Sixty-year-old Colin kept catching something on the side of his neck when shaving. The appearance looked typical for a seborrhoeic keratosis – benign, warty well-demarcated lesions that form on many people’s skin as they age. It had been there a year; the repeated razor trauma eventually made Colin come into the surgery.
We’d recently had a dermatoscope on loan from the manufacturer. These expensive pieces of kit magnify skin lesions under polarised light, which eliminates surface reflection and reveals extraordinary detail of the deeper architecture. Once the preserve of dermatologists, dermatoscopes are slowly being adopted by GPs to help differentiate skin cancers from the myriad harmless lesions patients bring to show us. I’d become adept at picking out the hallmark features of several common pathologies, including seborrhoeic keratoses. Colin’s would have been an ideal case to practise on, but the dermatoscope had been returned and we were weighing up whether the hefty price could be justified by what it would add to our clinical practice.
I arranged to remove Colin’s keratosis under local anaesthetic. I popped the excised tissue in a formalin pot to send to the pathology lab. I told him that if anything surprising came back I would let him know.
We were still agonising about whether to purchase a dermatoscope. Like every other practice in the country, our funding has been cut every year for the past decade, and spending decisions have become acute. Then, in one of those moments of beautiful serendipity, the local Co-op got in touch. They were planning a distribution from their plastic bag levy, the 5p charge introduced in 2015 to discourage disposable carrier bag use. Nationally, it’s been spectacularly successful, consumption has fallen by 85 per cent, and more than £58m has been donated to good causes. The Co-op had £2,000 available to fund items of equipment that would help our practice.
We got our dermatoscope a few weeks ago, and I am back using it on every skin lesion I see. I’ve already been able to reassure two patients that what they feared might be a mole turned nasty was just a seborrhoeic keratosis, which could safely be left alone.
In the meantime, the pathologists analysed Colin’s specimen. It turned out to have been an unusual variant of malignant melanoma – the most serious form of skin cancer – termed a verrucous naevoid melanoma. Unexpected news of this nature prompts a lot of soul-searching, and I’ve spent considerable time reflecting on whether I should have made the diagnosis clinically.
It turns out I’m in good company. Verrucous naevoid melanomas are rare, and display none of the features of classic melanomas. To the naked eye they often look identical to benign lesions and are diagnosed as such in more than half of cases. Late presentation is common, with patients often initially reassured by clinicians deceived by their mimicry. Dermatoscopes improve diagnostic pick-up. Had I had one available I suspect it would have led me to question my first impression and refer Colin for definitive surgery directly.
Colin’s case could so easily have been different. Were it not for the shaving trauma, he might not have come in. Were the lesion somewhere less troublesome, I might have sent him away with false reassurance. As it was, we got a tissue diagnosis at first presentation, and he’s now had a wide local excision under the plastic surgeons. Hopefully Colin will have been cured. And thanks to a measure designed to reduce plastic pollution, I now have a dermatoscope that will lead to greater diagnostic accuracy for future patients.
A collection of Phil’s columns, “Chicken Unga Fever”, is published by Salt
This article appears in the 14 Nov 2018 issue of the New Statesman, How the Brexiteers broke history