• A patient presenting with skin lesions suggestive of skin cancer or in whom a biopsy has been confirmed should be referred to a team specialising in skin cancer (D).
• All primary healthcare professionals should be aware of the 7-point weighted checklist for assessment of pigmented skin lesions (C).
• All primary healthcare professionals who perform minor surgery 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 (D).
• Patients with persistent or slowly evolving unresponsive skin conditions in which the diagnosis is uncertain and cancer is a possibility should be referred to a dermatologist (D).
• All excised skin specimens should be sent for pathological examination (C [DS]).
• On making a referral of a patient in whom an excised lesion has been diagnosed as malignant, a copy of the pathology report should be sent with the referral correspondence, as there may be details (such as tumour thickness, excision margin) that will specifically influence future management (D).

• Change is a key element in diagnosing malignant melanoma. For low-suspicion lesions, careful monitoring for change should be undertaken using the 7-point checklist for 8 weeks. Measurement should be made with photographs and a marker scale and/or ruler (D).
• All primary healthcare professionals should use the weighted 7-point checklist in the assessment of pigmented lesions to determine referral:
• Major features of the lesions:
• Change in size
• Irregular shape
• Irregular colour
• Minor features of the lesions:
• Largest diameter 7 mm or more
• Inflammation
• Oozing
• Change in sensation
• Suspicion is greater for lesions scoring 3 points or more (based on major features scoring 2 points each and minor features scoring 1 point each). However, if there are strong concerns about cancer, any one feature is adequate to prompt urgent referral (C).
• In patients with a lesion suspected to be melanoma, an urgent referral to a dermatologist or other suitable specialist with experience of melanoma diagnosis should be made, and excision in primary care should be avoided (C).

• Squamous cell carcinomas present as keratinizing or crusted tumours that may ulcerate. Non-healing lesions larger than 1 cm with significant induration on palpation, commonly on face, scalp or back of hand with a documented expansion over 8 weeks, may be squamous cell carcinomas and an urgent referral should be made (C).
• Squamous cell carcinomas are common in patients on immunosuppressive treatment, but may be atypical and aggressive. In patients who have had an organ transplant who develop new or growing cutaneous lesions, an urgent referral should be made (C).
• In any patient with histological diagnosis of a squamous cell carcinoma made in primary care, an urgent referral should be made (C).

• Basal cell carcinomas are slow growing, usually without significant expansion over 2 months, and usually occur on the face. Where there is a suspicion that the patient has a basal cell carcinoma, a non-urgent referral should be made (C).

• All pigmented lesions that are not viewed as suspicious of melanoma but are excised should have a lateral excision margin of 2 mm of clinically normal skin and cut to include subcutaneous fat in depth (B [DS]).

The referral timelines used in this guideline are as follows:

• Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary.
• Urgent: the patient is seen within the national target for urgent referrals (currently 2 weeks).
• Non-urgent: all other referrals.