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This article is for informational purposes, represents the views of its authors and does not replace professional medical advice.

The most dangerous and aggressive skin cancer, malignant melanoma, can have a wide variety of appearances and usually develops rapidly. The ABCDE rule (also known as the ABCD rule in some countries) has therefore been promoted to help lay people recognize when it is time to see a dermatologist. But how effective is this rule? Our data clearly shows that another self-monitoring protocol has a superior sensitivity and better outcomes than the outdated ABCDE rule.

Authors: Dr. Tudor, Adrian; Dr. Feldman, Jonathan; Dr. Diamandis, Carolina – Full research report available here: https://zenodo.org/record/5731554

Status Today

The standard care in the G20 countries has been running for years according to the same scheme: the patient is screened by a dermatologist at certain intervals, usually once a year, and the rest of the time the ABCDE rule2 (regionally slightly different in the interpretation)8 should be used by the patients to detect skin cancer by means of self-observation.

Dermatologists tend to use the dermatoscope rather than the scalpel, just as if an excisional biopsy were a major surgical event, which of course it is not. Instead endless follow-up checks and an absurdly complex system of self-monitoring is imposed on complete laymen:2,3,4,9

The ABCDE rule

A for asymmetry

New skin protocol

Uneven, asymmetrical shape. This means a structure that is not uniformly round, oval or elongated.

B for border:

The margins appear washed out, jagged or uneven and rough. Or a colored skin mark has tongue-like extensions and indentations, blurred contours or grows frayed into the healthy skin area.

C for color

The skin mark is irregular and inconsistently colored, sometimes ranging from jet black to skin colored. Lighter and darker patches can be seen in a mark. The color of the skin mark mixes with pink, gray, blue, or black dots, or it has a crusty overlay.

D for diameter:

Uneven, asymmetrical shape. This means a structure that is not uniformly round, oval or elongated.

The margins appear washed out, jagged or uneven and rough. Or a colored skin mark has tongue-like extensions and indentations, blurred contours or grows frayed into the healthy skin area.

E for elevation or evolution

If the lesion measures more than five millimeters at its widest point, this is considered critical. However, the exact size specifications differ in the scientific literature. Some propose to replace “diameter” with “dark color”8 which is hard to understand why when color is already included and people with light skin are the minority on this planet. In about 80% of the world population normal nevi are black. Therefore the proposal by Goldsmith and Solomon8 would, if at all, only help caucasian patients. Some might considers this racist, inappropriate and not helpful.

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Many medical professionals believe that this complex list can be used by laymen while many physician themselves struggle with it.5 However, the main problem is: countless types of benign skin lesions also exhibit some of these features, in fact almost all lesions have at least one of the “ABCDE” aspects and are thus considered to require diagnostic workup (dermatoscopy or biopsy). On the other hand, many melanomas appear visually like a harmless nevus, bruise, or sore, especially if they develop from an existing nevus or are localized in a difficult-to-see location. This raises the question of how helpful the ABCDE rule is when even many general practitioners have no clue how to use it.5,7

Starting point for us was the subjective impression that two aspects are highly problematic in dermatological daily routine in practices and clinics and yet continue to be applied worldwide:

1)

Regular screening without education about the highly aggressive and fast-growing nature of particularly dangerous skin cancers creates a false sense of security among patients (“illusion of interval safeness”). Vigilance appears to drop dramatically due to this illusory sense of security, as the normal patient associates screening with a reduction in their risk of developing skin cancer, especially melanoma. This is an implicit misleading of all medical laymen, as melanomas can arise de novo at any time and develop rapidly. If studies and practical experience are taken together, patients should actually be informed that a precautionary interval screening is well suited to the early detection of certain types of skin carcinomas, but that this is by no means the case for the classic and rightly feared malignant melanoma, which develops at a very rapid pace. In relation to this most dangerous skin cancer, the annual or otherwise timed interval screening by a dermatologist is mostly useless.3,7,9

2)

The ABCD(E)8 rule in all its regional variants flushes the wrong people into practices and clinics. The rule seems far too complicated and misleading for laymen.3 People over the age of 50, especially those with advanced seborrheic keratoses, fill the waiting rooms because this invariably benign (harmless) entity usually violates almost every letter of the ABCD(E) rule. In contrast, all those whose small, round, sharply marked melanoma “only” bleeds briefly in between stay at home. “Can happen”, the layman thinks, because in fact millions of people every day injure some skin lesion when removing body hair.

Therefore, we were grateful that a befriended research team from Spain provided us with anonymized data from a study that could not be completed there due to a stop in funding.3,5

The details of the study (data and results) can be referred to in the full paper: (No paywall): https://zenodo.org/record/5731554

Discussion

In research, it is rare that study results are so unambiguous. We immediately drew consequences for the management of our patients and introduced a new diagnostic protocol for the prevention of advanced skin cancers of all types, including malignant melanoma. This means: of course we continue to provide our patients with the usual annual interval examinations. However, we have completely abolished the ABCD(E)

rule and replaced it with the C-Rapid-H-Plus Protocol to be used by the patients at home.

C stands for Change in any way, shape, or form.

