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As life expectancy has prolonged nowadays, interest has increased to change patterns of life, which include improving the consequences of skin ageing through slowing the ageing process. There are two main processes of skin ageing either intrinsic or extrinsic. Intrinsic ageing reflects genetic background in which skin appears thin with exaggerated expression lines. However, extrinsic ageing is caused by external factors such as smoking, excessive use of alcohol, poor nutrition and sun exposure. Extrinsically aged skin appears predominantly not only by wrinkles, but also by pigmented lesions such as freckles, lentigines and patchy hyperpigmentation, and depigmented lesions such as guttate hypomelanosis. Epidermal and dermal atrophy, rough skin texture, flushing, erythema, telangiectasias, dilated pores and loss of tone and elasticity are also other signs of skin aging. Over the past few years, the use of Mesobotox has broadened and it is now commonly used as rejuvenation procedure with different dilutions. Our work aimed to compare between three commonly used dilutions of Mesobotox regarding its efficacy and safety, as this comparison was not done previously. Aim of the study The aim of this work is to evaluate and compare between different dilutions of Mesobotox in mid and / or lower facial rejuvenation. Patients and methods We included 30 patients complaining of facial wrinkles. Patients were divided into three equal groups to study three different dilutions of Mesobotox 1:5, 1:7 and 1:10. Assessment of treatment response was done using 3D Antera camera. Results Assessment of treatment response using Antera camera in 1:5 dilution revealed statistically significant improvement in all the parameters (periorbital and midface) with more evident improvement after 1 month of treatment compared to after 6 months of treatment. With 1:7 dilution and 1:10 dilution, response revealed statistically significant improvement in most of the parameters (periorbital and midface) with more evident improvement after 1 month of treatment compared to after 6 months of treatment.

Summary Full skin examination (FSE) may improve the detection of malignant melanoma (MM). The objective of this study was to assess the safety of targeted lesion examination (TLE) compared with FSE in our Pigmented Lesion Clinic (PLC). Patients attending the PLC were randomized in a 2 : 1 ratio to FSE (intervention) or TLE (standard care). Demographic details and risk factors were documented, and the time taken to perform FSE and TLE was noted. Of 763 participants, 520 were assigned to FSE and 243 were assigned to TLE. On average, FSE took 4.02 min and TLE took 30 s to perform. Of the 520 participants assigned to FSE, 37 (7.1%) had incidental findings, of whom 12 patients (2.3%) had additional lesions biopsied. No additional melanomas were detected that would have been missed by use of the standard protocol. This study suggests that in low‐risk patients referred to a PLC with a lesion of concern, the possibility of missing incidental cutaneous malignancies using lesion‐directed examination is low.

we noted with interest the recent letter by Earnshaw and colleagues documenting decreased skin cancer referrals to their dermatology department and report a similar phenomenon seen in Ireland on a national level1 . An analysis of skin cancer referrals from the National Cancer Control Programme (NCCP) Ireland from January to June in 2019 and 2020 showed that between the months of January to June 2019, there was 2,994 pigmented lesion electronic referrals from primary care. During the same months in 2020, there was 2,507 pigmented lesion electronic referrals, a reduction of 487 referrals. Monthly recordings demonstrate a decrease in referrals since the introduction of the lockdown in March, April and May. During the month of March there was a 47% reduction in referrals from 470 to 252 in 2019 and 2020, respectively. During the month of April, there was a 58% reduction in referrals from 502 to 210 in 2019 and 2020, respectively and a 30% reduction in referrals during the month of May, Figure 1.

Summary Acquired dermal melanocytosis (ADM) is a relatively rare, but well-described disease among adolescent to middle-aged East Asian women, particularly those of Japanese and Chinese descent. Clinically, ADM manifests as multiple punctate and greyish-brown pigmented areas 1–3 mm in diameter occurring on both sides of the forehead and zygomatic region. The subtype of ADM affecting the face and extremities is extremely rare even in East Asian women. We describe three patients with ADM of the face and extremities (ADMFE) and their characteristic clinical features. All patients were Japanese women, and showed multiple greyish-brown pigmentations on both nasal wings and on the extensor surface of the extremities. We found that the clinical features were strikingly uniform, and that a pigmented lesion on the nasal wing can be an important clue to distinguish ADMFE from other hyperpigmented diseases of the hands and feet. One patient was treated with Q-switched ruby laser with excellent outcome. Increased awareness of ADMFE can lead to earlier diagnosis and potential treatment.

