Skin lesions, hair loss and nail abnormalities

Recognise a concerning lesion

Ask about duration, evolution, bleeding, itching, prior cancer, immunosuppression and family history. Examine the entire lesion and relevant surrounding skin, with dermoscopy when trained. Asymmetry, irregular borders, varied colour and evolution can suggest melanoma, but small diameter or lack of pigment does not exclude it. A growing firm nodule, non-healing ulcer or an “ugly duckling” that differs from nearby lesions deserves assessment. Acral melanoma occurs on palms, soles and nail units and can be missed if screening is limited to sun-exposed skin.

A suspicious pigmented lesion generally needs complete excision biopsy with a narrow margin when feasible, preserving accurate assessment of depth. Difficult anatomical sites or large lesions may need a specialist-planned alternative. Do not destroy a suspicious lesion with cryotherapy or superficial treatment before diagnosis. Provide pathology with the clinical concern and ensure the result is acted on. A benign partial sample may not explain a clinically discordant remaining lesion; revisit or refer rather than treating the report as infallible.

Common benign and keratinocyte lesions

Seborrhoeic keratoses, naevi and dermatofibromas are often benign, but a clinical label requires a compatible appearance and course. Basal-cell cancer can appear as a pearly lesion, ulcer or subtle plaque; squamous-cell cancer may be a growing keratotic or ulcerated lesion. Site, size, differentiation, immune status and perineural symptoms influence referral and treatment. Actinic keratoses mark UV damage and can need field or lesion treatment, while a thick, tender or rapidly growing lesion merits investigation for invasive disease. One appearance cannot dictate every management choice.

Discuss sun protection and self-awareness without promising that sunscreen eliminates cancer risk. Review follow-up based on individual risk, including immunosuppression and prior melanoma. A population mass-screening recommendation is distinct from surveillance of a high-risk patient or investigation of a new symptom. Explain the plan in terms of what change should trigger review. Ensure pathology follow-up has a responsible clinician, including when a patient moves or a locum performed the biopsy; “no news” must not be treated as proof of a benign result.

Patterned, patchy and diffuse hair loss

Distinguish scarring from non-scarring loss, and patterned, patchy or diffuse distribution. Ask about postpartum change, recent illness, weight loss, medicines, nutrition, traction and family history. Telogen effluvium may follow a physiological stress with delayed diffuse shedding. Alopecia areata can cause smooth patches, whereas scale, broken hairs or inflammation raises fungal or other scalp disease. Loss of follicular openings, scarring, pain or progressive inflammation requires specialist assessment because permanent loss may occur. Check thyroid/iron or other tests when the history suggests them; indiscriminate panels are not routine for every patterned loss.

Androgenetic hair loss has a characteristic distribution and can be managed with suitable therapies after discussing realistic time to benefit, side effects and pregnancy considerations. Excess hair with menstrual irregularity suggests endocrine assessment, while rapid virilisation raises a tumour and needs prompt investigation. Do not infer PCOS from hair changes alone. Hair loss can substantially affect identity and mental health; explore distress respectfully. Cultural hairstyle practices and traction should be discussed without stereotyping or assigning blame.

Nail assessment

Examine all nails, skin and joints. Thickened dystrophic nails can reflect fungus, psoriasis, trauma or other disease; obtain appropriate mycological confirmation before a prolonged systemic antifungal course when indicated. Review liver disease and interactions for systemic treatment. Pitting or onycholysis may accompany psoriasis, while acute painful swelling at a nail fold may need drainage or antimicrobial assessment. Chronic paronychia often involves irritant exposure; addressing moisture and inflammation differs from repeatedly prescribing antibiotics.

A new widening irregular pigmented band, pigmentation extending onto surrounding skin, nail destruction or a persistent unexplained single-nail lesion raises nail-unit melanoma. Trauma history does not reliably exclude cancer. Subungual blood should migrate with nail growth, but observation must have a defined review interval and escalation plan. Nail-unit biopsy can cause permanent damage and should be planned by an experienced service. Clubbing can point to pulmonary, cardiac, GI or other disease; it is a sign requiring context rather than a diagnosis of lung cancer by itself.

Applied follow-up

A growing pink nodule can be melanoma despite lacking brown pigment. A person with a widening thumb band and periungual pigment needs specialist assessment rather than antifungal treatment based solely on discolouration. A postpartum patient with diffuse shedding and a normal non-scarring scalp can receive explanation and targeted assessment, with review if persistent or atypical. A scarred inflamed scalp needs earlier referral. Match urgency to the disease pattern and the risk of irreversible harm.

Document size, site, morphology, evolution and the agreed review responsibility. Use consented clinical images for comparison through secure systems. Explain pathology findings and next steps promptly, including any uncertainty. After cancer diagnosis, provide a supportive discussion, appropriate staging/referral and practical support rather than simply naming the result over an unplanned message.

RACGP skin biopsy principles, RACGP hair and nails and nail-unit melanoma.

Review checkpoints

• Change in a pigmented lesion requires assessment for melanoma.
• A suspicious pigmented lesion should not be destroyed before diagnosis.
• Patchy scarring hair loss needs early evaluation to prevent permanent loss.