The Warning Signs

For many consumers, a trip to an aesthetic clinic or beautician is designed to be a relaxing, pampering or eyen life-changing experience. It may also be the first time a professional has examined the state of their skin.

As a result, it is important that everyone working in the beauty and aesthetic sector takes their role seriously and knows what they are looking at. In particular, we need to be able to recognise something considerably more serious than acne or blackheads. If necessary, we can then stop treatment and warn the patient. Continuing treatments - particularly laser procedures - on potentially cancerous skin lesions can worsen the problem. I now see more patients with laser-developed melanomas.

Facial pigmented lesions, whether small or large, can cause a significant degree of anxiety for members of the public. The impact of such lesions is broadly grouped into whether the lesion could be potentially harmful or if it is just a cosmetic nuisance. The person perception of the lesion will determine the path they will take for treatment. If it is thought to be suspicious, they will seek medical attention. But if it is just perceived to be a cosmetic concern hey may consider an aesthetic solution instead. So as it is common to see benign pigmented skin lesions in the skin cancer clinic, it is not unusual for skin cancer to present to aesthetic practitioners.

Diagnosing facial pigmented lesions is fraught with difficulty for both non-skin experts and the general public. Providing skin cancers are diagnosed before aesthetic treatment is commenced, they can be re-routed to skin cancer experts and avoiding mistreatment. But this may not be as easy as it sounds.

Culprits

The two main culprits in this diagnostic conspiracy are the lowly seborrhoeic keratosis and the more infamous melanocytic proliferation, melanoma. These pigmented skin lesions can look almost identical clinically but the ramifications of misdiagnosis can be devastating. So how can we increase confidence in diagnosis?

Firstly, we must take the time to discuss risk factors for skin cancer with the individual. People with risk factors for skin cancer include those with fair skin with a history of high UV exposure. In these individuals, any new pigmented facial lesion should be scrutinised and melanoma - or its precursor lentigo maligna -should be considered and excluded before any treatment is offered.A number of simple features can help differentiate between these two diagnoses. There is usually safety in numbers - if there are other lesions that look similar to the lesion in question, then the biological process generating the lesion is likely to be benign. If solitary, consider whether it is occurring on a sun exposed site.

Secondly, the skin lesion must be inspected closely. There is no substitute to detailed clinical scrutiny of  pigmented lesions using good illumination and magnification. This can usually be achieved with the bright examination lamps typically present in all clinical or aesthetic settings.

However, there are times when examining the skin surface is not enough. Seborrhoiec keratoses, and their precursor lesion solar lentigos, typically fulfil all the standard criteria for a suspicious pigmented lesion such as changes in asymmetry, border, colour and diameter (ABCD). So changes in ABCD should raise suspicion but are not diagnostic. Microscopic examination will help to distinguish between these lesions, but it is impractical and unacceptable for all lesions. However, there is an easy solution - dermoscopy.

Dermoscopy

Dermoscopy is a diagnostic technique allowing for quick and easy visualisation of specific structures within skin lesions, increasing confidence in diagnosis. This is achieved using handheld dermatoscopes which combine x10 magnification with LED lighting to allow visualisation of structures in the skin as deep as the papillary dermis. As digital imaging and technology have improved, this technique has increased in popularity. Now these devices are the standard of care for skin examination by skin specialists in over a hundred countries worldwide.

Dermoscopy aids in the diagnosis of facial pigmented lesions by helping to identify specific structures to confirm whether a lesion is melanocytic - including features specific for melanoma - or if it is a non-melanocytic lesion such as a seborrhoeic keratosis. Features specific to seborrhoeic keratosis are quick to identify and are easily recognisable.

Integrating dermoscopy into aesthetic practice can help reduce the potential for misdiagnosis and mismanagement. As an example, a 50 year old man had aesthetic treatment six years ago with a laser to remove a new pigmented macule on his right cheek (see 'Melanoma following laser treatment').  Over the last 12 months, the lesion enlarged with the development of  melanoma, confirmed on excision biopsy.

Could this have been avoided? The exact circumstances of the initial consultation cannot be known. But the lack of a documented clinical diagnosis prior to treatment allowed for a probable lentigo maligna or an in situ melanoma to be mistreated. In this instance, dermoscopy may have helped to identify this as an early melanoma.

So what should we do when a patient presents with a skin lesion that gives cause for concern? It should go without saying that uttering the phrase "that looks like it could be cancerous" is not going to be helpful.

Firstly, stop the treatment to prevent any further damage. Explain to the patient that they have a mark on their skin that warrants further checks and which prevents you, as an aesthetic professional, from continuing with treatment.

Suggest the patient either goes to their GP or to a reputable skin cancer clinic. They should not visit a high street mole clinic as they are only likely to be seen by a nurse or medical photographer.

The Cadogan Clinic offers same-day skin cancer testing, thanks to an on-site laboratory allowing the patient's skin lesion to be seen by a consultant dermatologist, biopsied, tested and the results returned within one working day.

This  considerably reduces stress and worry to the patient. They may even begin any necessary treatment before they leave the clinic. Next time you’re looking at someone skin, remember the ABCD rule and bear in mind that your vigilance could save someone's life.

Dr Jonathan Bowling is a consultant dermatologist and shin cancer expert based at London Cadogan Clinic.
T: 020 7901 8500
W: www.cadoganclinic.com

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