Tumoral melanosis describes a pigmented lesion clinically similar to melanoma but on histology reveals dense aggregates of melanin-laden, benign macrophages without malignant cells. In the few reported cases so far, tumoral melanosis has arisen in the skin or lymph node of a patient with a regressed melanoma or an epithelioid tumour. As a marker of regressed primary melanoma, its discovery may prompt investigation and surveillance for undiagnosed local or metastatic disease. Here, we present a unique case of extensive tumoral melanosis arising during ipilimumab treatment of in-transit metastases from a previously excised melanoma.

Summary Background Melanomas vary in growth rate from rapidly developing nodular melanomas to slow-growing melanomas (SGM) that hardly change over years. Objectives To evaluate longitudinal changes in dermoscopic findings of SGM. Methods We retrospectively analysed a dermoscopic image dataset from 15 pigmented lesion clinics, of SGM that were followed sequentially by digital dermoscopy for at least 1 year. We evaluated baseline and follow-up images for changes in global pattern, organization, colours, structure and size. Results Our series consisted of 92 SGM. On follow-up, these melanomas developed the following dermoscopic findings: more homogeneous and less reticular global dermoscopic pattern; more frequent disorganization of pattern (baseline, 67% vs. follow-up, 79%); decreased prominence of light brown colour, increased prominence of dark brown colour, and increased frequency of the colours red, white, grey, blue and black (baseline: 29%, 3%, 18%, 6% and 33% vs. follow-up: 41%, 10%, 31%, 13% and 45%, respectively); decrease in prominence of dermoscopic structure of pigmented network, with a concomitant increase in prominence of structureless areas; and increased prominence or new appearance of melanoma-specific dermoscopic structures, including negative network, blue–white structures and blotches. The majority of lesions (75%) remained the same size or grew by

Summary Background Dermoscopy greatly improves the clinical diagnosis of pigmented lesions. Few studies have investigated, however, how dermoscopy is guiding management decisions in everyday clinical practice. In addition, most studies have been performed in the setting of dermoscopy experts working in pigmented lesion clinics. Objectives To assess the impact of dermoscopy on clinical diagnosis and management decisions for pigmented lesions in everyday practice of general dermatologists. Methods We performed a prospective study in general dermatology clinics in community hospitals run by dermatologists with intermediate dermoscopy experience and expertise. Each clinician independently included suspicious lesions from consecutive patients. Pre- and postdermoscopy diagnoses and management decisions were recorded. Pathology was used as reference diagnosis. Results In total, 209 suspicious lesions were included in the study by 17 dermatologists. Fourteen lesions were histologically proven in situ or invasive malignant melanomas. Based on clinical diagnoses, dermoscopy improved sensitivity from 0·79 to 0·86 (P = 1·0). All 14 melanomas were intended to be excised based on naked eye examination alone, independent of dermoscopic evaluation. Specificity increased from 0·96 to 0·98 (P = 0·22). Dermoscopy resulted in a 9% reduction of the number of excisions. Conclusions Dermoscopy reduced the number of excisions, but did not improve the detection of melanomas. Our results suggest that in everyday clinical practice of general dermatologists the main contribution of dermoscopy is a reduction of unnecessary excisions.

