Pigmented Skin Lesions

Last updated 1 Jun 2026 · Dermatology / Oncology

📋 Key Information Summary

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Australia has the highest melanoma incidence globally — approximately 17,000 new diagnoses per year; lifetime risk ≈1 in 17 (AIHW 2024).
Most pigmented lesions are benign naevi; the clinical challenge is distinguishing benign from malignant with high sensitivity and appropriate specificity.
ABCDE criteria (Asymmetry, Border irregularity, Colour variegation, Diameter >6 mm, Evolving) remain the cornerstone of clinical melanoma screening.
Red-flag features requiring urgent excision biopsy: the "ugly duckling" sign, new pigmented lesion in a patient >40 years, nodular or rapidly growing lesions, bleeding, or ulceration.
Dysplastic (atypical) naevi are a marker of increased melanoma risk but are not themselves premalignant in most cases — excision is indicated only when clinical suspicion warrants.
Congenital melanocytic naevi — large/giant variants (≥20 cm projected adult size) carry a measurable risk of melanoma and neurocutaneous melanocytosis; require specialist follow-up.
Melanoma subtypes: superficial spreading melanoma (70%), nodular melanoma (15%), lentigo maligna melanoma (10%), and acral lentiginous melanoma (5%) — each has distinct demographics and behaviour.
Dermoscopy significantly improves diagnostic accuracy (sensitivity +20–30% over naked-eye examination) and is recommended for every pigmented lesion assessment.
Full-thickness excisional biopsy with 2 mm clinical margins is the gold-standard first step for any suspicious pigmented lesion — avoid shave or curette of suspected melanoma.
Sentinel lymph node biopsy (SLNB) is recommended for stage IB–IIC melanoma (Breslow ≥0.8 mm or ≥0.8 mm with ulceration) per AJCC 8th edition staging.
Adjuvant immunotherapy (nivolumab or pembrolizumab) is PBS-listed for resected stage IIB–III melanoma; targeted therapy (dabrafenib + trametinib) for BRAF V600-mutant stage III disease.
Surveillance: skin self-examination monthly; clinical review every 6–12 months for 5 years, then annually for a further 5 years; whole-body photography and sequential dermoscopy for high-risk patients.
Aboriginal and Torres Strait Islander peoples have lower melanoma incidence but present later with thicker lesions and worse outcomes — culturally safe screening programmes are essential.

Introduction & Australian Epidemiology

Pigmented skin lesions encompass a broad spectrum of melanocytic and non-melanocytic conditions, ranging from ubiquitous benign naevi to life-threatening melanoma. In Australian general practice, pigmented lesions are among the most frequently encountered dermatological presentations, accounting for a substantial proportion of skin-cancer-related consultations. The clinical imperative is to identify melanoma at the earliest possible stage while avoiding unnecessary excision of benign lesions.

Australia and New Zealand bear a disproportionate global burden of melanoma. Key epidemiological data include:

Incidence: ~17,000 new melanoma diagnoses annually in Australia (AIHW 2024); age-standardised rate ≈49 per 100,000 — the highest in the world.
Mortality: ~1,300 deaths per year; melanoma is the fourth most common cancer in both sexes.
Lifetime risk: Approximately 1 in 17 Australians will be diagnosed with melanoma before age 85.
Breslow thickness at diagnosis: Median Breslow has decreased over the past two decades due to public awareness campaigns, but a significant minority (≈15%) still present with thick (>4 mm) or metastatic disease.
Non-melanoma skin cancer (NMSC): Australia records >900,000 treatments for NMSC per year (basal cell carcinoma, squamous cell carcinoma) — while not pigmented in the classical sense, NMSC contributes to the broader skin-cancer surveillance burden in general practice.

Risk factors for melanoma include Fitzpatrick skin types I–II, high naevus count (>50 common naevi), personal or family history of melanoma, prior non-melanoma skin cancer, immunosuppression, history of severe sunburn (particularly blistering burns in childhood), and the presence of dysplastic naevi. Ultraviolet radiation (UVR) exposure remains the principal modifiable risk factor, and Australian UV indices routinely reach extreme levels (11+) during summer months.