Rapid means immediate excision without dermatoscopy prior to excision.

H is about leaving to make the definitive diagnosis to the histopathologists.

Plus indicates the offer to send in photos of skin lesions anytime (24/7) during the interval along with a message to be seen, analyzed and responded to by a dermatologist no later than 24 hours.

Since we did launch the C-Rapid-H-Plus Protocol in 2020 in the clinics we work at, it is yet too early to publish reliable data from clinical practice. However, the number of skin cancer cases requiring follow-up treatment after a wide and deep excision has dropped to zero in our own patients. This is remarkable. We assume that it is also related to the less complex patient education and the digital consultation room that is always open. The latter in particular seems to be of immense importance.

Of course, this study has countless limitations. We received the Spanish data only as an anonymized data donation. Even though we know that it was done correctly, we lacked the possibility to ask for some details. Nevertheless, we decided to publish this work because its topic is of profound importance for general health and thousands of relevant situations that occur every day in clinics and practices around the world.

Conclusion

By replacing the ABCDE rule with the C-Rapid-H-Plus Protocol, we were able to reduce the number of advanced skin cancer cases in our patients to zero. A result that is consistent with the data from Spain. Telemedicine will and must also play an important role in this new approach, just as the hesitation against the routine use of scalpels must come to an end.

Conflicts of Interest Dr. Diamandis works in the field of dermatology as a clinician. Dr. Tudor and Dr. Feldman have nothing to declare.

References

Suppa M, Daxhelet M, del Marmol V. Dépistage du mélanome [Melanoma secondary prevention]. Rev Med Brux. 2015 Sep;36(4):255-9. French. PMID: 26591309.
Maire C, Vercambre-Darras S, Desmedt E. Diagnostic du mélanome [Diagnosis of melanoma]. Rev Prat. 2014 Jan;64(1):61-8. French. Erratum in: Rev Prat. 2014 Mar;64(3):349. PMID: 24649548.
De Giorgi V, Papi F, Giorgi L, Savarese I, Verdelli A, Scarfì F, Gandini S. Skin self- examination and the ABCDE rule in the early diagnosis of melanoma: is the game over? Br J Dermatol. 2013 Jun;168(6):1370-1. doi: 10.1111/bjd.12250. PMID: 23738643.
Garrido AQ, Wainstein AJA, Brandão MPA, de Vasconcellos Santos FA, Bittencourt FV, Ledsham C, Drummond-Lage AP. Diagnosis of Cutaneous Melanoma: the Gap Between the Knowledge of General Practitioners and Dermatologists in a Brazilian Population. J Cancer Educ. 2020 Aug;35(4):819-825. doi: 10.1007/ s13187-020-01735-z. Erratum in: J Cancer Educ. 2020 May 27;: PMID: 32193871.
Benelli C, Roscetti E, Dal Pozzo V. Reproducibility of the clinical criteria (ABCDE rule) and dermatoscopic features (7FFM) for the diagnosis of malignant melanoma. Eur J Dermatol. 2001 May-Jun;11(3):234-9. PMID: 11358731.
Coups EJ, Manne SL, Stapleton JL, Tatum KL, Goydos JS. Skin self-examination behaviors among individuals diagnosed with melanoma. Melanoma Res. 2016 Feb;26(1):71-6. PMID: 26426762.
Goldsmith SM, Solomon AR. A series of melanomas smaller than 4 mm and implications for the ABCDE rule. J Eur Acad Dermatol Venereol. 2007 Aug;21(7):929-34. doi: 10.1111/j.1468-3083.2006.02115.x. PMID: 17659002.
Bandic J, Kovacevic S, Karabeg R, Lazarov A, Opric D. Teledermoscopy for Skin Cancer Prevention: a Comparative Study of Clinical and Teledermoscopic Diagnosis. Acta Inform Med. 2020 Mar;28(1):37-41. doi: 10.5455/ aim.2020.28.37-41. PMID: 32210513; PMCID: PMC7085326.

Tudor, Adrian, Feldman, Jonathan, & Diamandis, Carolina. (2021). Why the ABCDE rule is not helpful but dangerous in skin cancer prevention. Zenodo Publishing. https://doi.org/10.5281/zenodo.5731554

This article is for informational purposes only and does not replace professional medical advice.

A new skin lesion that you had never noticed before is always a reason for concern. This concern can in select cases be lifesaving owing to the timely diagnosis and treatment of otherwise fatal malignancies. Everyone needs to be constantly vigilant and aware of any suspicious appearing skin lesions due to the poor prognosis associated with a delayed diagnosis of skin cancer. But what is the description of a suspicious skin lesion? Does every mole, freckle and blemish need a skin biopsy to rule out the possibility of a malignant tumor? No, it doesn’t. More often than not, a freckle is just a freckle and will require no further management.

Therefore, any new skin lesion needs to be examined by a professional before jumping to conclusions with a self-assumed diagnosis. To this end the question again arises, what types of skin lesion need a professional opinion? In order to understand this, you will need to know the typical warning signs of a premalignant or malignant skin lesions, which will be discussed below.

