July 1, 2024 • 25 mins
If you go and sit in front of your doctor and say, “would you have a look at this skin lesion doc? I'm a bit worried about it” what will they say and what will they be looking for?
In this episode, your hosts Dr George Moncrieff and Dr Roger Henderson answer these questions by discussing...
- The current approach to spotting and diagnosing a melanoma, ABCD
- Dr George Moncrieff’s improved approach to spotting and diagnosing melanomas, which includes elements of ABCD and adds E, F and G
- Why doctors should be asking you to return for a thorough skin check if you are concerned about a skin lesion
By the time you’ve finished this episode, you’ll have a better understanding of your skin lesions, such as moles and other odd dark spots, and which ones you should be going to talk to your doctor about. It might not be the one you think!
Thank you to our kind sponsor AproDerm, who provide a range of emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
Everyone’s skin is unique and what works for one person, may not work for another. That’s why AproDerm has developed the AproDerm Emollient Starter Pack. This pack contains all four of their emollients varying in their formulation, consistency and hydration, giving you the choice to find a routine which suits you.
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We hope you find this podcast interesting and helpful. Please leave us a review or email info@aproderm.com with any feedback on this episode or suggestions on dermatology topics that you would like to hear about in future podcasts.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:11):
Hello, and welcome to this Skin Deeppodcast, where we look at skin-related
issues, conditions and treatments inan interesting and informative way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff, Iwas also a GP, although I've
now retired from my practice.
And I was the past Chair of theDermatology Council for England.
(00:35):
Today, George and I will be talking aboutthe diagnosis of malignant melanomas.
And if you were with us for our first one,where we talked about the risk factors
involved with this particular type ofcancer, we do hope you found it helpful.
So to kick off this week's podcast,George, let's look at what we
(00:56):
should be perhaps thinking aboutwhen considering if a skin lesion
is a possible cause for concern.
So if a patient comes and sits infront of us and says, "would you
have a look at this skin lesiondoc, I'm a bit worried about it."
What should we bethinking about initially?
Well, having taken into accountwhether you believe your patient's a
risk candidate, high-risk candidatefor a melanoma, which is clearly
(01:20):
important, looking at the individuallesion, does the lesion worry you?
Well, if you can get a history ofchange, the patient says, "this mole
wasn't here before" or, "unlike myother moles, which look the same as
they did last year, this one is nowgrowing or developing new colours,
becoming more raised" or whatever.
(01:41):
Any change, history of changeis, we talked about history
last time, it is so important.
So, any history of change would alert me.
Obviously benign things also can change,they can become inflamed if you catch them
or they get infected and things like that.
But, I think it's as importantas saying, "does it worry me?"
(02:02):
Can I turn it on the head andsay, "can I recognise it's
an obviously benign lesion?"
I mentioned last time that dermatologistssee the cases that we refer to the cancer
bureau for suspected skin cancer andthey say that, over 8 out of 10 are not
just benign, they're obviously benign.
(02:22):
And they're things like a patch ofpost-inflammatory increased pigmentation
from a leg ulcer or, a giant blackhead,you can get these giant thick blackheads
sometimes, or, simply just a blood vessel,that [to the] naked eye can look worrying.
And so, unless you look at itvery carefully, you might miss
these obviously benign lesions.
(02:43):
So first of all, decide, am I absolutelyconfident it's a benign lesion, and
I'll come on to the sort of featuresthat distinguish those two as we go on.
And is it a lesion that's changing?
A history of change in somebody at higherrisk would definitely make me stop in
my track and look at it very carefully.
So, if we have got a patient in frontof us and we think, hmm, yes, I need
(03:08):
to look at this in a bit more detail.
Let's think about thealphabet, by which I mean ABCD.
Now, if we were taught anything aboutdermatology as junior doctors, we were
probably taught this acronym ABCD.
And it's still one of the most commonlyremembered by GPs and by medical students.
(03:29):
And for those who don't know, thisstands for asymmetry, B for border,
C for colour, and D for diameter.
So it's really easy to remember.
And I used to think this was the bee'sknees, but as with so much of medicine,
the more you do, the more you realiseit's shades of grey, not black and white.
(03:50):
So I've started to have some slight qualmsabout the almost over simplification
of ABCD and having spoken with youabout your views on this, I think it
would be an understatement of somewhatheroic proportions to say that you've
got some issues with ABCD as well.
So, why?
(04:12):
Well, I think this underpins, overreferral of obviously benign lesions.
Let's look at them.
Asymmetry.
The two halves of thelesion are not identical.
Well, yeah, that is a feature ofmelanoma, but so too are benign lesions.
Many benign lesions areirregular in that way.
(04:34):
So the lack of symmetry doesn'tsafely distinguish a malignant
lesion from a benign lesion.
When they talk about border,they're talking about an
irregular or a ragged border.
Well, again, that doesn'tdiscriminate, obviously, benign
lesions from the melanomas.
(04:54):
Yes, melanomas are likely tohave an irregular border, but
so too can benign lesions.
In fact, regarding the border, it'sthe nature of the border that matters
more than whether it's irregular.
Benign lesions tend to have avery sharply demarcated edge.
They end abruptly.
(05:15):
Whereas tumours tend to, spread intothe surrounding tissue a little bit.
