Skin Cancer and Melanoma: Symptoms, NHS Diagnosis and Treatment in the UK

Skin cancer is the most common cancer in the UK, with over 17,000 new melanoma cases and approximately 147,000 non-melanoma skin cancer cases diagnosed each year in England alone. Rates have been rising steadily for decades. Despite the UK’s relatively low sunshine levels, skin cancer incidence is comparable to countries with sunnier climates — partly reflecting past behaviours, the popularity of package holidays, and indoor tanning sunbed use. The good news is that when caught early, skin cancers have excellent survival rates. Understanding the warning signs, knowing how to use the ABCDE rule, and acting promptly on changes in your skin can be lifesaving. This guide covers all major types of skin cancer, NHS diagnosis pathways, and current treatment options.

Types of Skin Cancer

Melanoma

Melanoma arises from melanocytes — the pigment-producing cells of the skin. It is the most serious type of skin cancer because of its tendency to spread (metastasise) to other organs. In the UK, melanoma is the 5th most common cancer overall. Around 2,300 people die from melanoma annually in England. However, survival rates have dramatically improved with new treatments: 5-year survival for stage I melanoma exceeds 98%; even stage IV (metastatic) melanoma now has 5-year survival rates of 25–35% with modern immunotherapy, compared with under 10% a decade ago.

Basal Cell Carcinoma (BCC)

BCC is the most common skin cancer and the most common cancer of any type in the UK. It arises from basal cells in the deepest layer of the epidermis. BCC grows slowly and very rarely spreads to other organs, making it the least dangerous of the skin cancers — but it can cause significant local tissue destruction if left untreated, particularly on the face around the eyes, nose, and ears. BCCs typically appear as pearly, translucent bumps, sometimes with visible blood vessels, or as flat, scar-like lesions.

Squamous Cell Carcinoma (SCC)

SCC arises from squamous cells in the outer layers of the skin. It is more likely than BCC to spread, though metastasis remains uncommon (occurring in about 2–5% of cases). SCCs typically appear as firm, red, scaly patches, open sores, or wart-like growths. They are more common on sun-exposed areas (head, neck, hands, arms) and in people who are immunocompromised (transplant recipients, those on long-term steroids). Actinic keratoses (rough, scaly patches from sun damage) are pre-cancerous lesions that can progress to SCC.

Merkel Cell Carcinoma

Merkel cell carcinoma is a rare but aggressive skin cancer arising from Merkel cells (sensory cells) in the skin. It is much less common than the other types but has a higher mortality rate. It typically presents as a flesh-coloured or blue-red nodule, often on the face, head, or neck.

Warning Signs: The ABCDE Rule

The ABCDE rule is used to assess moles and skin lesions for features suspicious of melanoma:

A — Asymmetry: one half of the mole is different from the other half
B — Border: irregular, ragged, notched, or blurred borders (unlike the smooth, defined borders of a benign mole)
C — Colour: variation in colour — shades of brown, black, red, white, or blue within a single lesion
D — Diameter: larger than 6mm (the size of a pencil eraser), though melanomas can be smaller
E — Evolving: any change in size, shape, colour, or any new symptom (bleeding, itching, crusting)

The “E” (evolving) criterion is particularly important — any mole or skin lesion that is changing should be assessed promptly, regardless of whether it fits the other criteria.

An additional rule used in the UK is the “ugly duckling” sign: a mole that looks different from all others on the body (“stands out from the crowd”) warrants attention, even if it does not clearly meet ABCDE criteria.