Summary Background Instruments designed to provide computer program-driven diagnosis of dermoscopic images of lesions are now commercially available. Multiple publications tout the improved diagnostic accuracy of these instruments compared with that of clinicians. Objectives Our aim was to evaluate the actual usefulness of these instruments for dermatologists practising in a pigmented lesion clinic. Methods Over a 4-month period we subjected lesions, which were being evaluated in one of our clinics, to automated computer diagnosis performed by three commercially available instruments. We intentionally included three groups of lesions: group 1 lesions were suspicious melanocytic lesions that were scheduled to be excised; group 2 lesions were nonmelanocytic lesions; group 3 lesions were clinically obvious melanomas. The automated diagnoses provided by the instruments were compared with the dermoscopy diagnosis of experienced physicians and with histopathology. Results We included a total of 107 lesions. One imaging system’s computer algorithm was unable to analyse one third of the lesions. All three instruments’ computer algorithms were able to identify the clinically obvious melanomas (group 3) correctly. However, all three systems tended to overdiagnose by incorrectly classifying most seborrhoeic keratoses (group 2) as potential malignant lesions. Concerning the suspect melanocytic lesions (group 1), which are precisely the lesions for which a dermatologist would welcome a second opinion, we found significant variability in the diagnostic accuracy of the instruments tested. However, all three systems providing computer-assisted diagnosis had a tendency to overdiagnose benign melanocytic lesions as potential melanomas. Conclusions Although the image analysis systems tested by us correctly identified the clinically obvious melanomas, they were not able to discriminate between most dysplastic naevi and early malignant melanoma. Thus, for the moment these computer-assisted diagnostic imaging machines provide little to no added benefit for the experienced dermatologist/dermoscopist.

The incidence of cutaneous malignant melanoma has increased considerably in south-east Scotland over recent years. In 1987 the Cancer Research Campaign launched a project to aid the early detection, diagnosis and treatment of malignant melanoma. Edinburgh, chosen as one of seven centres in the U.K. to participate in the study, was provided with funding for a direct access pigmented lesion clinic from 1987 to 1989. The changes in the pattern of cutaneous malignant melanoma before, during and after the publicity campaign have been examined; between 1982 and 1990. The incidence of malignant melanoma doubled from 5.7 to 11.4/100,000 per annum. The percentage of thin tumours (Breslow thicknessor = 1.5 mm) increased steadily and significantly (from 43% in 1982 to 68% in 1990), but the number of thick tumours (Breslow thickness3.0 mm) remained constant over the same period (22 +/- 3.8). The influence of publicity was assessed using a questionnaire. Those who were influenced by publicity were significantly younger and had more thin tumours (Breslowor = 1.5 mm) than those who were uninfluenced by publicity. Five-year survival has significantly increased from 70% in the 1982-84 cohort to 84% in the 1987-89 cohort. The effect of the publicity campaign has been beneficial, but the impact on mortality cannot yet be assessed.

The aim of this study was to audit all malignant melanomas confirmed histologically in the Scarborough Health District over six years, prompted by the continuing rise in incidence rate nationally and relatively high number of malignant melanomas excised by general practitioners (GPs) in this area. A total of 157 malignant melanomas were diagnosed (60% from females and 40% from males) over the six years; primary excisions being carried out by GPs (37%) and hospital specialists (63%). The clinical diagnosis of malignant melanoma was made in 9% of GP cases and 35% of the hospital specialist cases. However another 45.5% of GP cases, and 38% of hospital specialist cases were regarded as suspicious pigmented lesions clinically. The histological diagnosis was of superficial spreading malignant melanoma in 72% of the GP and 69% of the hospital specialist cases. Most of the GP melanomas were excised with a lateral margin of 2 mm or less (71%); around half of the hospital excisions had a margin of over 2 mm (49%). Most melanomas were 2 mm or less in depth (Breslow depth) in both the GP (81%) and hospital specialist (75%) series. Over the six year period (1993–98) the incidence of malignant melanomas has continued to rise, but Breslow depth at diagnosis has not changed significantly. It is therefore important to continue with early recognition of this condition by GPs in the first instance, reduction in its incidence being the long term goal. During five years of the study there were only 67 lesions thought clinically to be malignant melanoma (26 GP and 41 hospital specialist cases), but which proved to be benign histologically.