And in fact, if you look around theborder, if part of the border is
discrete and another part of the borderis vague, that would be worrying.
But if all the way around theedge of the lesion, it's sharply
demarcated, that's pretty reassuring.
(05:37):
C for colour does matter.
Yes.
When white light goes throughany medium, whether it be the
sky or water or even the skin.
The blue light is scattered more.
That's why the sky looks blue,that's why the sea looks blue.
(05:57):
Similarly, when white light penetratesthe skin, the deeper it goes into
the skin before it's reflected,the more red light you've lost.
And so, melanin, which is...
I'm talking here about eumelanin,there are different melanins, but
there's eumelanin which is brown/black.
When that's up on the surfaceof the skin, in the top layers
(06:18):
of the skin, in the epidermis,it's going to be black or brown.
But if you've got melanin that'smigrated deeper into the skin and
then the light is reflecting fromthat, say really down deep in the
skin, it can come back looking blue.
Cut that bit of blue melaninout, it will be black.
But because it's got the artefactof going through the skin, the
(06:39):
red light's been scattered andyou're just left with blue light.
So when you see lots of different coloursin the lesion, one of the explanations
for that can be that the light isreflecting from elements of the lesion,
some are superficial and some are deep.
And of course, melanomas are tumoursthat invade and they go down deep
and so you get deeper elements.
(06:59):
So colour is very important.
Yeah, I like C for colour.
And then D for diameter.
People have sort of usedvarious diameters, I think
currently it's six millimetres.
That, I think, is dangerously wrong.
I have diagnosed many melanomas thatare only two or three millimetres.
(07:22):
Tiny.
Yes, they're melanomas.
Yes, it's good to get them out.
But they were only twoor three millimetres.
Why wait for it to growup to six millimetres?
And majority of benign lesionsare also over six millimetres.
So diameter does not discriminate.
So A, B, and D, I think,are dangerously wrong.
(07:47):
And a chap called Giuseppe Agenzianofrom Naples, who is one of the absolute
world experts in this field, and hasdone more work and research onto melanoma
than anybody else I've ever come across.
He said that relying on ABCD alonewould mean that over two thirds
(08:08):
of melanoma would be missed.
Admittedly, they're going to be thesmaller ones, but I'd rather have
my melanoma removed when it's small.
And countless patients will befacing really totally unnecessary
worry with having failed the ABCDwith their large, benign lesions.
Being referred on to secondarycare, overloading secondary care.
(08:31):
Costing the nation a fortune,causing them unnecessary anxiety
and causing the GP also more work.
So I think ABCD seriously lets us down.
It does not discriminate.
Right.
There's your headline for thepodcast, right there, George.
Fantastic stuff.
Now I'm a bearer of very littlebrain and I like simple things to
remember, especially in a busy surgery.
(08:53):
So, if I'm not going to reach for myABCD, what would be your alternative,
simply, as an alternative to ABCD?
Well, I suppose I could say E, F, and G.
But before I say that, yeah,I think in the history.
If you've got evidence that thisis a new mole, they've got a
(09:15):
photograph on the beach last year,and it wasn't there, now it's there.
And you feel it is a mole, amelanocytic naevus, and if they're
over 30, I would be a little anxious.
If they're over 40, I'd be moreanxious, and if they're over 50...
I would need very, very good reasonsnot to advise that this mole, however
(09:39):
innocent it looks, ought to come out.
So there are a lot of other thingsthat are pigmented, that are new,
that we develop as we get older.
Sunspots and pigmented seborrhoeickeratoses, and the list can go on.
But if somebody's got a newmole, and they're over 30, I'd
prefer them not to have it.
And if they're over 50,I would say no choice.
(10:00):
So that's the first thing.
The second thing would be thelesion that just doesn't look
like its brothers and sisters.
They've got lots of moles.
But here's this one that justdoesn't look like the others.
It's called the ugly duckling sign.
If they've got an ugly duckling, Iwould say, "look, why don't we just
get it out and not worry about it?"
(10:20):
And that, for us as GPs, inevitablymeans referral to secondary care.
But I think referring an uglyduckling, I think, is reasonable.
Clearly site matters a little bit, soI'm a little bit more cautious about
the back in men, but that doesn't meanto say I'm not also anxious about other
areas of their skin and the leg in women,but the differences aren't that huge.
But yeah, E, F, and G.
(10:42):
E, for me, stands for elevation.
If you run your hand over the lesion andyou can't feel it, it's completely flat.
It's only got horizontal growth atworst and we measure the prognosis
of a melanoma by how deep it's going.
(11:03):
So if it's completely flat, you've gotplenty of time, you can take a close
up photograph in focus and perhapslook at it again in a few months.
If it's changing, then that matters.
The converse is that if it's raised,you run your hand over it and it's
a bump, you can feel it's raised.
It's already got vertical growthand you therefore must make
(11:27):
a decision about that, today.
You can't afford to say to the patient,let's see if it's doing anything.
It's already potentiallygot vertical growth.
If you're certain it's a benign lesion,and many benign lesions are raised.
That's fine.
You can reassure the patient and relax.
But if you aren't certain it'sbenign and it's raised, then I
(11:48):
think that needs to be cut out.