Classification of Pigmented Skin Lesions

Pigmented skin lesions are classified by their cellular origin, clinical behaviour, and degree of melanocytic atypia. A systematic approach to classification aids clinical decision-making and triage.

Benign Melanocytic Lesions

Lesion	Key Features	Dermoscopic Pattern	Management
Common acquired naevus	Symmetric, uniform colour (<6 mm), stable over time	Reticular, globular, or combined pattern	Reassurance; routine surveillance
Compound naevus	Slightly raised, pigmented, well-defined borders	Globular or cobblestone pattern peripherally	Reassurance if stable
Intradermal naevus	Skin-coloured to lightly pigmented, dome-shaped, soft	Arborising vessels, minimal pigment network	Reassurance; cosmetic removal if desired
Halo naevus	Central naevus with surrounding depigmented ring; common in children/adolescents	Central globular pattern, peripheral white structureless zone	Reassurance; monitor for concurrent melanoma in adults
Blue naevus	Blue-black, dome-shaped, typically <10 mm; often on dorsum of hands/feet or scalp	Homogeneous blue-grey pattern	Excise if atypical features (size >10 mm, irregular colour)

Non-Melanocytic Pigmented Lesions

Lesion	Key Features	Management
Seborrhoeic keratosis	"Stuck-on" waxy plaque; horn pseudocysts on dermoscopy; extremely common in elderly	Reassurance; cryotherapy or curettage if symptomatic
Solar lentigo	Flat, well-demarcated brown macule on sun-exposed skin; sharp borders	Reassurance; differentiate from lentigo maligna
Pigmented basal cell carcinoma	Pearly/pigmented papule with arborising vessels and blue-grey ovoid nests on dermoscopy	Excision; histological confirmation required
Dermatofibroma	Firm, dimple-sign positive nodule; often lower extremities	Reassurance
Ink-spot lentigo	Very dark, reticulated macule resembling ink splash; benign variant	Dermoscopy to confirm; reassurance

Premalignant / High-Risk Melanocytic Lesions

Dysplastic (atypical) naevi and large congenital melanocytic naevi are discussed in detail in the sections below.

Congenital & Acquired Naevi, Dysplastic Naevi

Acquired Melanocytic Naevi

Acquired naevi begin to appear in childhood, peak in number during the third and fourth decades, and involute from the sixth decade onward. Average adult naevus count in fair-skinned Australians is 20–40; counts >50 are associated with increased melanoma risk. Most acquired naevi follow a predictable lifecycle — flat junctional naevus → raised compound naevus → dome-shaped intradermal naevus — and remain stable for years to decades.

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Teaching point: A lesion that does not fit the patient's overall naevus pattern ("ugly duckling") warrants closer scrutiny, even if it does not meet full ABCDE criteria.

Congenital Melanocytic Naevi (CMN)

CMN are present at birth (or appear within the first few months of life) and are classified by projected adult size:

Category	Size	Prevalence	Melanoma Risk	Management
Small	<1.5 cm	~1 in 100	Very low (~0.01%)	Photographic monitoring; excision if cosmetic or changing
Medium	1.5–20 cm	~1 in 1,000	Low (~0.1%)	Dermoscopy + photography at 6–12-month intervals; consider excision
Large / Giant	≥20 cm	~1 in 20,000	Moderate (~1–5%); lifetime risk ~2–5% of cutaneous melanoma	Paediatric dermatology referral; staged excision where feasible; MRI brain/spine to assess neurocutaneous melanocytosis risk

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Neurocutaneous melanocytosis: Large/giant CMN (especially with multiple satellite naevi) carry a risk of melanocytic proliferation within the CNS. MRI of the brain and total spine should be performed by 6 months of age in all infants with large/giant CMN, ideally under general anaesthesia in a paediatric centre.

