Pigmented skin lesions

This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

A 74 year old white man with fair skin that burns and tans easily has a pigmented lesion on the upper back that his partner noticed three months ago. It is slowly enlarging. The man is retired from office work. He grew up in Africa, and historically enjoyed a lot of outdoor activities. He has no family history of melanoma. Examining the entirety of the back, the lesion stands out compared with his other lesions, most of which appear as stuck on, and have macroscopic crumbly keratotic cerebriform surfaces. The lesion in question has no associated tenderness or induration. It is raised with an irregular border and asymmetry of colour.

Dermatological presentations account for about a quarter of primary care consultations in the UK,1 with concerns about pigmented lesions and skin cancer comprising a large proportion. As a result, specialist dermatology services in the UK receive more than one million new referrals each year, about 50% of which relate to pigmented skin lesions2 (box 1). About 6% of patients with a pigmented skin lesion are diagnosed subsequently with melanoma or squamous cell carcinoma via urgent skin cancer referral pathways.6