The second thing is F for firmness.
All tumours are firm.
Yes, some benign things are firm.
Some are even more firm than tumours.
But if it's, the converse is, if it'ssoft and it's wobbly, it is not a tumour.
(12:11):
So if you can sort of wobble itaround, little sort of fleshy,
lumpy, soft, fatty lump or something.
So if it's soft and wobbly,you've got nothing to worry about.
If it's firm and it doesn't give, thenthat could be something to worry about.
And I keep G for growth, i.e.
it's changing, so dynamic features.
(12:32):
So I think new moles, ugly ducklings,and E, F, and G, are the important ones.
I did some work with CRUK some yearsago, they wanted to produce a toolkit for
GPs to help them to diagnose melanoma.
And all the lesions that theywere asking us to use in this
(12:52):
toolkit were nodules, (bumps).
A nodule is a raised lumpy lesion andthey were all ulcerated and bleeding.
Well, yeah, they were obviousmelanomas, but frankly, if you're
going to wait till your melanomasreach that point, it's just too late.
I think that's not clever.
You need to be diagnosingmelanomas well before they become
(13:15):
ulcerated and bleeding nodules.
Another important fact to remember isthat if you're very fair-skinned, with
blonde or ginger hair, blue or greeneyes, that sort of genetic makeup, you're
significantly more likely to develop amelanoma with that sort of skin type.
(13:35):
And indeed, if you've gotmultiple moles as well, then you
have a 25-fold increased risk.
It could be a pink melanoma.
And by pink I mean they really are areal pink, like raspberry or strawberry
blancmange, that sort of pink colour.
But if you've got a firm, pink nodule,in particular if it's changing, in
(13:57):
somebody with Celtic type skin, bejust as alarmed about that as you
would if it was brown or black.
When you've got Celtic skin, you'remaking some eumelanin, this brown/black
melanin I spoke about, but you're alsomaking a pink melanin called pheomelanin.
And so when you get a melanoma, it canbe a melanoma made up of pheomelanin.
(14:21):
Some people call them amelanotic,but A means without, and
they're not without melanin.
They've got pheomelanin, so Icall them pheomelanotic melanomas.
Some people call them hypomelanotic,meaning reduced melanin.
I think that's reasonable.
So hypomelanotic melanomas.
But just be aware of the pink, firmnodule in somebody with fair skin.
(14:42):
Treat it with respect.
Unless you know what it is.
On the foot and the hand, what wecall acral skin, you obviously can get
normal melanomas, pigmented melanomas,and they do behave a bit different
to melanomas elsewhere on the body.
(15:03):
These are the ones that are just as commonin dark skin as they are in light skin.
They've got nothing to dowith ultraviolet light.
They tend to have a bad prognosis, notbecause they're aggressive, they're
actually very nonaggressive, but they'reoften missed for a very long time, and
they present and are diagnosed quite late.
So, those do matter, but theones that frighten me more are
(15:24):
the ones that are not pigmented.
They're often scaly, which is unusualfor a melanoma, and they ulcerate early,
and these are really nasty, aggressiveones, they're called non-lentiginous.
They're very tricky to diagnose,and unless you keep them in
your mind, you will miss them.
(15:46):
So if you've got a nodule or a raisedlesion on the foot, or the hand that
is not healing, scaly, changing andyou don't know for certain that it's
something benign, you must assumethat, that could be one of these
aggressive, difficult melanomas onthe foot, called non-lentiginous.
(16:06):
And they can, they grow veryfast and they are nasty.
I think the final thing to say is thatif somebody comes to you worried about a
mole and you've decided that they are apotential candidate for a melanoma, i.e.
they're a human being, but you'velooked at the lesion they were
concerned about and you reassuredthem that it is actually completely
(16:29):
innocent and you're certain about that.
It doesn't mean that they're notstill a candidate for a skin cancer.
They've presented to you, or you've raisedthe concern because you've seen a lesion,
and you're worried they could have amelanoma, well they could have a melanoma.
And unless you look at theirskin properly, you could miss
that skin cancer that matters.
And one thing that worries me aboutthe way in which the health service
(16:50):
is changing, we're moving into an erawhere we are not referring the patient,
we're referring a picture of the lesion.
Yes.
And specialists are going tolook at that lesion and say,
that lesion doesn't worry me.
But you were sufficiently worriedto send that picture and the
patient hasn't been examined.
So if, in general practice,we're not examining their skin
(17:11):
properly, we'll miss their cancers.
And in Oxfordshire, a few years ago,they did some work and they found that
a fifth of all the cancers that theyneeded to excise from patients who'd come
up to their hospital to be seen with alesion that the GP was worried about, a
fifth of the cancers that were cut outwere not the lesion that we'd sent up.
We've sent patients who are riskypatients, with a benign lesion, but
(17:37):
we hadn't spotted the cancer thatwas in their armpit or under their
pants or between their toe webs.
So I think to do a proper skin checkand sometimes I say to patients,
"look, this needs to be done.
Would you like to come back whenI can put some time aside, I can
get a chaperone if necessary.
And I would like to look betweenyour toe webs, in your natal
cleft, that's between the buttocks.