Dysplastic (Atypical) Naevi

Dysplastic naevi are clinically and histologically distinct from common naevi. They are characterised by:

Clinical: ≥5 mm diameter; irregular, ill-defined borders; variable colour (tan, brown, pink, dark brown); macular and papular components ("fried-egg" appearance).
Histological: Architectural disorder (lateral shoulder growth pattern) and cytological atypia (mild, moderate, or severe).
Significance: Individuals with ≥5 dysplastic naevi have a 6–10-fold increased lifetime risk of melanoma. The dysplastic naevus itself is not considered a premalignant lesion requiring mandatory excision; rather, it is a phenotypic marker of melanoma-prone skin.

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When to excise a dysplastic naevus: Excisional biopsy is indicated when (1) the lesion shows features suspicious for melanoma on clinical or dermoscopic assessment; (2) severe histological atypia is reported on a previous biopsy; or (3) the lesion is changing or symptomatic. Moderate or mildly dysplastic naevi with clear excision margins do not require re-excision.

Patients with the dysplastic naevus syndrome (familial atypical multiple mole melanoma — FAMMM syndrome) require referral to a dermatologist for whole-body photography, sequential dermoscopic surveillance, and genetic counselling. CDKN2A germline mutations confer a lifetime melanoma risk of 60–80%.

Melanoma — ABCDE, Red Flags, Subtypes

ABCDE Criteria

The ABCDE mnemonic remains the most widely validated clinical screening tool for melanoma detection:

Asymmetry

The lesion cannot be divided into mirror-image halves along any axis.

Border irregularity

Edges are scalloped, notched, or poorly defined rather than smooth and round.

Colour variegation

Multiple shades of brown, black, red, white, or blue within a single lesion.

Diameter >6 mm

Melanomas are often >6 mm at diagnosis, but small melanomas exist — do not rely on size alone.

Evolving

Any change in size, shape, colour, elevation, or new symptoms (itching, bleeding) over weeks to months.

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Limitations of ABCDE: Nodular melanoma and amelanotic melanoma may fail to satisfy ABCDE criteria. The "EFG" rule — Elevated, Firm, Growing progressively for >1 month — should be applied to any new or changing raised lesion. The "ugly duckling" sign (an outlier that does not match the patient's overall naevus pattern) further improves sensitivity.

Red-Flag Features Requiring Urgent Excision Biopsy

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New pigmented lesion appearing after age 40
Any lesion meeting ≥2 ABCDE criteria
Rapid growth over weeks (especially nodular or polypoid morphology)
Spontaneous bleeding or ulceration without trauma
The "ugly duckling" sign — a lesion that stands out from the patient's other naevi
Regression structures (white scar-like areas) within a pigmented lesion on dermoscopy
Blue-white veil overlying raised area (dermoscopy)
Atypical pigment network — thickened, abrupt cutoff lines (dermoscopy)
New or changing lesion in a patient with personal/family history of melanoma

Melanoma Subtypes

Subtype	Frequency	Typical Site	Clinical Features	Behaviour
Superficial spreading melanoma (SSM)	~70%	Trunk (men), lower legs (women)	Flat, irregularly pigmented plaque with radial growth phase lasting months to years before vertical growth	Good prognosis if caught in radial growth phase
Nodular melanoma (NM)	~15%	Trunk, head, neck	Rapidly growing, often uniformly pigmented (or amelanotic) nodule; may ulcerate; no prolonged radial growth phase	Aggressive; thicker at diagnosis; often fails ABCDE — apply EFG rule
Lentigo maligna melanoma (LMM)	~10%	Chronically sun-damaged skin (face, ears, scalp)	Slowly enlarging, flat, variegated brown-to-dark-brown patch on elderly patient's face; may take years to become invasive	Indolent; good prognosis if excised before invasive growth
Acral lentiginous melanoma (ALM)	~5%	Palms, soles, subungual	Irregular dark patch on sole or palm; longitudinal melanonychia with Hutchinson's sign (pigment extending onto proximal nail fold) for subungual melanoma	Often diagnosed late; not UV-related; commonest subtype in darker skin tones
Desmoplastic melanoma	<2%	Head, neck (chronically sun-damaged skin)	Firm, scar-like, often amelanotic; may mimic dermatofibroma or scar	Higher local recurrence rate; neurotropic; requires wider excision margins