Risk Factors for Skin Cancer

UV exposure: the primary risk factor for all three major types; both cumulative lifetime exposure and episodes of sunburn (especially blistering sunburn in childhood and adolescence) increase risk
Indoor tanning (sunbeds): using a sunbed before age 35 increases melanoma risk by up to 75%; sunbeds are banned for under-18s in the UK under the Sunbeds (Regulation) Act 2010
Fair skin, light hair, blue eyes, freckles: reduced melanin protection increases UV damage
High mole count: having more than 100 moles, or 5+ atypical (dysplastic) moles, significantly increases melanoma risk
Family history: approximately 10% of melanomas occur in people with a family history; CDKN2A gene mutations greatly increase risk
Immunosuppression: organ transplant recipients have a 65-fold increased risk of SCC
Previous skin cancer: significantly increases risk of further lesions
Certain medical conditions: xeroderma pigmentosum, albinism, actinic keratoses

NHS Diagnosis Pathway

If your GP suspects skin cancer, they will refer you under the 2-week wait (2WW) urgent suspected cancer referral pathway. NICE NG12 (Suspected Cancer: Recognition and Referral) specifies the criteria:

Refer urgently for dermoscopy/assessment of lesions suspicious for melanoma in adults under 2WW
Refer urgently if there is a new or changing mole with any suspicious features
Refer routinely for lesions suspicious for BCC or SCC where malignancy cannot be excluded

At the dermatology or plastic surgery clinic, assessment typically involves dermoscopy — a handheld magnifying device with polarised light that allows detailed inspection of skin lesion structure. Dermoscopy significantly improves diagnostic accuracy over naked-eye examination alone.

Suspicious lesions are biopsied — either by excision biopsy (removing the entire lesion) or incision biopsy — and sent for histopathological analysis. For melanoma, the key pathological information includes: Breslow thickness (depth of invasion, the most important prognostic factor), Clark level, mitotic rate, and ulceration. These determine staging and treatment planning.

Sentinel lymph node biopsy (SLNB) may be offered for melanomas with a Breslow thickness greater than 1mm, to determine whether cancer cells have spread to the nearest lymph nodes.

NHS Treatment Options

Surgery

Surgery is the primary treatment for most skin cancers. For melanoma, the initial excision is followed by wide local excision (WLE) — removing a margin of healthy skin around the melanoma. The required margin depends on Breslow thickness: 0.5mm for melanoma in situ, 1cm for Breslow ≤1mm, 1–2cm for 1–2mm, and 2cm for >2mm.

For BCC and SCC, surgical excision with appropriate margins is standard. Mohs micrographic surgery — a specialised technique where tissue is removed in thin layers and examined under a microscope during the procedure to ensure complete excision — is used for high-risk BCCs (particularly on the face) and achieves the highest cure rates with minimal tissue loss.

Immunotherapy

The treatment of advanced melanoma has been transformed by checkpoint inhibitors. In the UK, NICE has approved:

Pembrolizumab (Keytruda) and nivolumab (Opdivo): anti-PD-1 antibodies; approved for adjuvant treatment of resected stage III melanoma and for advanced/metastatic melanoma
Ipilimumab (Yervoy): anti-CTLA-4 antibody; used in combination with nivolumab for advanced melanoma with particularly good response rates (though higher toxicity)

These treatments are available through the NHS Cancer Drugs Fund (CDF) where NICE approved.

Targeted Therapy

Approximately 40–50% of melanomas carry a BRAF V600E/K mutation. For these tumours, BRAF inhibitors (vemurafenib, dabrafenib) combined with MEK inhibitors (trametinib, cobimetinib) produce high response rates. NICE has approved several BRAF/MEK inhibitor combinations for metastatic BRAF-mutated melanoma. All melanomas should be tested for BRAF mutation at diagnosis of advanced disease to determine eligibility.

Radiotherapy

Radiotherapy is used for BCC and SCC in situations where surgery is not feasible (e.g., elderly patients, certain anatomical locations), and for palliative treatment of metastatic melanoma. It is sometimes used adjuvantly after surgery for high-risk SCC.