(17:58):
Maybe in the genital area, look behindyour ears, look in your scalp, in
the hair, and do a proper thoroughskin check to reassure me and you
that you haven't got the cancer therethat we're concerned you could have."
Final thing I'd like to say though,and I can't stress this enough.
I could not give an opinion on alesion, on the skin at all without
(18:26):
using a device called a dermatoscope.
And this is not something thatis taught at medical school.
It's not something that every GP hasaccess to, but I think to try to give
an opinion on a pigmented lesion inparticular without this special device,
which is a very simple device to have.
It takes some learning how torecognise what you're seeing.
(18:48):
It gives so much more information.
But I think to try and do it withouta dermatoscope is a fool's game.
It can utterly transformwhat you're seeing.
Yeah, I think that's one of the topthree pieces of GP kit, in my tool bag.
As you were talking there, I wasjust thinking, I just remembered this
chap who came in with an obviouslybenign lesion on his arm, and he
(19:09):
was really worried about this.
I was very happy to reassure him.
But did what you did, I must have hada bit of time that day and I said,
"well, just slip your top off and letme have a good look at you" you know,
arms, legs, trunk and everything.
And he was a single man.
So, no one was there inhis house to tell him this.
And he turned around and he hadthe mother of all melanomas right
between his shoulder blades.
(19:30):
But he had no idea it was there.
And if I'd sort of just looked at his armsand said, "yes, you're fine, off you go."
You know, he'd have been pushingup daisies, and fortunately
we got it in time, but yes,that's a fantastic statistic.
That 20% of cancers excised weren'tthe lesion that was referred.
That's remarkable.
It's shocking,
isn't it?
Yeah.
Incredible.
(19:50):
I mean, we've covered an enormous amountin a very short time here George, and
really given people food for thought.
So looking at perspective, let'stry and sort of pull this together a
little bit, from all our experience.
What would be your key take home pointsto remember that we might not have
considered previously about melanomas?
Just to really get it lined upin perspective and not worry
(20:15):
unnecessarily, but also just tobear in mind for future reference.
I think that's a great thing to do.
Thank you.
Yeah.
I think at the end of the day, I say,I wouldn't be too worried about this.
I'm not worried about melanoma.
You're 68 times more likelyto die of a heart attack or a
stroke than from any skin cancer.
(20:37):
Right.
Wow.
And ultraviolet light, whilst itdoes increase your risk, definitely,
of squamous cell carcinoma, andthe risk in adults of ultraviolet
light, non-burning ultravioletlight, I think is controversial
as far as melanoma is concerned.
It does significantly reduce yourrisk of heart attacks and strokes.
So here's something that you're 68 timesmore likely to die from and you can go out
(21:00):
in the sun and you can reduce that risk.
So you don't need to reduce that risk bya huge percentage before you can make your
chances of survival massively greater.
And to put it into some context, thereare twice as many deaths from falls
each year than there are from melanoma.
And the modern treatments ofmelanoma are quite revolutionary.
Even metastatic disease where it'sspread, we've now got treatments
(21:22):
that can transform that landscape.
And it got me thinking well, ourancestors, when they moved out of
Central Africa, I think sometime between50,000 and 200,000 years ago, they
had dark black skin, my ancestors.
Why, when they migrated to northernand southern latitudes, where the
ultraviolet light was weaker, didthey evolve to have less black skin?
(21:46):
What was the driving factor to lose darkskin that protects you from this cancer?
Evolution doesn't do something withoutthere being a good reason and the
reason is that sunlight has benefits.
Yes, it has risks, and we need tobe sensible about those risks, and
we need to put them into context.
(22:07):
But I'm much more scared of dyingof a heart attack or a stroke.
When sunlight reduces thatrisk, maybe evolution has
something to do with all that.
The story about sunlight is farmore than just vitamin D, and
vitamin D is far more than justyour calcium, metabolism, and bones.
So, as I've been saying, the riskto your health from non-burning UV
(22:29):
exposure in adulthood is overemphasised.
Yes, it will cause my skin toage more, and I'll look older.
Yes, I'll get these keratotic cancers.
But in an immune competent adult,those are relatively low risk.
And I think that it's only melanomathat behaves badly on the whole.
(22:50):
So I think that we need toget these things in balance.
And then a final figure is that adiagnosis of a non-melanoma skin cancer,
which is usually called a basal cellcarcinoma, which is a very low grade.
Wait for this.
If you have a diagnosis of non-melanomaskin cancer, in a big study from
Germany, looking at 33 millionpopulation, was associated with a three
(23:13):
to four year longer life expectancythan individuals who had not given
themselves a non-melanoma skin cancer.
Okay, a lot of confounding factors there.
They'd more like to present tothe doctor, perhaps have more
holidays abroad and so on.
I think the important message toremember is that aggressive skin
cancers, like melanomas, change.
(23:33):
They grow, they become moreugly, but they start small.
So don't wait for a melanoma toget to six millimetres before
you do something about it.
You can diagnose it when it'ssmall, if you know it's changing.
They become ugly, and by thatI mean they don't look like
their brothers and sisters.
They look different to their other moles.
They're increasing loss of symmetry,increasing number of different colours,
(23:57):
but don't wait for them to become hard,raised nodules which then ulcerate.
That's not good for anyone.
