Red flags in the history

Some historical features are so significant that they should prompt referral regardless of the dermoscopic appearance. These are situations where the clinical story alone justifies action.

Rapid growth

A lesion that has grown noticeably over weeks to months demands assessment. Rapid growth is characteristic of both nodular melanoma and other aggressive lesions. Nodular melanoma, in particular, can appear deceptively bland on dermoscopy — it may lack the classic melanoma features because it has not spread laterally enough to develop them.

Spontaneous bleeding

A lesion that bleeds without trauma — or with minimal trauma that would not cause other lesions to bleed — is concerning. While many benign lesions can bleed if scratched or caught on clothing, spontaneous or easily provoked bleeding in a new or changing lesion raises the threshold for referral.

The lesion that does not heal

A lesion that repeatedly crusts, appears to heal, and then breaks down again is a classic presentation for basal cell carcinoma. This cycling pattern — sometimes described by patients as "a sore that will not heal" — may continue for months before the patient seeks help.

New lesion in a high-risk patient

Any new or changing pigmented lesion in a patient with established risk factors (previous melanoma, familial atypical mole syndrome, significant immunosuppression) should have a low threshold for referral. In these patients, the pre-test probability is already elevated.

The patient's instinct

Do not underestimate the value of a patient saying "something is not right." Patients live with their skin every day. They may notice subtle changes that are difficult to capture in a single examination. A patient who is persistently concerned about a lesion — even after initial reassurance — deserves to have that concern taken seriously.

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