Typical Morphological Characteristics of a Malignant Skin Lesion

Size: A new or previously existing skin lesion that changes in size either gradually or rapidly over a period of weeks to even years can be a sign of malignancy. If a new skin lesion is greater than 5mm in diameter, it is best to have it examined.

Appearance: The lesion appears irregular and doesn’t conform to typical feature of moles or freckles. Abnormal non-uniform color, structure and surface of the skin lesion are typical features of a malignant lesion. Multiple skin lesions of new onset with abnormal morphology is an important warning sign that needs to promptly be examined.

Keratin Plug: Keratin plugs can be a benign finding but presence of a large keratin plug over nodules greater than 5 mm in diameter with a suspicious appearance demands a visit to a dermatologist.

Ulcerations or Crust: Skin lesions with spontaneous development of crusts or ulcerations without history of any trauma or irritation is another red flag that needs urgent evaluation.

Adherent Scale: Scales are not a finding of a normal healthy skin, and can be caused by a number of genetic, allergic or autoimmune etiologies. Sometimes, it can also be a sign of a premalignant skin lesion such as actinic keratosis, Bowen disease, lichen planus, etc.

Erythematous Halo: A ring or halo of redness around a nodule or papule resembling a bulls eye pattern can also be seen in malignant skin lesions and therefore needs to be further examined.

Location of the lesion: Although skin cancer can appear in any part of the body, some areas are more prone to develop malignant lesions such as the scalp, peri-ocular region, genital orifices, ungual area, and orifices. Lesions in these regions always require a specialist’s eye for evaluation.

Growth Pattern: Rapidly growing aggressive growth pattern warrants urgent evaluation.

Distinguishing Features Of Skin Cancer Subtypes

Skin Cancer is a broader term for various cancerous skin lesions including many subtypes. Each of them exhibit their own unique distinguishing features such as:

Melanoma

Melanoma is a cancer of the melanocytes present in the basal layer of the epidermis. Its features can be remembered with the easy mnemonic ABCDE

A– Asymmetry
B– Border Irregularity
C– Color Variation
D– Diameter greater than 6mm
E– Evolving

Often, early lesions of melanoma are ignored by the patient due to their similarity in appearance with freckles and moles. All are pigmented and appear benign and can only be differentiated via a biopsy in the early stages. Any mole that display the ABCDE characteristics needs to be evaluated. It should be noted that previously benign mole or freckle may undergo malignant transformation as well.

Squamous cell carcinoma

Squamous cell carcinoma is a cancer of the epidermis which is made of stratified squamous epithelium. They often develop in the form of a plaque or a nodule over a period of weeks to months and can become ulcerated. Painful ulcerated nodules should raise the suspicion of squamous cell carcinoma.

Basal Cell Carcinoma

Basal cell carcinoma involves the basal layer of the epidermis, and usually presents with a typical nodulo-ulcerated lesion with early bleeding. Its growth is slower than squamous cell carcinoma and it can take years for the patient to seek an expert’s opinion due to their relatively slower growth pattern. Therefore, any persisting skin lesion that doesn’t go away within a few weeks should be examined regardless of the growth rate.

Morphological Features of a Benign Skin Lesion

To further aid you in differentiating benign from malignant skin lesions, it is imperative to also know the features of a benign skin lesion.

Size: The size remains constant, stable and grows either very slowly or not at all over decades.

Appearance: Uniform color, shape and structure with no ulcerations, plaques, bleeding or Erythematous ring.

Stability: The size, shape, color and structure of a benign skin lesion doesn’t change over time.

The typical features described above are as stated: typical i.e. they are commonly seen features of malignancy, but atypical cases may not present in a similar manner. Furthermore, all the above features are not a criterion for diagnosis as some malignant skin lesions may present with only one of the above features or in atypical cases none of the above features.

In high risk people such as people with frequent sun exposure, elderly people, smokers, or with genetic predisposition to malignancy, all skin lesions should be considered to have malignant potential until examined thoroughly by an experienced dermatologist familiar with skin cancer.

References

Cancer 2014 Sep 03;[EPub Ahead of Print], VR Belum, AC Rosen, N Jaimes, G Dranitsaris, MP Pulitzer, KJ Busam, AA Marghoob, RD Carvajal, PB Chapman, ME Lacouture

Ribas A, Flaherty KT. BRAF targeted therapy changes the treatment paradigm in melanoma. Nat Rev Clin Oncol. 2011; 8: 426‐ 433.

Jaimes N, Zalaudek I, Braun RP, Tan BH, Busam KJ, Marghoob AA. Pearls of keratinizing tumors. Arch Dermatol. 2012; 148: 976.

Rosendahl C, Cameron A, Argenziano G, Zalaudek I, Tschandl P, Kittler H. Dermoscopy of squamous cell carcinoma and keratoacanthoma. Arch Dermatol. 2012; 148: 1386‐ 1392.

Lacouture M, Chapman PB, Ribas A, et al. Presence of frequent underlying RAS mutations in cutaneous squamous cell carcinomas and keratoacanthomas (cuSCC/KA) that develop in patients during vemurafenib therapy [abstract]. J Clin Oncol. 2011; 29(suppl): 8520.