Yeah, so think about the ugly duckling.
That's what we're saying.
Excellently done, George.
That was a fantastic précis.
I've learnt a lot, as I always do inthese podcasts, but that was fantastic.
And I think that's a great place tobring this particular episode to a close.
(24:20):
And as always, thank youso much for listening.
George and I really do appreciate it.
And we do hope you found this particularpodcast interesting and helpful.
So Roger and I hope you'll joinus again, when we'll be discussing
more skin-related conditions.
And we'd like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
(24:41):
We couldn't have done it without them.
So, as always, until the nexttime, it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
Hello, and welcome to this Skin Deeppodcast, where we look at skin-related
issues, conditions and treatments inan interesting and informative way.
I'm Dr Roger Henderson.
I'm a GP with a long-standinginterest in this area of health.
And I'm Dr George Moncrieff, Iwas also a GP, although I've
now retired from my practice.
And I was the past Chair of theDermatology Council for England.
(00:35):
Today, George and I will be talking aboutthe diagnosis of malignant melanomas.
And if you were with us for our first one,where we talked about the risk factors
involved with this particular type ofcancer, we do hope you found it helpful.
So to kick off this week's podcast,George, let's look at what we
(00:56):
should be perhaps thinking aboutwhen considering if a skin lesion
is a possible cause for concern.
So if a patient comes and sits infront of us and says, "would you
have a look at this skin lesiondoc, I'm a bit worried about it."
What should we bethinking about initially?
Well, having taken into accountwhether you believe your patient's a
risk candidate, high-risk candidatefor a melanoma, which is clearly
(01:20):
important, looking at the individuallesion, does the lesion worry you?
Well, if you can get a history ofchange, the patient says, "this mole
wasn't here before" or, "unlike myother moles, which look the same as
they did last year, this one is nowgrowing or developing new colours,
becoming more raised" or whatever.
(01:41):
Any change, history of changeis, we talked about history
last time, it is so important.
So, any history of change would alert me.
Obviously benign things also can change,they can become inflamed if you catch them
or they get infected and things like that.
But, I think it's as importantas saying, "does it worry me?"
(02:02):
Can I turn it on the head andsay, "can I recognise it's
an obviously benign lesion?"
I mentioned last time that dermatologistssee the cases that we refer to the cancer
bureau for suspected skin cancer andthey say that, over 8 out of 10 are not
just benign, they're obviously benign.
(02:22):
And they're things like a patch ofpost-inflammatory increased pigmentation
from a leg ulcer or, a giant blackhead,you can get these giant thick blackheads
sometimes, or, simply just a blood vessel,that [to the] naked eye can look worrying.
And so, unless you look at itvery carefully, you might miss
these obviously benign lesions.
(02:43):
So first of all, decide, am I absolutelyconfident it's a benign lesion, and
I'll come on to the sort of featuresthat distinguish those two as we go on.
And is it a lesion that's changing?
A history of change in somebody at higherrisk would definitely make me stop in
my track and look at it very carefully.
So, if we have got a patient in frontof us and we think, hmm, yes, I need
(03:08):
to look at this in a bit more detail.
Let's think about thealphabet, by which I mean ABCD.
Now, if we were taught anything aboutdermatology as junior doctors, we were
probably taught this acronym ABCD.
And it's still one of the most commonlyremembered by GPs and by medical students.
(03:29):
And for those who don't know, thisstands for asymmetry, B for border,
C for colour, and D for diameter.
So it's really easy to remember.
And I used to think this was the bee'sknees, but as with so much of medicine,
the more you do, the more you realiseit's shades of grey, not black and white.
(03:50):
So I've started to have some slight qualmsabout the almost over simplification
of ABCD and having spoken with youabout your views on this, I think it
would be an understatement of somewhatheroic proportions to say that you've
got some issues with ABCD as well.
So, why?
(04:12):
Well, I think this underpins, overreferral of obviously benign lesions.
Let's look at them.
Asymmetry.
The two halves of thelesion are not identical.
Well, yeah, that is a feature ofmelanoma, but so too are benign lesions.
Many benign lesions areirregular in that way.
(04:34):
So the lack of symmetry doesn'tsafely distinguish a malignant
lesion from a benign lesion.
When they talk about border,they're talking about an
irregular or a ragged border.
Well, again, that doesn'tdiscriminate, obviously, benign
lesions from the melanomas.
(04:54):
Yes, melanomas are likely tohave an irregular border, but
so too can benign lesions.
In fact, regarding the border, it'sthe nature of the border that matters
more than whether it's irregular.
Benign lesions tend to have avery sharply demarcated edge.
They end abruptly.
(05:15):
Whereas tumours tend to, spread intothe surrounding tissue a little bit.
And in fact, if you look around theborder, if part of the border is
discrete and another part of the borderis vague, that would be worrying.
But if all the way around theedge of the lesion, it's sharply
demarcated, that's pretty reassuring.
(05:37):
C for colour does matter.
Yes.
When white light goes throughany medium, whether it be the
sky or water or even the skin.
The blue light is scattered more.
That's why the sky looks blue,that's why the sea looks blue.
(05:57):
Similarly, when white light penetratesthe skin, the deeper it goes into
the skin before it's reflected,the more red light you've lost.
