The "Ugly Duckling" Sign: An Early Melanoma Recognition Tool For Clinicians and the Public

Alon Scope, MD; Ashfaq A. Marghoob, MD


The Melanoma Letter. 2007;25(3):1-3. 

In This Article

The Advent of the Ugly Duckling Concept

In 1998, Grob, et al[7] introduced the ugly duckling concept-the observation that nevi in the same individual tend to resemble one another, and that MM often deviates from this nevus pattern. This clinical realization pointed to the importance of not just evaluating the morphology of the lesion in question, but also comparing it to that of surrounding lesions, looking for an outlier in the background of similar-appearing moles. For example, the outlier lesion can be larger and darker than the surrounding moles (Figure 1 A), or conversely, small and red in the background of multiple large dark moles (Figure 1 B). Finally, if the patient has few or no other moles (Figure 1 C). any changing lesion should be considered a suspicious outlier.

Figure 1.

Three Examples of an Ugly Duckling

Three different clinical scenarios are shown where outlier lesions (" ugly ducklings ") should prompt suspicion. Squares A, B, and C each represent a body area such as the back. In A, the patient has one dominant mole pattern with slight variation in size. The outlier lesion is clearly darker and larger than all other moles. In B, the patient has two predominant nevus patterns, one with larger nevi and one with small, darker nevi. The outlier lesion is small but lacks pigmentation. In C, the patient shows only one lesion on the back. If this lesion is changing, symptomatic, or deemed atypical, it should be removed.

The clinician utilizing the ugly duckling sign is engaged in a process called differential recognition. Gachon, et als described the three principle mental processes for image recognition: overall pattern recognition, known as gestalt; analytic criteria recognition such as the ABCDEs; and differential recognition—recognizing the differences between objects—i.e., the ugly duckling concept. In their study, Gachon, et al surveyed dermatologists for perception parameters that prompted surgical removal of pig-mented lesions. Differential recognition of the ugly duckling sign was more discriminatory between MM and other nevi than the ABCDE criteria.[8]


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.