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11/13/24, 7\:09 PM Guide | Pigmented skin lesion exam

Pigmented skin lesion exam

Table of contents

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Explain the need for a chaperone if the skin lesion is located in an intimate area\:
p r e s e n t t h r o u g h o u t t h e e x a m i n a t i o n , a c t i n g a s a c h a p e r o n e , w o u l d t h a t b e o k ?”
Gain consent to proceed with the examination.
Adequately expose the skin lesion and position the patient so that you can clearly visualise it.
Ask the patient if they have any pain before proceeding with the clinical examination.
“ O n e o f t h e w a r d s t a

General inspection

Skin lesions

Note the number, location and distribution of the patient's skin lesions from the end of the bed.
Number of lesions
Lesion assessment typically involves the examination of a single lesion, however, there may be multiple lesions on a patient.
If there is a single lesion, state this. If there are multiple, it is good practice to verbalise you have noticed the surrounding skin
and picked out the relevant lesion for further examination or comment.
" I c a n s e e t h i s p a t i e n t h a s n u m e r o u s p i g m e n t e d l e s i o n s o n t h e i r b a c k , f u r t h e r i n s p e c t i o n .
"
b u t t h e l e s i o n o n t h e m i d-u p p e r b a c k s t a n d s o u t f o r
Location
Make a mental note of exactly where the lesion(s) is/are to describe the/their location accurately when presenting your

person.
Distribution
Note the distribution of the lesion(s)\:
Acral distribution\: distal areas including the hands and feet (e.g. hand, foot and mouth disease)
Central distribution\: over chest and back (photo-protected)
Peripheral distribution\: over arms and legs (more sun-exposed)
Sun-exposed (photo) distribution\: areas of high sun exposure will have a higher incidence of lesions caused by chronic sun
damage (face, ears, nose, arms, lower legs). These areas are more likely to present with worrying pigmented lesions later in
life. Young people are more likely to have new, worrying pigmented lesions in minimally photo-damaged areas.

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
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Medical equipment\: may include bandages/dressings, oral medications and topical medications.
Mobility aids\: items such as wheelchairs and walking aids give an indication of the patient’s current mobility status.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications.

Close inspection

ABCDE of pigmented lesions

When assessing a pigmented (melanocytic) lesion, it is important to assess the risk of the lesions through the ABCDE criteria
and communicate this to the examiner in your summary.
Asymmetry
Asymmetry of a lesion typically refers to networks, patterns, markings, colours or features that are not regularly distributed
through the entire lesion.
An example would be a pepperoni pizza with pepperoni on only one quarter.
Border
Benign lesions typically have a smooth and regular border.
If an irregular border is present (e.g. streaks, wavy edge) this increases the likelihood of malignancy.
Colour
Benign lesions typically demonstrate uniform colour throughout.
The presence of more than 2 colours increases the likelihood of malignancy.
The types of colours too are notable - describe the colours as you see them and keep it simple (e.g. light brown, mid-brown,
dark brown).
Colours within pigmented lesions such as pinks, blues, greys, whites or deep blacks increase the likelihood of malignancy.
Diameter
A lesion with a diameter of 6mm or more increases the likelihood of malignancy.
Evolution
A history of abnormal evolution of the lesion is one of the most concerning risk factors for potential malignancy.
Lesions that are growing quickly and/or changing in appearance over a short time period are highly concerning for
malignancy.
Clues to this may be within the vignette (e.g.
right upper back.
").
"Please examine this patient with a new lesion,
Elevation of a pigmented lesion
Elevation within a pigmented lesion is not a hard sign of malignancy and can confuse matters. Most melanomas are
or macular (i.e. super
Most pigmented lesions are papules or nodules and are usually benign melanocytic naevi (moles).

Lesions which should not be confused with melanoma

When assessing a pigmented lesion, it is always useful to understand if the lesion is truly pigmented (melanocytic) or just
darker/thickened skin.
A common and wholly benign class of lesion that can score highly on the ABCDE criteria are seborrhoeic keratoses (a.k.a
seborrhoeic warts). These have very speci
suspicion for malignancy if absent. These include\:
Stuck-on appearance\: seborrhoeic keratoses look like they have been stuck to the top of the skin. These would be
described as a stuck-on papule, nodule, or plaque.
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Cerebriform pattern\: cerebriform, or brain-like, describes the gyri and sulci of the stuck-on plaque or nodule. It can also be
described as a
Pseudo-comedones\: these are blackhead-like structures within the keratosis. They are not true comedones but resemble
them.
Keratin pearls\: these go hand in hand with pseudo-comedones and are small, pale, round structures that dot a keratosis.
Shiny or wart-like\: seborrhoeic means "greasy
"
. This refers to the smoother, more shiny keratoses. They are exactly the same
underlying pathology as the more wart-like lesions which are dull and have a rough, warty or verruciform structure.
Seborrhoeic keratosis [1]

Types of pigmented lesions

These are the main types of pigmented lesions and their malignant potential\:
Melanocytic naevus ("mole")\: benign - a collection of a high number of melanocytes along the dermo-epidermal junction.
Early lesions are usually
Compound melanocytic naevus\: benign - raised melanocytic naevus which is palpable and soft. Many
raised, compound naevi over time.
Dysplastic naevus\: benign but with histologically concerning features - usually presents clinically with a suspicious naevus
which scores on the ABCDE criteria. Some abnormal melanocytes but in a normal naevus pattern.
Melanoma in situ\: malignant (in situ) - malignant melanocytic cells but none that have crossed the basement membrane.
Super
the basement membrane and are in a horizontal growth phase
Nodular melanoma\: malignant (aggressive) - abnormal and malignant nests of melanocytes with high growth rate, with
vertical growth.
(Solar) Lentigo\: benign - a macular "sunspot"
- higher number of benign melanocytes on a sun-exposed or photo-damaged
area.
Lentigo maligna\: malignant (in situ) - an area of melanoma in situ within a lentigo.
Lentigo maligna melanoma\: malignant - abnormal and malignant nests of melanocytes within a lentigo.

