Family physicians play a critical role in early detection of skin cancers. Although visual inspection is the initial step, dermoscopy significantly improves diagnostic accuracy, particularly for melanoma and basal cell carcinoma. Advanced imaging technologies such as reflectance confocal microscopy, optical coherence tomography, and high-frequency ultrasonography may further enhance accuracy and reduce unnecessary procedures. However, these technologies are primarily used in academic or specialty dermatology settings. Biopsy is required for definitive diagnosis. For nonmelanoma skin cancers, no single biopsy technique has demonstrated superiority. A shave, punch, incisional, or excisional technique should be selected based on lesion characteristics, patient factors, and clinical judgment. For melanoma, excisional biopsy with margins of 1 to 3 mm and full-thickness removal is preferred. Saucerization (deep shave removal of the entire clinical lesion to the mid-dermis or deeper) may be acceptable if it allows accurate assessment of Breslow depth. Basal cell carcinoma subtypes include nodular, superficial, morpheaform (sclerosing), and infiltrative. Cutaneous squamous cell carcinoma is classified as in situ or invasive. The clinical subtypes of melanoma include superficial spreading, nodular, lentigo maligna melanoma, amelanotic, and acral lentiginous. If biopsy is not feasible because of lesion location or clinical suspicion persists despite benign histology, prompt dermatology referral is warranted.
Nelson M, Hamel RK, Nash J. Skin Cancer: Diagnosis. FP Essent. 2026;564:14-22.
Case 2. YJ is a 65-year-old farmer who presents with an irregular brown patch on his right cheek. It measures 2.5 cm × 2 cm and has color variation. You suspect lentigo maligna (melanoma in situ) but are uncertain how to proceed with the biopsy. The closest dermatologist is 2 hours away and has a 6-month wait.
Clinical Evaluation and Dermoscopy
Family physicians are often the first point of contact for patients with concerning skin lesions. A thorough evaluation includes a focused history, skin examination, and clinical photographs. Dermoscopic images, when available, improve diagnostic accuracy.1 For basal cell carcinoma, visual inspection alone has a sensitivity of 79%, which increases to 93% with dermoscopy.2 In a theoretical sample of 1,000 lesions, dermoscopy would identify 24 additional basal cell carcinomas and prevent 183 unnecessary procedures for benign lesions.3 There are insufficient data for the accuracy of visual inspection compared with dermoscopy for cutaneous squamous cell carcinomas.2 For melanoma, dermoscopy increases sensitivity from 76% to 92% and specificity from 75% to 95%.4 In a Cochrane review, primary care physicians using visual inspection alone correctly identified 92% of melanomas but also misidentified approximately 20% of benign lesions as suspicious, although this estimate had a wide confidence interval (26.2%-99.8%).5
Training in dermoscopy can increase a family physician’s diagnostic accuracy from 54% to between 76% and 79%.6 A survey of family medicine residency programs found that at least one-half had a faculty member with a dermoscope and experience using it. However, only 6.8% of residents received 4 or more hours of hands-on dermoscopy training.7
Several online dermoscopy courses are available, including a free option from DermNet (https://dermnetnz.org/cme/teledermatology-skin-cancer/dermoscopy-training-options). Another dermoscopy resource for family physicians is the Primary Care Dermatology Society website (https://www.pcds.org.uk/dermoscopy-an-overview). Mayo Clinic offers an annual practical course in dermoscopy with virtual and in-person options (https://ce.mayo.edu/dermatology/content/21st-annual-practical-course-dermoscopy-update-malignant-melanoma-2026). The American Dermoscopy meeting provides virtual and in-person options as well (https://americandermoscopy.com/2026). Smartphone apps, such as the free Dermoscopy Two Step Algorithm app, can assist clinicians who are new to dermoscopy by providing examples of benign and malignant lesions.
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