And so, melanin, which is...
I'm talking here about eumelanin,there are different melanins, but
there's eumelanin which is brown/black.
When that's up on the surfaceof the skin, in the top layers
(06:18):
of the skin, in the epidermis,it's going to be black or brown.
But if you've got melanin that'smigrated deeper into the skin and
then the light is reflecting fromthat, say really down deep in the
skin, it can come back looking blue.
Cut that bit of blue melaninout, it will be black.
But because it's got the artefactof going through the skin, the
(06:39):
red light's been scattered andyou're just left with blue light.
So when you see lots of different coloursin the lesion, one of the explanations
for that can be that the light isreflecting from elements of the lesion,
some are superficial and some are deep.
And of course, melanomas are tumoursthat invade and they go down deep
and so you get deeper elements.
(06:59):
So colour is very important.
Yeah, I like C for colour.
And then D for diameter.
People have sort of usedvarious diameters, I think
currently it's six millimetres.
That, I think, is dangerously wrong.
I have diagnosed many melanomas thatare only two or three millimetres.
(07:22):
Tiny.
Yes, they're melanomas.
Yes, it's good to get them out.
But they were only twoor three millimetres.
Why wait for it to growup to six millimetres?
And majority of benign lesionsare also over six millimetres.
So diameter does not discriminate.
So A, B, and D, I think,are dangerously wrong.
(07:47):
And a chap called Giuseppe Agenzianofrom Naples, who is one of the absolute
world experts in this field, and hasdone more work and research onto melanoma
than anybody else I've ever come across.
He said that relying on ABCD alonewould mean that over two thirds
(08:08):
of melanoma would be missed.
Admittedly, they're going to be thesmaller ones, but I'd rather have
my melanoma removed when it's small.
And countless patients will befacing really totally unnecessary
worry with having failed the ABCDwith their large, benign lesions.
Being referred on to secondarycare, overloading secondary care.
(08:31):
Costing the nation a fortune,causing them unnecessary anxiety
and causing the GP also more work.
So I think ABCD seriously lets us down.
It does not discriminate.
Right.
There's your headline for thepodcast, right there, George.
Fantastic stuff.
Now I'm a bearer of very littlebrain and I like simple things to
remember, especially in a busy surgery.
(08:53):
So, if I'm not going to reach for myABCD, what would be your alternative,
simply, as an alternative to ABCD?
Well, I suppose I could say E, F, and G.
But before I say that, yeah,I think in the history.
If you've got evidence that thisis a new mole, they've got a
(09:15):
photograph on the beach last year,and it wasn't there, now it's there.
And you feel it is a mole, amelanocytic naevus, and if they're
over 30, I would be a little anxious.
If they're over 40, I'd be moreanxious, and if they're over 50...
I would need very, very good reasonsnot to advise that this mole, however
(09:39):
innocent it looks, ought to come out.
So there are a lot of other thingsthat are pigmented, that are new,
that we develop as we get older.
Sunspots and pigmented seborrhoeickeratoses, and the list can go on.
But if somebody's got a newmole, and they're over 30, I'd
prefer them not to have it.
And if they're over 50,I would say no choice.
(10:00):
So that's the first thing.
The second thing would be thelesion that just doesn't look
like its brothers and sisters.
They've got lots of moles.
But here's this one that justdoesn't look like the others.
It's called the ugly duckling sign.
If they've got an ugly duckling, Iwould say, "look, why don't we just
get it out and not worry about it?"
(10:20):
And that, for us as GPs, inevitablymeans referral to secondary care.
But I think referring an uglyduckling, I think, is reasonable.
Clearly site matters a little bit, soI'm a little bit more cautious about
the back in men, but that doesn't meanto say I'm not also anxious about other
areas of their skin and the leg in women,but the differences aren't that huge.
But yeah, E, F, and G.
(10:42):
E, for me, stands for elevation.
If you run your hand over the lesion andyou can't feel it, it's completely flat.
It's only got horizontal growth atworst and we measure the prognosis
of a melanoma by how deep it's going.
(11:03):
So if it's completely flat, you've gotplenty of time, you can take a close
up photograph in focus and perhapslook at it again in a few months.
If it's changing, then that matters.
The converse is that if it's raised,you run your hand over it and it's
a bump, you can feel it's raised.
It's already got vertical growthand you therefore must make
(11:27):
a decision about that, today.
You can't afford to say to the patient,let's see if it's doing anything.
It's already potentiallygot vertical growth.
If you're certain it's a benign lesion,and many benign lesions are raised.
That's fine.
You can reassure the patient and relax.
But if you aren't certain it'sbenign and it's raised, then I
(11:48):
think that needs to be cut out.
The second thing is F for firmness.
All tumours are firm.
Yes, some benign things are firm.
Some are even more firm than tumours.
But if it's, the converse is, if it'ssoft and it's wobbly, it is not a tumour.
(12:11):
So if you can sort of wobble itaround, little sort of fleshy,
lumpy, soft, fatty lump or something.
So if it's soft and wobbly,you've got nothing to worry about.
If it's firm and it doesn't give, thenthat could be something to worry about.
And I keep G for growth, i.e.
it's changing, so dynamic features.
