A skin examination that stops at the lesion the patient pointed to is not a skin examination

The lesion a patient brings is the one they can see. The melanomas that are missed sit where they cannot: the scalp under hair, behind the ears, between the toes, the soles, the nail beds, the buttocks and the perineum. In Indian and other darker-skinned populations acral and subungual melanoma make up a far larger share of cases than in white populations, which makes the soles and nails the highest-yield part of the examination rather than an optional extra.

So undress the patient properly, use the same light and the same sequence every time, and part the hair. A longitudinal pigmented band in a nail deserves attention to where it starts: pigment extending onto the proximal nail fold is the sign that matters, and a single digit affected in an adult is different from several.

Count naevi while you are there and write the number down. A naevus count changes what the next appointment is for, and it cannot be reconstructed later from a note that says the skin was examined.

• Examine scalp, behind the ears, web spaces, soles, nails, buttocks and perineum at every full skin check
• Treat soles and nails as high-yield in patients with darker skin, where acral and subungual melanoma are proportionally commoner
• For a pigmented nail band, look for pigment extending onto the proximal nail fold and note whether one or several digits are involved
• Record an actual naevus count rather than an impression — it sets the surveillance interval
• Use the same sequence and the same lighting each time so that change between visits is real change

Why it matters

The lesion that presents and the lesion that kills are usually not the same lesion.

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