AJCC 8th Edition Staging — Key Features

Staging integrates tumour thickness (T), ulceration, mitotic rate, nodal status (N), and distant metastasis (M). Key thresholds for clinical decision-making:

Stage	Tumour (T)	Nodes (N)	Metastasis (M)	5-Year Survival
IA	T1a (≤0.8 mm, no ulceration)	N0	M0	~99%
IB	T1b or T2a (0.8–1.0 mm ± ulceration)	N0	M0	~97%
IIA	T2b or T3a (1.0–4.0 mm ± ulceration)	N0	M0	~91%
IIB	T3b or T4a (>4.0 mm ± ulceration)	N0	M0	~82%
IIC	T4b (>4.0 mm + ulceration)	N0	M0	~75%
III	Any T	N1–N3	M0	~63–78% (IIIA) to ~40% (IIID)
IV	Any T	Any N	M1	~30% (M1a) to ~15% (M1d)

Management Algorithm & Surveillance

Step 1 — Clinical Assessment

Every pigmented lesion should be assessed systematically: history (duration, change, symptoms, risk factors), naked-eye examination, and dermoscopic evaluation. GPs with dermoscopy training can significantly reduce unnecessary referrals while maintaining high sensitivity for melanoma detection.

Step 2 — Biopsy Technique

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Critical: For any lesion suspicious for melanoma, perform a full-thickness excisional biopsy with 2 mm clinical margins.

Do NOT perform shave biopsy, curettage, or electrocautery of suspected melanoma — this compromises Breslow thickness measurement and staging.
Incisional or punch biopsy of the thickest area is acceptable only when excisional biopsy is impractical (e.g., very large lesion on the face, palmar/plantar lesion).
Send specimen in formalin with clinical details including site, size, dermoscopic features, and suspicion of melanoma.

Step 3 — Definitive Surgical Margins

Breslow Thickness	Recommended Clinical Margin	Notes
In situ (stage 0)	5 mm	Lentigo maligna may require wider margins (5–10 mm) due to subclinical extension; consider staged excision (Mohs or CCPDMA)
≤1.0 mm (T1)	1 cm	Adequate for most thin melanomas
1.01–2.0 mm (T2)	1–2 cm	2 cm preferred for T2b (ulcerated)
2.01–4.0 mm (T3)	2 cm	No survival benefit from margins >2 cm in T3 melanoma
>4.0 mm (T4)	2 cm	Refer to melanoma multidisciplinary team

Step 4 — Sentinel Lymph Node Biopsy (SLNB)

SLNB should be discussed for all patients with stage IB–IIC melanoma (Breslow ≥0.8 mm or Breslow <0.8 mm with ulceration or high mitotic rate). SLNB is performed at the time of or within 12 weeks of wide local excision. Referral to a melanoma surgical centre with nuclear medicine SLNB capability is required.

Step 5 — Systemic Adjuvant Therapy

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Nivolumab

Opdivo® · PD-1 checkpoint inhibitor

Indication Adjuvant: resected stage IIB–IV melanoma

Adult dose 480 mg IV every 4 weeks for 12 months

Paediatric dose ≥12 years: weight-based dosing per oncology protocol

Key adverse effects Immune-related: thyroiditis, hepatitis, colitis, pneumonitis, adrenal insufficiency, type 1 diabetes, vitiligo

PBS status 🔒 PBS Authority Required

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Pembrolizumab

Keytruda® · PD-1 checkpoint inhibitor

Indication Adjuvant: resected stage IIB–III melanoma

Adult dose 200 mg IV every 3 weeks or 400 mg IV every 6 weeks for 12 months

Key adverse effects Similar immune-related adverse effects as nivolumab

PBS status 🔒 PBS Authority Required

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Dabrafenib + Trametinib

Tafinlar® + Mekinist® · BRAF + MEK inhibitor combination

Indication Adjuvant: resected stage III BRAF V600-mutant melanoma

Adult dose Dabrafenib 150 mg PO BD + trametinib 2 mg PO daily for 12 months

Key adverse effects Pyrexia, fatigue, arthralgia, skin rash, cardiac dysfunction, uveitis