Rare types of malignant melanoma

Acral-lentiginous melanoma\: melanoma of the acral skin (hands and feet). These are di
malignant clinically, so it is best practice to inspect further with a dermatoscope.
Subungual melanoma\: a form of acral-lentiginous melanoma starting at the nail fold or nail bed in the
gives the worrying Hutchinson's sign (pigmented nail starting at the proximal nail fold and extending to the distal nail or
lateral nail fold).
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Amelanotic melanoma\: a di
lesions are aggressive, pink-white in colour and may have been pigmented originally.
Melanocytic naevus ('mole')

Final steps

If you identify a skin lesion that may be malignant you should perform a comprehensive assessment (full skin check) for
other suspicious lesions.

Palpation

Don gloves if there is a risk that the skin lesion is infective and/or is likely to expose you to bodily
Assess the surface characteristics of the lesion\:
Texture\: note if the lesion feels smooth (e.g. benign naevus, seborrhoeic keratosis) or rough (e.g. warty seborrhoeic keratosis
or actinic keratosis).
Elevation\: note if the lesion is
Crust\: if present, assess if you can remove the crust and inspect the underlying tissue (e.g. psoriasis).
Examine the regional lymph nodes if a suspicious lesion is identi
'Wobble sign'
A 'soft' sign of benignity in a lesion, the 'wobble sign' is positive if when viewing the lesion with a
dermatoscope, the lesion is soft and can wobble from side to side. This usually denotes it being a benign intradermal
naevus which is soft and
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Normal mole

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your

Further assessments and investigations

Suggest further assessments and investigations to the examiner\:
Perform relevant examinations of any systems that may be related to dermatological
assessment).
Swabs/skin scrapings of lesions\: for microbiology, virology and fungal culture.
Dermatoscopy of lesions\: to more accurately assess a skin lesion (particularly melanocytic or vascular lesions).
Photography of lesions\: a standard of 3 images to help with care and documentation - locating image (shown on the body
the lesion is), macro image (close-up image), and dermoscopic image with cross-polarised light (to show dermoscopic
features).
Perform a biopsy of the skin lesion\: for histological analysis - a 2mm peripheral margin with a cu
further wide local excision after pathological staging. Never partially excise a concerning melanocytic lesion.

References

Text references

1. British Association of Dermatologists. Handbook for Medical Students and Junior Doctors. Published in 2014.
2. Dermnet New Zealand. Dermatology terminology. Published in 1997. Revised in 2017.
3. NICE Clinical Knowledge Summaries. Melanoma and pigmented lesions. Revised March 2011.

Image references

  1. Делфина. Adapted by Geeky Medics. Seborrhoeic keratosis. Licence\: CC BY-SA.
    https\://app.geekymedics.com/osce-guides/clinical-examination/pigmented-skin-lesion-exam/ 5/611/13/24, 7\:09 PM Guide | Pigmented skin lesion exam
    2. Dermanonymous. Adapted by Geeky medics. Compound naevus. Licence\: CC BY-SA 4.0
    3. Dermanonymous. Adapted by Geeky medics. Melanoma in situ. Licence\: CC BY-SA 4.0
    4. Juliana Casagrande Tavoloni Braga, Mariana Petaccia Macedo, Clovis Pinto, João Duprat, MariaDirlei Begnami, Giovanni
    Pellacani, Gisele Gargantini Rezze. SuperCC BY 4.0
    5. 0x6adb015. Adapted by Geeky Medics. Nodular melanoma. Licence\: CC BY-SA 4.0
    6. Kilbad. Adapted by Geeky Medics. Lentigo maligna. Licence\: CC BY 3.0
    7. Omar Bari, Philip R. Cohen. Adapted by Geeky Medics. Lentigo maligna melanoma. Licence\: CC BY 3.0
    8. Xavier-Júnior, José & Munhoz, Tania & Souza, Vinicius & Campos, Eloísa & Stolf, Hamilton & Marques, Mariângela. Adapted by
    Geeky Medics. Acral lentiginous melanoma. Licence\: CC BY 4.0
    9. Future FamDoc. Adapted by Geeky Medics. Actinic keratosis. Licence\: CC BY-SA.
    10. Jmarchn. Adapted by Geeky Medics. Keratocanthoma. Licence\: CC BY-SA.
    11. Svdmolen. Adapted by Geeky Medics. Scar. Licence\: CC BY-SA.
    12 Htirgan Adapted by Geeky Medics Keloid scar Licence\: CC BY SA
    Source\: geekymedics.com
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