The importance of a full clinical examination: assessment of index lesions referred to a skin cancer clinic without a total body skin examination would miss one in three melanomas.

Traditional clinical teaching emphasises the importance of a full clinical examination. In the clinical assessment of lesions that may be skin cancer, full examination allows detection of incidental lesions, as well as helping in the characterisation of the index lesion. Despite this, a total body skin examination is not always performed. Based on two prospective studies of over 1,800 sequential patients in two UK centres we show that over one third of melanomas detected in secondary care are found as incidental lesions, in patients referred for assessment of other potential skin cancers. The majority of these melanomas occurred in patients whose index lesion turned out to be benign. Alternative models of care--for instance some models of teledermatology in which a total body skin examination is not performed by a competent practitioner--cannot be considered equivalent to a traditional consultation and, if adopted uncritically, without system change, will likely lead to melanomas being missed.