Malignant skin conditions

Risk factors: UV, AK/Bowen, immunosuppression, lip smoking, chronic ulcers (Marjolin), some genetic syndromes.

Features: Rapidly enlarging, often painless ulcerated nodule on sun-exposed sites; may look cauliflower-like. Better prognosis: well differentiated, under 20 mm diameter, under 2 mm depth. Worse prognosis: poorly differentiated, over 20 mm, over 4 mm deep, or immunosuppression.

Management: Urgent 2WW referral; surgical excision with margin.

AKT pearl: Penile SCC is high yield. Intermittent bleeding plus inguinal nodes, or a non-healing penile ulcer with weight loss and nodes in an older man, points to SCC. A persistent velvety red penile lesion raises PeIN (penile intraepithelial neoplasia).

Red flags: Any suspected SCC needs urgent 2WW.

Features: Classic nodular BCC: pearly papule with telangiectasia on sun-exposed skin; may ulcerate centrally.

Management: Excision, curettage, cryotherapy, Mohs (highest cure for high-risk sites), topical imiquimod or 5-FU in selected cases.

Referral: Usually routine (not 2WW) referral unless diagnostic doubt or aggressive features.

Features: Use the weighted 7-point checklist. Score of 3 or more warrants urgent 2WW referral. Major (2 points each): change in size; irregular shape; irregular colour. Minor (1 point each): diameter 7 mm or more; inflammation; oozing; change in sensation.

Management: Urgent 2WW; complete excision with nodal management as needed in secondary care.

AKT pearl: Memorise the weighted 7-point checklist. AKT stems often hide a score of exactly 3.

Features: Dark purple flat-to-raised lesions on face, limbs, or mouth.

Management: Bloods including HIV; urgent secondary-care MDT referral.

Features: Itchy patches with mixed colours; less uniform than eczema or psoriasis.

Referral: Refer if atypical chronic eczema fails usual treatment or morphology is wrong.