(12:32):
So I think new moles, ugly ducklings,and E, F, and G, are the important ones.
I did some work with CRUK some yearsago, they wanted to produce a toolkit for
GPs to help them to diagnose melanoma.
And all the lesions that theywere asking us to use in this
(12:52):
toolkit were nodules, (bumps).
A nodule is a raised lumpy lesion andthey were all ulcerated and bleeding.
Well, yeah, they were obviousmelanomas, but frankly, if you're
going to wait till your melanomasreach that point, it's just too late.
I think that's not clever.
You need to be diagnosingmelanomas well before they become
(13:15):
ulcerated and bleeding nodules.
Another important fact to remember isthat if you're very fair-skinned, with
blonde or ginger hair, blue or greeneyes, that sort of genetic makeup, you're
significantly more likely to develop amelanoma with that sort of skin type.
(13:35):
And indeed, if you've gotmultiple moles as well, then you
have a 25-fold increased risk.
It could be a pink melanoma.
And by pink I mean they really are areal pink, like raspberry or strawberry
blancmange, that sort of pink colour.
But if you've got a firm, pink nodule,in particular if it's changing, in
(13:57):
somebody with Celtic type skin, bejust as alarmed about that as you
would if it was brown or black.
When you've got Celtic skin, you'remaking some eumelanin, this brown/black
melanin I spoke about, but you're alsomaking a pink melanin called pheomelanin.
And so when you get a melanoma, it canbe a melanoma made up of pheomelanin.
(14:21):
Some people call them amelanotic,but A means without, and
they're not without melanin.
They've got pheomelanin, so Icall them pheomelanotic melanomas.
Some people call them hypomelanotic,meaning reduced melanin.
I think that's reasonable.
So hypomelanotic melanomas.
But just be aware of the pink, firmnodule in somebody with fair skin.
(14:42):
Treat it with respect.
Unless you know what it is.
On the foot and the hand, what wecall acral skin, you obviously can get
normal melanomas, pigmented melanomas,and they do behave a bit different
to melanomas elsewhere on the body.
(15:03):
These are the ones that are just as commonin dark skin as they are in light skin.
They've got nothing to dowith ultraviolet light.
They tend to have a bad prognosis, notbecause they're aggressive, they're
actually very nonaggressive, but they'reoften missed for a very long time, and
they present and are diagnosed quite late.
So, those do matter, but theones that frighten me more are
(15:24):
the ones that are not pigmented.
They're often scaly, which is unusualfor a melanoma, and they ulcerate early,
and these are really nasty, aggressiveones, they're called non-lentiginous.
They're very tricky to diagnose,and unless you keep them in
your mind, you will miss them.
(15:46):
So if you've got a nodule or a raisedlesion on the foot, or the hand that
is not healing, scaly, changing andyou don't know for certain that it's
something benign, you must assumethat, that could be one of these
aggressive, difficult melanomas onthe foot, called non-lentiginous.
(16:06):
And they can, they grow veryfast and they are nasty.
I think the final thing to say is thatif somebody comes to you worried about a
mole and you've decided that they are apotential candidate for a melanoma, i.e.
they're a human being, but you'velooked at the lesion they were
concerned about and you reassuredthem that it is actually completely
(16:29):
innocent and you're certain about that.
It doesn't mean that they're notstill a candidate for a skin cancer.
They've presented to you, or you've raisedthe concern because you've seen a lesion,
and you're worried they could have amelanoma, well they could have a melanoma.
And unless you look at theirskin properly, you could miss
that skin cancer that matters.
And one thing that worries me aboutthe way in which the health service
(16:50):
is changing, we're moving into an erawhere we are not referring the patient,
we're referring a picture of the lesion.
Yes.
And specialists are going tolook at that lesion and say,
that lesion doesn't worry me.
But you were sufficiently worriedto send that picture and the
patient hasn't been examined.
So if, in general practice,we're not examining their skin
(17:11):
properly, we'll miss their cancers.
And in Oxfordshire, a few years ago,they did some work and they found that
a fifth of all the cancers that theyneeded to excise from patients who'd come
up to their hospital to be seen with alesion that the GP was worried about, a
fifth of the cancers that were cut outwere not the lesion that we'd sent up.
We've sent patients who are riskypatients, with a benign lesion, but
(17:37):
we hadn't spotted the cancer thatwas in their armpit or under their
pants or between their toe webs.
So I think to do a proper skin checkand sometimes I say to patients,
"look, this needs to be done.
Would you like to come back whenI can put some time aside, I can
get a chaperone if necessary.
And I would like to look betweenyour toe webs, in your natal
cleft, that's between the buttocks.
(17:58):
Maybe in the genital area, look behindyour ears, look in your scalp, in
the hair, and do a proper thoroughskin check to reassure me and you
that you haven't got the cancer therethat we're concerned you could have."
Final thing I'd like to say though,and I can't stress this enough.
I could not give an opinion on alesion, on the skin at all without
(18:26):
using a device called a dermatoscope.
And this is not something thatis taught at medical school.
It's not something that every GP hasaccess to, but I think to try to give
an opinion on a pigmented lesion inparticular without this special device,
which is a very simple device to have.
It takes some learning how torecognise what you're seeing.
(18:48):
It gives so much more information.