Non-Surgical Treatments for BCC and Superficial SCC

For superficial BCCs (not on high-risk facial sites), NICE-approved alternatives to surgery include:

Imiquimod cream (Aldara): immune-modulating cream applied topically; effective for superficial BCC
Photodynamic therapy (PDT): photosensitising agent applied to skin, then activated by a specific wavelength of light; effective for superficial BCC and actinic keratoses
Fluorouracil (5-FU) cream: chemotherapy cream for actinic keratoses and some superficial BCCs
Cryotherapy: liquid nitrogen; used for actinic keratoses and small, low-risk BCCs

Skin Cancer Prevention in the UK

Public Health England and Cancer Research UK recommend:

Using SPF 30+ sunscreen (SPF 50+ for fair skin) on sun-exposed skin, reapplying every 2 hours
Seeking shade between 11am and 3pm when UV is strongest
Wearing protective clothing, a wide-brimmed hat, and UV-blocking sunglasses
Avoiding sunbeds entirely
Not burning — even one blistering sunburn doubles lifetime melanoma risk
Regularly checking your skin using the ABCDE rule and the ugly duckling sign

People with a history of skin cancer, many atypical moles, or a strong family history may be offered surveillance through NHS dermatology, including annual skin checks and, at some centres, total body photography to track moles over time.

UK Support Organisations

Melanoma UK (melanomauk.org.uk) — UK charity dedicated to melanoma; patient information, clinical nurse specialist support, clinical trial information
Skcin (skcin.org) — UK skin cancer charity focusing on prevention and awareness
Cancer Research UK (cancerresearchuk.org) — comprehensive skin cancer information and clinical trial listings
Macmillan Cancer Support (macmillan.org.uk) — practical and emotional support for people affected by skin cancer; helpline 0808 808 0000
British Association of Dermatologists (bad.org.uk) — patient leaflets on BCC, SCC, melanoma, and treatment options

What Competitors Miss About Skin Cancer

1. The “E” in ABCDE — evolution — is the most important criterion. Most skin cancer awareness campaigns emphasise the visual criteria (asymmetry, irregular borders, varied colour) but underemphasise evolution. A melanoma can be symmetrical, regularly bordered, uniformly coloured, and under 6mm — and still be dangerous if it is growing or changing. Any lesion that is behaving differently from the others on your body, or that you notice is different from when you last looked, should be assessed promptly, regardless of whether it otherwise looks reassuring.

2. Nodular melanoma can be deceptively “normal-looking.” Nodular melanoma — a particularly fast-growing subtype — may be uniformly coloured (even amelanotic, i.e., skin-coloured or pink), symmetrical, and less than 6mm at presentation. It does not fit the classic ABCDE criteria. The EFG rule was developed specifically for nodular melanoma: Elevated, Firm, Growing. A raised, firm lesion that is growing within weeks should be urgently referred regardless of colour or shape. This rule is almost completely absent from standard patient information.

3. Melanoma can occur in people with dark skin — on the palms, soles, and under nails. The misconception that skin cancer only affects fair-skinned people leads to delayed diagnosis in people with darker skin. Acral lentiginous melanoma — which occurs on the palms, soles, and under fingernails and toenails — is the most common subtype in people with darker skin and has no relationship to UV exposure. Dark streaks under a nail (subungual melanoma) are frequently dismissed as bruising. Any persistent dark band in a nail, particularly if it is widening, should be assessed by a dermatologist.

4. The revolution in metastatic melanoma treatment is not reaching all patients equally. Five-year survival for stage IV melanoma has improved from approximately 5–10% to 25–35% with modern checkpoint inhibitors and targeted therapy. However, not all patients are offered full genomic profiling of their tumour (BRAF testing) or prompt referral to a specialist melanoma centre. NHS guidelines require BRAF testing for all newly diagnosed advanced melanoma, but implementation is not universal. Patients with newly diagnosed stage III/IV melanoma are entitled to ask their oncologist about BRAF mutation testing and whether they are eligible for immunotherapy or targeted therapy clinical trials.

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