Expert opinion - The role of GP dermoscopy in melanoma

GPs have a key role in the timely diagnosis of melanoma, but more training is needed. By Dr Stephen Hayes

Following the recent publication of two reviews on melanoma,1,2 I wrote some notes on them for the Primary Care Dermatology Society Bulletin and a letter to the BMJ calling for better lesion recognition training and wider access to dermoscopy.3

The reviews say that melanoma incidence is rising and early excision (which depends on early diagnosis) is still the only cure. This article discusses the NICE guidance on skin cancer, melanoma and the role of GP dermoscopy as an aid to lesion recognition. The place of dermoscopy is under debate and as yet, there have been no UK primary care trials. However, there is evidence that dermoscopy works in trained hands.

Melanoma incidence and mortality
The incidence of malignant melanoma continues to rise, with 9,583 cases and 1,852 fatalities reported in 2005.4 The role of the GP is to diagnose and promptly refer. To this I would add opportunistic education, especially of mothers with red-haired children in view of their much higher risk from sun damage.

The NICE skin cancer guidance is clear that all suspected melanomas (and squamous cell cancers) should be referred to secondary care by 14-day faxed referral. As an aside on the guidance, some GPs are unhappy to be barred from all skin cancer work, but the guidance is being implemented and those who continue to excise or curette basal cell carcinomas (BCCs) may be hearing from clinical governance before long.

Where there is a good local case for a suitably skilled GP to do this work, the Primary Care Dermatology Society is contending that the accreditation rules should be applied with flexibility, but the days of any GP treating skin cancer at will are over.

NICE guidance
Although GPs may not treat skin cancer unless approved, the hospital service cannot manage if we over-refer. The GP is the first point of contact for most patients and there is a lot for GPs to do. The NICE guidance runs to 173 pages, much of which concerns secondary and tertiary care, but our role can be summed up as follows.

Lesions on trunk and limbs 1cm or less in diameter are low-risk BCCs. Large, recurrent, poorly defined and head and neck lesions are high risk, as are those in immune-suppressed patients (for example, transplantees on ciclosporin or azathioprine). There is a debate about whether experienced and audited GPSIs may treat small, well-defined head and neck BCCs which are well clear of critical anatomy. It should be noted that there is a potential conflict between choice (Choose and Book) and the guidance. The guidance presumably takes precedence, at least until the next reorganisation.

GP referral
Owing to limited dermatology training, GPs' lesion recognition skills are variable. This may cause over-referral, or delayed referral of a dangerous lesion, which is much worse. The Primary Care Dermatology Society hears of cash-strapped PCTs asking GPs to refer less, but the decision not to refer a pigmented lesion calls for good lesion recognition skills. Some PCTs are expressing interest in community-based dermoscopic screening of pigmented lesions to reduce referrals. This could help, but investment in training and equipment is required and no GP should be pressured to cut corners on safety; falsely reassuring a melanoma patient could prove fatal.

The role of dermoscopy
Dermoscopy allows a deeper view of skin lesions and can improve the trained user's ability to reassure patients about the many benign pigmented lesions that present. These patients need not then be referred. This saves money and eases pressure on busy clinics, but there is also a saving in patients' anxiety.

So is dermoscopy a quick fix for a rising melanoma rate and busy hospital clinics? Certainly not quick, because training is required and there will always be patients who, for whatever reason, present late. But I never hold a hospital clinic without seeing patients with obviously benign lesions.

These are usually haemangiomas, seborrhoeic warts, dermatofibromas and benign moles. It is disappointing to see dermatofibromas, because they have such a typical hardness, like a dried pea under the skin, which dimples when pinched between the examining finger and thumb, but then again, they often show irregular pigmentation, which can cause concern. The other lesions are readily identified with a modest level of dermoscopy skills.

There is still no recognised standard for dermoscopy training (see box 1), too few courses and scepticism in some quarters. I taught myself by attending a seminar, reading, applying the dermoscope to lesions and attending courses when I could. I honed my skills working with senior doctors in a hospital clinic and am still on a learning curve, but it took little time to learn to use the dermoscope well enough to recognise the typical signs of warts and haemangiomas. These cases could readily and safely be kept out of hospital clinics, with benefits to all, not least the urgently referred patient who fears a melanoma.

BOX 1: TRAINING AND RESOURCES

Dermoscopy courses and web resources
www.dermoscopic.blogspot.com
www.dermoscopic.blogspot.com
www.dermoscopy-ids.org
www.pcds.org.uk

Further reading
Johr RH, Soyer P, Argenziano G, Hofman-Wellenhof R. Dermoscopy: The Essentials. London, Mosby, 2004
Menzies Scott W, Crotty KA, Ingwar C et al. An Atlas of Surface Microscopy of Pigmented Lesions: dermoscopy (second edition) London, McGraw-Hill Medical, 2003

- Dr Stephen Hayes is a trustee and committee member of the Primary Care Dermatology Society and a dermatology GPSI and hospital practitioner in Southampton.

REFERENCES
1. Bataille V, de Vries E. Melanoma - part 1: epidemiology, risk factors, and prevention. BMJ 2008; 337: a2249.
2. Thirlwell C, Nathan P. Melanoma - part 2: management. BMJ 2008; 337: a2488.
3. Hayes SF. Early detection of melanoma is key, so let's teach it. BMJ 2009; 338: a3138.
4. Cancer Research UK. CancerStats Key Facts on Skin Cancer

Want news like this straight to your inbox?
Sign up for our bulletins

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register
Already registered?
Sign in

Register or Subscribe to MIMS

GPs can get MIMS print & online and GPonline for free when they register online – take 2 minutes, and make sure you get your free MIMS access! If you're not a GP, you can subscribe to MIMS for full access.

Register or subscribe

MIMS Dermatology

Read the latest issue online exclusively on MIMS Learning.

Read MIMS Dermatology

MIMS Adviser

Especially created for prescribing influencers.

Request free copy

Mobile apps

MIMS: access the full drug database and quick-reference tables on the go

MIMS Diagnosis and Management: concise information on signs and symptoms, investigations and diseases