Approach to Skin Cancer: Types, Clues, and Clinical Management For PLAB 2

Ann Augustin
Apr 10
4 min read

Updated: Apr 30

🌞 Introduction

Skin cancer is the most common cancer in the UK, and understanding its approach is crucial for both general practice and PLAB 2 candidates.While early lesions can appear subtle, prompt recognition and referral can save lives.

This article covers:

How to approach a suspicious skin lesion
The main types of skin cancer
Their clinical features, risk factors, and signs of metastasis
Key differentiating points, investigations, and treatment options

🔍 Step-by-Step Clinical Approach

1. History Taking

Begin with a structured exploration:

Onset & Duration: When first noticed? Has it changed recently?
Progression: Increase in size, change in colour, bleeding, or ulceration?
Symptoms: Pain, itch, bleeding, discharge, non-healing?
Sun Exposure: Outdoor work, holidays, tanning bed use, sunburns.
Past & Family History: Previous skin cancers or precancerous lesions.
Immunosuppression: Organ transplant, steroids, HIV.

🗣️ Always ask about patient’s ideas and concerns — most worry it might be “skin cancer” or “melanoma.”

☀️ 2. Major Types of Skin Cancer

Type	Common Site	Typical Appearance	Growth & Spread	Risk of Metastasis
Basal Cell Carcinoma (BCC)	Face, neck, upper trunk	Pearly or waxy papule with rolled edges and central ulcer (“rodent ulcer”)	Slow growing	Very low
Squamous Cell Carcinoma (SCC)	Sun-exposed areas – scalp, ears, hands, lower lip	Crusted, ulcerated, firm nodule; may bleed or be tender	Faster than BCC	Moderate (esp. on lips, ears, scars)
Malignant Melanoma	Anywhere (esp. legs in women, back in men)	Irregular pigmented lesion following ABCDE rule	Variable; can grow rapidly	High
Actinic (Solar) Keratosis	Forehead, nose, scalp	Rough, scaly patch, feels like sandpaper	Pre-malignant	Small risk of progression to SCC

🧬 3. Risk Factors

🌞 Environmental

Chronic UV exposure
Sunburns (especially childhood)
Use of tanning beds

🧑‍⚕️ Personal / Genetic

Fair skin, light hair, light eyes
Freckles or multiple moles (>50)
Family history of skin cancer
Immunosuppression (transplant, chemotherapy, HIV)
Previous radiotherapy or chronic wounds/scars

🧩 4. Distinguishing Clinical Features

🔹 Basal Cell Carcinoma (BCC)

Pearly or translucent nodule, sometimes pigmented
Telangiectasia visible on surface
May ulcerate and bleed (“rodent ulcer”)
Never metastasises, but locally destructive
Slow growth, commonest skin cancer

🔹 Squamous Cell Carcinoma (SCC)

Keratinised, crusted, firm lesion on sun-exposed area
Ulcerated centre with indurated edges
Painful or tender, may bleed or discharge
May arise from actinic keratosis or old scars (Marjolin ulcer)
Regional lymphadenopathy may suggest metastasis

🔹 Malignant Melanoma

Use the ABCDE rule:

Feature	Description
A – Asymmetry	Uneven shape or colour
B – Border	Irregular, scalloped or poorly defined
C – Colour	Variation – black, brown, red, blue, or white
D – Diameter	>6 mm or increasing in size
E – Evolution	Any change over time (size, colour, symptoms)

Additional signs:

Itching, bleeding, or non-healing mole
Satellite lesions nearby
May metastasise early to lymph nodes, lung, brain, liver

🩸 5. Associated Symptoms and Signs of Metastasis

System	Symptoms / Signs
Lymphatic	Enlarged, firm, non-tender regional nodes
Respiratory	Cough, dyspnoea (lung spread)
Hepatic	Weight loss, hepatomegaly
Neurological	Headache, seizures (brain spread)
Constitutional	Fatigue, night sweats, weight loss

🧫 6. Investigations

Step	Investigation	Purpose
Initial	Full skin examination under good lighting	Identify number, size, colour, border, and secondary lesions
Definitive	Biopsy (Excisional preferred)	Histological diagnosis
If malignancy confirmed	Lymph node examination/ultrasound

CT or MRI (if high-risk or advanced disease) | Staging and metastasis check || Adjuncts | - Dermoscopy (for pattern analysis)
Blood tests (if systemic symptoms) | Supportive |

🧠 Never perform a shave biopsy for suspected melanoma — complete excision with margin is preferred.

🩹 7. Management Principles

1️⃣ Basal Cell Carcinoma

Excision with margin (4–5 mm)
Curettage, cryotherapy, or photodynamic therapy (for small lesions)
Mohs micrographic surgery for recurrent or facial lesions
Topical imiquimod or 5-FU for superficial types

2️⃣ Squamous Cell Carcinoma

Wide local excision (≥6 mm margins)
Radiotherapy if surgery not feasible
Lymph node dissection if regional metastasis
Systemic therapy (rare, for advanced/metastatic cases)

3️⃣ Malignant Melanoma

Wide local excision (1–2 cm margin) depending on Breslow thickness
Sentinel lymph node biopsy for staging
Adjuvant therapy: Immunotherapy (e.g., nivolumab, pembrolizumab), targeted BRAF/MEK inhibitors
Follow-up: Regular full-body skin checks

🧠 8. Key Differentiating Table

Feature	BCC	SCC	Melanoma
Growth	Slow	Moderate	Rapid
Pain	Rare	Sometimes tender	Often painless
Ulceration	Common	Common	Sometimes
Colour	Pearly / skin-coloured	Red / crusted	Brown / black / variable
Sun exposure	Strongly associated	Strongly associated	Associated
Metastasis	Very rare	Possible	Common
Treatment	Local excision	Wide excision	Excision + staging ± systemic therapy

🛡️ 9. Prevention & Patient Education

Avoid direct midday sun exposure (11 am–3 pm)
Use SPF 30+ sunscreen, reapply every 2 hours
Wear hats and protective clothing outdoors
Avoid tanning beds
Self-examine moles monthly; seek medical advice for any change

“Slip, Slop, Slap” — Slip on clothing, Slop on sunscreen, Slap on a hat.

🧾 10. Summary for PLAB 2

When faced with a “suspicious skin lesion” case:

Gather detailed history (duration, change, risk factors).
Perform focused examination (site, size, colour, borders, ulceration, nodes).
Discuss urgent dermatology referral (2-week wait).
Offer reassurance and education on sun protection.
Explain that biopsy is essential for diagnosis.

💬 Key Takeaway

Early recognition and referral save lives.Most skin cancers are curable if detected early — but delay in diagnosis increases the risk of metastasis, disfigurement, and mortality.