One of the questions I'm asked most often by physios and sports medicine clinicians is some version of this: "I noticed something on a patient's skin during an assessment. How do I know if it's actually worth referring?"
It's a good question to be asking. The answer is more straightforward than most clinicians expect, and it doesn't require dermatological training.
Our job is triage, not diagnosis
The first thing to get clear is what we are and are not trying to do. We are not attempting to diagnose skin lesions. We are not expected to differentiate between a dysplastic naevus and a superficial spreading melanoma. That is the dermatologist's job, and it requires training, equipment, and expertise that goes well beyond what allied health practitioners have or need.
What we are trying to do is notice when something looks wrong, communicate that observation clearly to the patient, and facilitate an appropriate referral. That is a triage skill, and it sits comfortably within the scope of every musculoskeletal and sports medicine practitioner.
The distinction matters because it lowers the threshold for action. You don't need to be certain something is sinister to refer. You need to notice that it looks atypical and respond accordingly.
The ABCDE framework
The ABCDE criteria are the most practical screening framework for suspicious pigmented lesions available to non-dermatologists. Most clinicians have encountered them at some point. The issue is not awareness but consistent application.
Asymmetry. One half of the lesion does not match the other when you draw an imaginary line through the centre.
Border. Irregular, notched, scalloped, or poorly defined edges rather than a smooth, well-circumscribed margin.
Colour. Variation within the lesion, multiple shades of brown, black, red, white, or blue, rather than uniform pigmentation throughout.
Diameter. Greater than 6mm, roughly the diameter of a pencil eraser, though smaller lesions with other concerning features still warrant attention.
Evolution. Any reported or observed change in size, shape, colour, or surface character. Any new symptom including bleeding, itching, or crusting. In my clinical experience, evolution is often the most significant single feature, and it is the one most reliably identified when you ask the patient directly.
The ABCDE criteria are primarily designed for pigmented lesions, particularly melanoma screening. They are a useful starting point but not the complete picture.
Beyond the ABCDE criteria
Several other presentations warrant escalation regardless of whether they fit the pigmented lesion pattern.
Non-healing ulcers or sores that have been present for more than a few weeks without clear cause or improvement. Rapidly growing nodules. Persistent scaly, crusted, or thickened patches, particularly on sun-exposed areas of the face, scalp, ears, and back of the hands. Lesions that bleed with minimal or no trauma. Anything that the patient describes as new, changing, or behaving differently from other spots on their body.
This last point is clinically important. Patients often have an intuitive sense that something is different about a particular lesion before they can articulate exactly why. That instinct is worth taking seriously. A patient who volunteers that a spot "just doesn't seem right" is giving you useful clinical information.
The role of sun exposure history in sport
For athletes, particularly those who have trained outdoors for years, the cumulative UV load is substantially higher than in the general population. Research consistently shows that outdoor athletes develop skin cancers at 1.5 to 2 times the rate of indoor workers. That background risk makes attentive skin observation more rather than less important in sport and exercise clinical settings.
A brief skin history as part of the new patient assessment for outdoor athletes, including cumulative outdoor training exposure, sunburn history, family history of melanoma, and any prior skin cancer, helps identify patients who warrant closer attention during physical assessment.
In practice
Build skin observation into the physical assessment systematically rather than as an afterthought. When a patient removes clothing for a shoulder, back, or lower limb assessment, take a moment to look at what is visible before you start palpating. The back is one of the most common sites for melanoma and one of the areas patients are least likely to inspect themselves.
You do not need to conduct a full body skin check. You are observing what is visible in the normal course of clinical assessment and noting anything that warrants escalation.
When you find something, the clinical response is the same regardless of what it is: document the finding, have the conversation with the patient, and refer.
The Clinician's Guide to Skin Health in Sport & Exercise covers skin observation, the referral conversation, and a full framework for integrating skin health into clinical practice.