This prospective controlled study aimed to evaluate the effectiveness and acceptability of a computer program (CAL) designed to educate patients about skin protection including signs of melanoma. Two hundred and twenty-seven patients were recruited either from the Pigmented Lesion Clinic (PLC) or the Orthopaedic Fracture Clinic (OFC). A baseline measure of anxiety was obtained and subjects were allocated to either non-interactive, interactive or control conditions. Measures of anxiety and knowledge about malignant melanoma and skin protection were obtained prior to discharge from the clinic and knowledge was assessed again at 1-week follow-up. Results indicate that, although anxiety in the PLC subjects decreased significantly more than in the OFC patients, there was no significant effect of intervention. There was a significant effect of intervention on knowledge (F = 81.06, d.f. 2, 218, P < 0.0001) with participants having better knowledge on leaving the clinic in the interactive CAL condition than in both the Non-interactive condition and control. Non-interactive CAL was associated with higher knowledge than control. Knowledge gains were maintained at 1-week follow-up.

The demand for pigmented lesion clinics (PLCs) is increasing in view of improved skin cancer awareness following public health education campaigns. These clinics offer an effective way of screening a large number of patients. However, there is no evidence, as yet, that they have an impact on mortality due to malignant melanoma. With the lack of follow-up inherent to these busy screening clinics, there is some concern that melanomas may be missed. This study reports on 7874 patient visits to a PLC in a teaching hospital between 1985 and 1994. In total, 1705 biopsies were performed over the 9-year period. Lesions were more likely to be biopsied in men compared with women. The yield for picking melanomas was one in 36 patient visits. The mean age of patients attending the PLC was 10 years less than the mean age for population-based melanomas. Melanoma thickness did not significantly change over the 9-year period. Only 0.2% of patients (14 cases) re-presented to the PLC for a second or third visit with a final diagnosis of melanoma, but for five of these patients, the interval between the two visits was over 2 years. Most of these 're-attending' melanomas were early lesions. PLCs offer a fast, safe and efficient service for the screening of pigmented lesions but their role in reducing mortality due to malignant melanoma remains to be established. It is likely that these clinics have an important role in terms of public health education regarding sun avoidance and early recognition of skin cancer.

The value of pigmented lesion clinics (PLCs) for the early detection and treatment of malignant melanoma has been questioned. We have examined the effect of the introduction of a PLC on the referral interval between patients with melanoma presenting to their general practitioner (GP) and their attendance at hospital. The case notes of all patients presenting with melanoma in Leicestershire between 1984 and 1994 were reviewed. There was a significant initial reduction in the mean referral interval following the introduction of the PLC from 27.9 days (SEM = 6.6) in 1984 to 11.3 (2.3) days in 1987 (P < 0.01). However, the referral interval gradually rose over the following 7 years to a mean of 20.4 (4.4) days in 1994, which was not significantly better than the 1985/86 level. The increase in the referral interval was due to a greater percentage of melanomas being referred to clinics other than the PLC. Only 48% of melanomas were referred to the PLC in 1994 compared with 70% in 1987. We also reviewed the referral letters for those patients presenting in 1991 and 1994, and decided, on the basis of the content of the letter, whether the GP had suspected the diagnosis of melanoma. More than 50% of the melanomas were correctly diagnosed by the GP, but only half of these were then appropriately referred to the PLC. We believe that PLCs are of value in the early diagnosis and treatment of melanoma, but only if they are appropriately utilized by GPs.

Seventy-nine patients presented to the pigmented lesion clinic between 1983 and 1996 with labial melanotic macules. We have followed up these patients for up to 13 years and 3 months (mean 6 years, 3 months). We present evidence that this is a benign entity. The appropriate management is reassurance and discharge, with the advice to return only if the lesion grows or darkens. This did not occur in any of our patients during the time of their follow-up.

Summary To assess the effect of a pigmented lesion clinic on referral patterns and thickness of melanoma at presentation, we have compared data from the centralized pathology services of the adjacent health authorities of Wandsworth, and Merton and Sutton. Both districts were the subject of a CRC public awareness campaign in 1987, but only Wandsworth is served by a pigmented lesion clinic. All patients presenting with malignant melanoma were included; from 1981 to 1990 for Wandsworth, and from 1984 to 1990 for Merton and Sutton. The Breslow thickness and clinic source of all melanomas was documented. Approximately equal numbers of melanomas were seen in the two districts, with no obvious difference in the numbers of thin (

We report our experience of the initial effects of a publicity campaign directed at early presentation of malignant melanoma in Leicestershire. The campaign resulted in a dramatic increase in workload and, at the pigmented lesion clinic, the numbers of new patients rose from 12.3 to 54.5 per clinic. There was a large rise in the number of new melanomas presenting in Leicestershire: from 1.02 per week before the campaign to 1.88 per week in the immediate post-publicity period. This was statistically significant (P less than 0.001). Although there was also an apparently encouraging rise in the percentage of thinner 'good prognosis' tumours, it was not possible to isolate this statistically from a pre-existing trend.

