The 9 mm pigmented lesion on the shoulder blade
Daniel, 47, Fitzpatrick type II, books a 'deep cleanse and freckle removal' facial. During consultation he points to a 9 mm pigmented lesion on his right shoulder blade. It is asymmetrical, has an irregular, notched border and contains areas of tan, dark brown and black. He says it has darkened over the past eight weeks and occasionally bleeds when he towels dry after swimming. He has no personal or family history of skin cancer and takes no medication. He is adamant that you 'freeze it or scrub it off' today because he is going on holiday in ten days. The salon has no medical director and your insurance covers cosmetic treatments only. You have a good view under magnifying lamp; the lesion is raised, 9 mm at widest point, and the colour is uneven.
1. Which features in Daniel's presentation meet the criteria for urgent referral, and what is the physiological reason for acting now rather than treating the lesion cosmetically?
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The lesion meets several ABCDE warning signs:
- A – Asymmetry: one half does not mirror the other.
- B – Border: irregular and notched.
- C – Colour: tan, dark brown and black within one lesion.
- D – Diameter: 9 mm, larger than the 6 mm threshold.
- E – Evolution: darkened over eight weeks and bleeds on towel-drying.
Bleeding in a pigmented lesion is particularly concerning because it suggests epidermal breakdown and possible vertical growth. Melanoma arises from melanocytes; the risk of metastasis rises with Breslow thickness, so delay matters. This is outside a beauty therapist's scope: you cannot diagnose melanoma, but you must recognise 'suspicious' features and refer. The correct action is an urgent GP referral, not cryotherapy, curettage, exfoliation or 'freckle removal'. The salon's insurance covers cosmetic treatments only, so treating would be both unsafe and outside indemnity. Document the ABCDE findings factually, avoid the word 'melanoma' in the client record, and use the suspected-cancer referral pathway available in your locality.
2. How would you manage the rest of the appointment and what would you say to Daniel?
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Stop the treatment before any product is applied to the lesion. Sit down, use plain language and avoid alarming him: 'This mark has features I am not trained to treat, and it needs a GP to look at it within two weeks.' Explain that freezing or scrubbing would not remove the concern and could damage the tissue or delay diagnosis. Do not squeeze, massage, exfoliate or apply acids over it. Offer a gentle cleanse of the rest of the face only if he consents, but do not charge for the cancelled 'freckle removal'. Give written information: the GP appointment, sun protection with SPF 50, and advice not to pick or shave over the lesion. Record the exact words he used, the size, site, colours and bleeding history, and note that he was advised to see his GP urgently. Ask him to confirm he has understood; if he declines referral, document that too. Follow your salon's incident/refusal policy and inform the manager.
3. What professional, insurance and record-keeping issues arise?
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You are working at the limit of your role: recognition and referral, not diagnosis. Check your professional indemnity policy; most cosmetic policies exclude medical diagnosis and treatment of lesions, so proceeding would leave you uninsured. Keep a factual record: date, time, site, size, ABCDE description, bleeding, the advice given, the written information supplied and the client's response. Do not write 'melanoma' as a diagnosis; write 'suspicious pigmented lesion-urgent GP referral'. Store the record securely under GDPR and do not share it on social media. If Daniel later returns saying the GP has cleared him, obtain written confirmation before any cosmetic work near the site. Reflect on the case: a magnifying lamp is not a diagnostic tool. Consider CPD on skin cancer recognition and know your local referral route.