How doctors assess moles, spots and freckles

Introduction

Doctors assess moles, spots and freckles by asking what has changed, checking your skin cancer risk, examining the spot closely, and often using dermoscopy (a handheld skin microscope).

The aim is to decide whether it looks harmless, should be photographed and monitored, needs a biopsy, should be removed, or should be referred for specialist assessment.

You do not need to know whether something is a freckle, mole, sunspot or skin cancer before booking. That is the point of the consult.

Getting an accurate history

The first step is understanding the story of the spot.

Your GP will usually ask:

• How long has it been there?
• Is it new, or has it been present for years?
• Has it changed in size, shape, colour or texture?
• Has it become itchy, painful, tender, crusted or bleeding?
• Does it heal and then break down again?
• Have you had skin cancer before?
• Is there a family history of melanoma?
• Have you had significant sun exposure, outdoor work or solarium use?
• Are you immunosuppressed?

This matters because change is one of the most important warning signs. A mole that has looked the same for years is usually approached differently from a mole that is changing over weeks or months.

Early skin cancer symptoms may include a spot, lump or scaly area, or a mole that changes colour, size or shape. Skin cancers may also bleed, become inflamed or feel tender [1]. This can cause them to look like a scab or pimple which isn’t going away after a few months.

Dermoscopy: the skin microscope

Dermoscopy is one of the most useful tools your GP will use in a skin cancer check.

A dermatoscope is a handheld device that uses magnification and light to examine skin structures that are not visible to the naked eye. It allows the doctor to look beneath the surface pattern of a mole, freckle or skin spot.

Dermoscopy works best when combined with the history, the appearance of the lesion, the rest of the patient’s skin, and the doctor’s training and experience.

Why dermoscopy is essential

Without dermoscopy, some skin cancers can look deceptively harmless. Some melanomas are not obviously dark or dramatic. Some basal cell carcinomas can look like a small pink bump, a pimple that will not heal, or a subtle shiny patch. Some squamous cell carcinomas can look like a thickened or scaly area of sun damage.

Dermoscopy improves the ability to assess these lesions. A Cochrane review found that dermoscopy is more accurate than visual inspection alone for diagnosing melanoma in adults, especially when used in person by trained clinicians [2].

What can doctors see under dermoscopy?

Under dermoscopy, doctors can assess features of moles or spots such as:

• pigment patterns
• blood vessel patterns
• symmetry or asymmetry
• borders
• colour variation
• structures suggesting a benign mole
• features suspicious for melanoma
• features suggesting basal cell carcinoma
• features suggesting squamous cell carcinoma or actinic keratosis

This can change the diagnosis. A spot that looks fairly harmless to the naked eye may show suspicious features under dermoscopy. The reverse can also happen: a spot that looks worrying to the patient may have dermoscopic features of a benign lesion.

That is why dermoscopy can help decide whether a spot can be safely monitored, or whether it needs biopsy, excision or another treatment.

The full skin check

A full skin check is a systematic examination of the skin, usually from head to toe. This is different from quickly looking at one mole.

The doctor will generally check sun-exposed areas such as the face, ears, neck, scalp, arms, hands, legs and feet, as well as less obvious areas depending on the type of appointment and your level of concern. The process is usually systematic so that areas are not missed.

During the check, the doctor may:

• examine your skin generally
• compare moles and spots with each other
• look for the “ugly duckling” (a spot that looks different from your usual pattern)
• use the dermatoscope on individual lesions
• take clinical or dermoscopic photos if monitoring is appropriate
• recommend a biopsy if the diagnosis is uncertain
• recommend excision if a lesion is suspicious or needs removal
• reassure you if the spot appears benign

Photography can be useful when a lesion is low-risk but worth monitoring. It gives a point of comparison at the next appointment. However, monitoring should have a clear timeframe and plan. A spot that is rapidly changing, bleeding, painful, crusting or not healing may need biopsy or removal rather than simply being watched.

What to do before your appointment

Before a skin check, it helps to:

• avoid covering the spot with makeup
• take a clear photo if the spot is changing
• write down when you first noticed it
• mention any symptoms such as bleeding, pain, itch or crusting
• bring previous skin cancer or biopsy results if you have them
• mention any family history of melanoma
• mention any past skin cancers or significant sun exposure
• book a full skin check appointment if you have multiple spots to review

A full skin check can take longer than a standard appointment, especially if there are many moles or sun-damaged spots to examine.

When should I get something checked?

You should book a skin check if a mole, freckle or skin spot is:

• new
• changing
• growing
• bleeding
• crusting
• itchy
• painful
• tender
• scaly
• shiny
• not healing
• changing colour
• changing shape
• different from your other spots

Cancer Council Australia advises seeing a doctor if a mole looks different, if a new mole appears after age 25, or if you are unsure whether something is a harmless mole, sun damage or possible skin cancer [3].

You should also consider skin checks if you have risk factors such as previous skin cancer, many moles, strong family history of melanoma, fair skin, high sun exposure, outdoor work, immunosuppression or previous solarium use.

RACGP preventive health guidance recommends a risk-based approach to skin checks rather than routine screening for everyone at the same interval [4]. In practice, that means the right timing depends on your personal risk and whether there is a specific spot of concern.

Summary

A proper skin check is more than a quick glance at a mole.

Doctors assess moles, spots and freckles by taking a history, examining the skin carefully, using dermoscopy, comparing lesions with the rest of your skin, and deciding whether the spot can be reassured, photographed, monitored, biopsied, removed or referred.

The most important reason to book is change. If a spot is new, growing, bleeding, crusting, itchy, painful, scaly, not healing, changing colour or shape, or simply looks different from your other spots, it is worth getting checked.

Dr Christian Peut is a GP in Adelaide with training in dermoscopy. He routinely performs skin cancer checks, assessment of suspicious moles, spots and freckles, and simple skin procedures including biopsies and selected skin cancer excisions and surgeries.

If you have multiple spots to check, book a full skin check appointment. These appointments can take around 20–30 minutes depending on the number of spots to examine.

References

1. Healthdirect Australia. Skin cancer and melanomas.
2. Dinnes J, Deeks JJ, Chuchu N, et al. Dermoscopy, with and without visual inspection, for diagnosing melanoma in adults. Cochrane Database of Systematic Reviews. 2018.
3. Cancer Council Australia. Check for signs of skin cancer.
4. RACGP. Guidelines for preventive activities in general practice: Skin cancer. Updated 28 June 2024.