An 88-year-old woman was admitted with a hugebilateral pulmonary embolism and acute renal failure.On physical examination, a well-defined irregularlypigmented plaque 20 · 40 mm with black, brown andpink hues and an irregular border was noticed over theumbilicus (Fig. 1). A clinical diagnosis of malignantmelanoma (MM) was suggested, and surgical excisionplanned. However, the patient’s prognosis was poor; shewas very dyspnoeic, with oxygen saturation levels of< 75%, despite the treatment for pulmonary embolism,thus we chose to perform a biopsy to confirm thediagnosis, with the intention to proceed to treatmentonce the patient recovered from the embolism.

A selective policy is proposed for the use of frozen section in suspected melanoma which provides maximal help while minimizing false frozen section diagnosis. It is based on the fact that suspected melanomas fall into two broad groups which present different problems in diagnosis and management. A raised lesion is likely to be a highly malignant melanoma or a lesion of non-naevoid cells. Differentiation is readily made on frozen section and allows immediate radical excision. A flat pigmented lesion is usually of obvious naevoid origin, and the problem is whether early malignant change has occurred. It is better managed by urgent paraffin section to avoid sampling error. Frozen section has a place in the management of a single doubtful node in a patient being managed by a “watch” policy.

Patients with ‘thin’ malignant melanoma (I mm thick) have excellent prospects for survival while those with tumours thicker than 3 mm have 5-year survival figures of under 40%. It is logical to assume that the first group receive treatment more rapidly than the latter. Delay in therapy may be due to the patient, the family doctor or the specialist. Of 1300 primary melanomas studied in Scotland from 1979 to 1983, 390 (30%) were < 1–5 mm in thickness. This contrasts with Australia where at present 80% of melanomas are in this thin, good prognosis group. We have conducted a detailed study of 115 Glasgow patients to establish the reason for the low percentage of good prognosis tumours. Records were studied and patients interviewed to establish the reasons for delay. One hundred patients (87%) had delayed for 3 months or longer in seeking treatment for a new or changing pigmented lesion and 38 (33%) had delayed for over a year. In only three patients (26%) was there family doctor delay, and there was no hospital delay. Patient delay was virtually always due to lack of knowledge rather than fear. Following this study, the West of Scotland Pigmented Lesion Education Project has been organized and will be described, as will the methods of measuring its impact.

The prognosis of patients with melanoma can be improved by early diagnosis and excision. In 1981 a ‘Pigmented Lesion Clinic’ was started in Southampton to ensure that all patients who went to their general practitioner with a possible melanoma were seen in the dermatology department within 1 week. Before the clinic started an evening lecture was given to local general practitioners and all were sent a booklet containing colour photographs of the common pigmented skin lesions. During the following 4 years 92 of the 1530 patients seen in this clinic had a malignant melanoma. Sixty-three per cent of the patients with malignant melanoma had skin type 1 or II and 62% blue or green eyes. Nineteen per cent had lived in Asia, Africa or Australia for more than I year. There was no correlation between the length of history as given by the patient and tumour thickness. Nor were bleeding or itching, present in 47% and 35% of patients respectively, factors which speeded up the patients presentation to their general practitioners. The mean thickness of the melanomas from patients attending the ‘Pigmented Lesion Clinic’ was not significantly different to that of the 42 patients with malignant melanomas referred to other specialists in Southampton not offering a rapid referral service—2.7 mm (± 2.3 mm S.D.) and 2.3 mm (± 2.9 mm S.D.) respectively. The results suggest that education of general practitioners without education of the general public did not improve the prognosis of patients with malignant melanoma in spite of easy access to hospital.