PBS status 🔒 PBS Authority Required

Step 6 — Metastatic Disease

Patients with stage IV melanoma should be managed by a medical oncologist at a specialised melanoma centre. Treatment options include:

Immunotherapy: Combination nivolumab + ipilimumab (first-line for BRAF-wild-type or BRAF-mutant with CNS metastases); single-agent anti-PD-1 for lower burden disease.
Targeted therapy: Dabrafenib + trametinib or encorafenib + binimetinib for BRAF V600-mutant melanoma.
Locoregional therapies: Stereotactic radiosurgery for brain metastases; isolated limb infusion/perfusion for in-transit metastases (available at specialised centres).
Tumour-agnostic therapy: Pembrolizumab for MSI-high/dMMR melanoma (rare in melanoma).

Surveillance Protocol

Ongoing — patient

Skin self-examination monthly. Teach the "ugly duckling" approach and use of mirrors for hard-to-see areas.

Months 0–36 post-excision

Clinical review every 6 months (history, full skin examination, lymph node basin palpation, review of imaging as indicated). Whole-body skin photography for high-risk patients.

Months 36–60

Clinical review every 6–12 months. Consider interval imaging for stage III+ patients per oncologist guidance.

Years 5–10

Annual clinical review. Continued skin self-examination. Melanoma can recur >10 years after initial treatment, particularly in patients with lentigo maligna melanoma.

Year 10+

Lifelong annual skin checks recommended for all melanoma survivors, given ongoing risk of second primary melanoma (~5–10% over 20 years).

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Imaging in follow-up: Routine CT/PET imaging is not recommended for stage I–II melanoma surveillance. For stage III patients, CT chest/abdomen/pelvis ± brain MRI every 6–12 months for 3 years is recommended per eviQ/Melanoma Institute Australia guidelines. Interval imaging should be guided by clinical concern.

Special Populations

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Pregnancy

Excisional biopsy of suspicious lesions is safe in pregnancy — local anaesthesia (lignocaine without adrenaline is preferred by some, though lignocaine with adrenaline is considered safe).

Wide local excision can be performed under local or regional anaesthesia; general anaesthesia is generally deferred where possible, especially in the first trimester.

SLNB is technically feasible in pregnancy using Tc-99m with a reduced dose; discuss with nuclear medicine and obstetric teams.

Adjuvant immunotherapy is contraindicated in pregnancy. If adjuvant treatment is urgently indicated, discuss timing relative to gestation with medical oncology and obstetrics.

Melanoma does not metastasise to the placenta more frequently than other cancers, but placental examination after delivery is recommended for all women with a melanoma history.

Pregnancy does not worsen melanoma prognosis for equivalent-stage disease (no evidence of worse outcomes when stage is controlled), but delay in diagnosis due to attribution of symptoms to pregnancy remains a risk.

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Paediatrics

Melanoma is rare in children (<1% of all melanomas) but does occur, including in prepubertal children. Spitzoid tumours are more common in childhood and may be difficult to distinguish from Spitz naevi histologically.

Congenital melanocytic naevi should be monitored by a paediatric dermatologist; large/giant CMN require MRI brain/spine and surgical planning at a tertiary paediatric centre.

Sun protection education should begin in infancy: slip, slop, slap, seek, slide. The Australian Cancer Council recommends no direct sun exposure for infants <12 months.

Spitz naevi in children with typical clinical/dermoscopic features can often be monitored rather than excised, as per current paediatric dermatology consensus.

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Elderly (>70 years)

Lentigo maligna melanoma is the most common subtype in older adults — flat, slowly growing facial lesions may be misdiagnosed as solar lentigines for years.

Older patients present with thicker melanomas on average, contributing to worse outcomes — maintain high index of suspicion for any new or changing pigmented lesion.

Comorbidity may limit surgical options; discuss conservative management of in situ disease with radiotherapy (topical imiquimod off-label or radiotherapy) in patients unfit for surgery.

