues to melanoma.

This is a typical example of a harmless seborrhoeic keratosis, which are thousands of times more common than melanomas and can very easily be positively diagnosed with a dermoscope by someone who has had a little training. Health care providers need to get on board with this- scarce dermatologist resources are being wasted because most GPs have not acquired the skills needed to distinguish warts from skin cancers. It’s not just the waste of an appointment, it’s the needless fear inspired by sending someone with a wart to a cancer clinic.

Permission has been given to include this image in a book I will start writing this coming winter which will be specifically aimed at this learning need. I plan to publish as an e-book on Kindle by Easter at a very low cost because I am so concerned about the unmet learning need of many GPs who can’t tell a wart from a cancer.