Skin 2ww Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.


REFERRAL GUIDELINES FOR SUSPECTED SKIN CANCER (All patients will be seen within 2 weeks of referral)

  • Refer patients with persistent or slowly evolving unresponsive skin conditions with uncertain diagnosis to a dermatologist.
  • If you perform minor surgery you should have received appropriate accredited training in relevant aspects of skin surgery including cryotherapy, curettage, and incisional and excisional biopsy techniques, and should undertake appropriate continuing professional development.
  • Only refer when patient is available to attend an appointment within the next 14 days.


  • All pigmented lesions that are not viewed as suspicious of melanoma but are excised should have a lateral excision margin of 2mm of clinically normal skin and cut to include subcutaneous fat in depth.
  • Send all skin specimens for pathological examination (excisions, curettes, shave excisions).
  • When referring a patient in whom an excised lesion has been diagnosed as malignant, send a copy of the pathology report with the referral correspondence.

Please refer to NICE referral guidelines for suspected cancer


Referral Criteria


  • Change is a key element in diagnosing malignant melanoma. For low-suspicion lesions, undertake careful monitoring for change using the 7-point checklist (see below) for 8 weeks. Make measurements with photographs and a marker scale and/or ruler.
  • Be aware of and use the 7-point weighted checklist for assessment of pigmented skin lesions.
  • Major features of lesions (scoring 2 points each):
    • change in size
    • irregular shape
    • irregular colour
    • change in sensation
  • Minor features of lesions (scoring 1 point each):
    • largest diameter 7 mm or more
    • inflammation
    • oozing/crusting
  • Lesions scoring 3 points or more in the 7-point checklist above are suspicious. If you strongly suspect cancer any one feature is adequate to prompt urgent referral.
  • Refer for a pigmented or non-pigmented skin lesion that suggests nodular melanoma
  • Please detail your suspicion of nodular melanoma
  • Has a dermoscopy suggested melanoma of the skin?
  • Indicate which suspected malignancy the patient is being referred for:
    • Suspected melanoma
    • Suspected squamous cell carcinoma
    • Crusting/non-healing lesion
    • Subcutaneous component
    • Documented expansion
  • Location: Lower leg/ back/ face/ scalp/ back of hand/ ears/ other (please specify)

Urgent 2ww:

  • With a lesion suspected to be melanoma. (Excision in primary care should be avoided).
  • With non-healing keratinizing or crusted tumours larger than 1cm with significant induration on palpitation. They are commonly found on the face, scalp of back of the hand with a documented expansion over 8 weeks.
  • Who have had an organ transplant and develop new or growing cutaneous lesions as squamous cell carcinoma is common with immunosuppression but may be atypical and aggressive.
  • With histological diagnosis of a squamous cell carcinoma.

Non-Urgent Referral

  • Basal cell carcinomas are slow growing, usually without significant expansion over 2 months, and usually occur on the face. If basal cell carcinoma is suspected, refer non-urgently.
  • Only consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with a skin lesion that raises the suspicion of a basal cell carcinoma if there is particular concern that a delay may have a significant impact, because of factors such as lesion site or size.

Referral Instructions

Supporting Information

Assurance & Governance

  • This guidance was developed on: 05.2017
  • This guidance was ratified by: OSCAR Assurance Group
  • Date ratified: 05.2017
  • Publication Date: 05.2017
  • Review Date: 02.2020
  • Ref No: CA9 – 05.2017
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