Age should not preclude investigation of suspicious lesions. Early-stage melanoma surgery can be performed under local anaesthesia in most elderly patients.

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Immunocompromised

Solid organ transplant recipients (SOTR) have a 2–5-fold increased melanoma risk compared with the general population.

Melanoma may behave more aggressively in immunosuppressed patients — lower threshold for biopsy and more frequent surveillance is warranted.

Adjuvant immunotherapy is complex in SOTR — risk of allograft rejection must be weighed against melanoma benefit. Manage jointly with transplant and melanoma teams.

HIV-positive patients with melanoma should receive standard staging and treatment; melanoma is not an AIDS-defining illness but may present at a more advanced stage.

Aboriginal and Torres Strait Islander Health Considerations

Epidemiology

While overall melanoma incidence is lower in Aboriginal and Torres Strait Islander peoples compared with non-Indigenous Australians (AIHW data: age-standardised rate approximately 10 per 100,000 vs. 50 per 100,000), melanoma in First Nations peoples is often diagnosed at a later stage with greater Breslow thickness and worse five-year survival. Acral lentiginous melanoma is proportionally more common.

Late presentation

Factors contributing to late-stage diagnosis include geographic remoteness, limited access to dermatology and specialist services, cultural barriers to skin examination, and lower awareness of melanoma risk in darker skin tones. Many remote communities have no resident dermatologist or surgical oncologist.

Culturally safe care

Skin examination requires cultural sensitivity — involve Aboriginal and Torres Strait Islander health workers, use same-sex practitioners where preferred, and ensure informed consent is obtained in a culturally appropriate manner. Provide health education in plain language and in local languages where possible.

Telehealth & outreach

Teledermatology services (e.g., ACRRM teledermatology, state-based programmes) can provide remote dermoscopic assessment and triage. Regular skin-cancer screening outreach clinics staffed by dermatologists and trained health workers improve access in remote communities. MBS telehealth item numbers (e.g., 99200, 99201) support Medicare rebates for video consultations.

Social determinants

Address the broader social determinants of health — housing (limited shade, no air conditioning), employment (outdoor work without sun protection), transport to appointments, and health literacy. Ensure that follow-up plans are feasible and culturally acceptable.

CA-MRSA & wound care

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is prevalent in remote Aboriginal and Torres Strait Islander communities. Post-excision wound infections may require empirical cover for CA-MRSA; consider local antibiogram data when prescribing. Discuss with local infectious diseases/AMS (Aboriginal Medical Service) pharmacy teams.

Investigations

GP Clinic Dermoscopy (clinical examination) Handheld polarised or non-polarised dermoscope; sensitivity for melanoma 89–96% in trained users. Recommended for all pigmented lesion assessments in general practice. Funded under standard GP consultation (MBS item 23/36).

GP Clinic Full-thickness excisional biopsy (histopathology) Gold standard for diagnosis. Specimen sent to pathology in formalin. Includes Breslow thickness, ulceration status, mitotic rate, margin status, and immunohistochemistry (S-100, HMB-45, Melan-A, SOX10). MBS items 30000–30024 (excision of skin lesion).

Specialist Sequential digital dermoscopy / total-body photography High-resolution sequential imaging for monitoring high-risk patients (multiple dysplastic naevi, personal history of melanoma). Available at dermatology practices and melanoma screening centres. No specific MBS item — funded through specialist consultation items.

Referral Sentinel lymph node biopsy (SLNB) Nuclear medicine lymphoscintigraphy + surgical SLNB. Available at melanoma surgical centres (e.g., Melanoma Institute Australia, major tertiary hospitals). Indicated for stage IB–IIC melanoma. MBS item 38802 (lymph node biopsy — nuclear medicine guided).

Referral CT chest / abdomen / pelvis with contrast Staging for stage IIB+ melanoma and clinically indicated surveillance. PET-CT may be used for equivocal findings or staging of advanced disease.

Referral Brain MRI with gadolinium Staging for stage III/IV melanoma; also for suspected neurocutaneous melanocytosis in infants with large/giant CMN. Available at all tertiary hospitals.