But I think to try and do it withouta dermatoscope is a fool's game.
It can utterly transformwhat you're seeing.
Yeah, I think that's one of the topthree pieces of GP kit, in my tool bag.
As you were talking there, I wasjust thinking, I just remembered this
chap who came in with an obviouslybenign lesion on his arm, and he
(19:09):
was really worried about this.
I was very happy to reassure him.
But did what you did, I must have hada bit of time that day and I said,
"well, just slip your top off and letme have a good look at you" you know,
arms, legs, trunk and everything.
And he was a single man.
So, no one was there inhis house to tell him this.
And he turned around and he hadthe mother of all melanomas right
between his shoulder blades.
(19:30):
But he had no idea it was there.
And if I'd sort of just looked at his armsand said, "yes, you're fine, off you go."
You know, he'd have been pushingup daisies, and fortunately
we got it in time, but yes,that's a fantastic statistic.
That 20% of cancers excised weren'tthe lesion that was referred.
That's remarkable.
It's shocking,
isn't it?
Yeah.
Incredible.
(19:50):
I mean, we've covered an enormous amountin a very short time here George, and
really given people food for thought.
So looking at perspective, let'stry and sort of pull this together a
little bit, from all our experience.
What would be your key take home pointsto remember that we might not have
considered previously about melanomas?
Just to really get it lined upin perspective and not worry
(20:15):
unnecessarily, but also just tobear in mind for future reference.
I think that's a great thing to do.
Thank you.
Yeah.
I think at the end of the day, I say,I wouldn't be too worried about this.
I'm not worried about melanoma.
You're 68 times more likelyto die of a heart attack or a
stroke than from any skin cancer.
(20:37):
Right.
Wow.
And ultraviolet light, whilst itdoes increase your risk, definitely,
of squamous cell carcinoma, andthe risk in adults of ultraviolet
light, non-burning ultravioletlight, I think is controversial
as far as melanoma is concerned.
It does significantly reduce yourrisk of heart attacks and strokes.
So here's something that you're 68 timesmore likely to die from and you can go out
(21:00):
in the sun and you can reduce that risk.
So you don't need to reduce that risk bya huge percentage before you can make your
chances of survival massively greater.
And to put it into some context, thereare twice as many deaths from falls
each year than there are from melanoma.
And the modern treatments ofmelanoma are quite revolutionary.
Even metastatic disease where it'sspread, we've now got treatments
(21:22):
that can transform that landscape.
And it got me thinking well, ourancestors, when they moved out of
Central Africa, I think sometime between50,000 and 200,000 years ago, they
had dark black skin, my ancestors.
Why, when they migrated to northernand southern latitudes, where the
ultraviolet light was weaker, didthey evolve to have less black skin?
(21:46):
What was the driving factor to lose darkskin that protects you from this cancer?
Evolution doesn't do something withoutthere being a good reason and the
reason is that sunlight has benefits.
Yes, it has risks, and we need tobe sensible about those risks, and
we need to put them into context.
(22:07):
But I'm much more scared of dyingof a heart attack or a stroke.
When sunlight reduces thatrisk, maybe evolution has
something to do with all that.
The story about sunlight is farmore than just vitamin D, and
vitamin D is far more than justyour calcium, metabolism, and bones.
So, as I've been saying, the riskto your health from non-burning UV
(22:29):
exposure in adulthood is overemphasised.
Yes, it will cause my skin toage more, and I'll look older.
Yes, I'll get these keratotic cancers.
But in an immune competent adult,those are relatively low risk.
And I think that it's only melanomathat behaves badly on the whole.
(22:50):
So I think that we need toget these things in balance.
And then a final figure is that adiagnosis of a non-melanoma skin cancer,
which is usually called a basal cellcarcinoma, which is a very low grade.
Wait for this.
If you have a diagnosis of non-melanomaskin cancer, in a big study from
Germany, looking at 33 millionpopulation, was associated with a three
(23:13):
to four year longer life expectancythan individuals who had not given
themselves a non-melanoma skin cancer.
Okay, a lot of confounding factors there.
They'd more like to present tothe doctor, perhaps have more
holidays abroad and so on.
I think the important message toremember is that aggressive skin
cancers, like melanomas, change.
(23:33):
They grow, they become moreugly, but they start small.
So don't wait for a melanoma toget to six millimetres before
you do something about it.
You can diagnose it when it'ssmall, if you know it's changing.
They become ugly, and by thatI mean they don't look like
their brothers and sisters.
They look different to their other moles.
They're increasing loss of symmetry,increasing number of different colours,
(23:57):
but don't wait for them to become hard,raised nodules which then ulcerate.
That's not good for anyone.
Yeah, so think about the ugly duckling.
That's what we're saying.
Excellently done, George.
That was a fantastic précis.
I've learnt a lot, as I always do inthese podcasts, but that was fantastic.
And I think that's a great place tobring this particular episode to a close.
(24:20):
And as always, thank youso much for listening.
George and I really do appreciate it.
And we do hope you found this particularpodcast interesting and helpful.
So Roger and I hope you'll joinus again, when we'll be discussing
more skin-related conditions.
And we'd like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
(24:41):
We couldn't have done it without them.
So, as always, until the nexttime, it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
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