Specialist BRAF V600 mutation testing Immunohistochemistry (VE1 antibody) and/or PCR-based molecular testing on excised melanoma specimen. Required for targeted therapy eligibility. Available at all major pathology laboratories in Australia. MBS item 73304 (molecular oncology — solid tumour).

Specialist LDH (lactate dehydrogenase) Serum LDH is an independent prognostic marker in metastatic melanoma. Elevated LDH indicates M1c staging. Available at all pathology laboratories.

Risk Stratification & Screening Recommendations

Low Risk

General Population

No personal/family history of melanoma; Fitzpatrick type I–II; <10 common naevi; no dysplastic naevi.

Skin self-examination monthly; GP skin check as part of routine health assessment; sun protection education.

Moderate Risk

Increased Risk Factors

One or more of: personal history of NMSC, fair skin with high sun exposure, 1–2 relatives with melanoma, 10–50 common naevi, immunosuppression.

Skin self-examination monthly; GP total-body skin examination annually; consider dermoscopy; baseline total-body photography.

High Risk

Very High Risk

Personal history of melanoma; ≥5 dysplastic naevi; ≥3 first-degree relatives with melanoma (FAMMM syndrome); CDKN2A mutation carrier; large/giant CMN; solid organ transplant recipient.

Dermatologist-led surveillance every 3–6 months; sequential digital dermoscopy; whole-body photography every visit; genetic counselling for FAMMM families.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Cancer data in Australia 2024. Canberra: AIHW; 2024. Available from: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia
2. Gershenwald JE, Scolyer RA, Hess KR, et al. Melanoma staging: evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(6):472–492.
3. Cancer Council Australia. Clinical practice guidelines for the management of melanoma in Australia and New Zealand. Sydney: Cancer Council Australia and the Melanoma Institute Australia; 2018 (updated 2023). Available from: https://www.cancer.org.au/clinicalguidelines
4. Melanoma Institute Australia. Guidelines for the management of melanoma in Australia. North Sydney: MIA; 2023. Available from: https://melanoma.org.au/
5. Kittler H, Marghoob AA, Argenziano G, et al. Standardization of terminology in dermoscopy/dermatoscopy: results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol. 2016;74(6):1093–1106.
6. Eggermont AMM, Blank CU, Mandalà M, et al. Adjuvant pembrolizumab versus placebo in resected stage III melanoma (EORTC 1325-MG/KEYNOTE-054): 5-year efficacy and safety results. Lancet Oncol. 2023;24(2):175–187.
7. Long GV, Hauschild A, Santinami M, et al. Adjuvant dabrafenib plus trametinib in stage III BRAF-mutated melanoma. N Engl J Med. 2017;377(19):1813–1823.
8. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Cancer. Canberra: AIHW; 2023. Available from: https://www.aihw.gov.au/reports/indigenous-australians/hpf-2023
9. RACGP. Guidelines for preventive activities in general practice (Red Book). 9th edn. Melbourne: RACGP; 2018 (updated 2023). Chapter 9: Skin cancer.
10. Guitera P, Pellacani G, Crotty KA, et al. The impact of in vivo reflectance confocal microscopy on the diagnostic accuracy of lentigo maligna and equivocal pigmented and nonpigmented macules of the face. J Invest Dermatol. 2010;130(8):2080–2091.
11. Kreusch J, Koch F. Incident light microscopic surface structures of benign and malignant melanocytic skin tumors. Hautarzt. 1997;48(12):889–895.
12. National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the management of melanoma in Australia and New Zealand. Wellington: Ministry of Health; 2008. (See Ref 3 for updated edition.)
13. Wong JR, Harris JK, Rodriguez-Galindo C, Johnson KJ. Incidence of childhood and adolescent melanoma in the United States: 1973–2009. Pediatrics. 2013;131(5):846–854.
14. Government of Australia. Medicare Benefits Schedule (MBS) — Category 3: Therapeutic Procedures. Canberra: Department of Health and Aged Care; 2024. Available from: http://www.mbsonline.gov.au

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).