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

For a Broader Interpretation

We propose that broaden ing the interpretation of the ugly duckling may enhance detection of MM and reduce MM-related mortality. Despite significant public awareness efforts, MM mortality has been increasing in older individuals, particularly elderly males.[12] The rise in mortality in elderly men has been attributed to the higher frequency of thicker MM, especially nodular MM.[13,14] Nodular melanoma comprises approximately 20 percent of all MMs, and unlike other subtypes, tends to grow rapid ly. Furthermore, it is notorious for lacking the classic ABCDE signs.[15] Based on its rapid growth rate and failure to manifest any of the ABCDE analytic criteria, this MM subtype may not be amenable to detection via traditional periodic physician-based screening efforts. Thus, we face the challenge of defining new strategies that both clinicians and the lay public can use to help detect nodular MM.

We suggest thinking of the ugly duckling as the lesion that at a given moment in time looks or feels different than the patient's other moles, or that over time, changes differently than the patient's other moles. Patients may also communicate anxiety about a specific lesion or ill-defined symptoms or sensations related to the lesion; frequently enough, their history on a lesion includes their report that it "feels different." Such patient reports should be taken seriously, and in the absence of clearly reassuring benign features, they should prompt excision or close monitoring.

At times, monitoring lesions using digital photography is a screening strategy for detection of change. Melanoma generally changes at a different rate or with a different pattern than a patient's other moles. This reflects the concept of "E" for evolution that was recently added to the ABCD acronym.[4] Patients should be instructed to contact their physician if they notice a rapidly changing ugly duckling; physicians, in turn, should be receptive to see the patient as an acute visit focused on this changing lesion.[16,17] Shorter intervals to biopsy could be important in avoiding a delay in diagnosis of a rapidly growing MM, such as nodular MM, whose growth rate in terms of thickness has been estimated at 0.5 mm per month.[15]

How does the ugly duckling sign fit into the overall scheme of early MM detection? The clinical approach to pigmented lesions is presented in the Table. In patients with numerous moles, we screen to identify suspicious lesions by using three variations of the ugly duckling concept: 1) by inquiring about changing or symptomatic lesions, 2) by comparing lesions to baseline images, and 3) by detecting outliers in the background pattern of the patient's moles. Once a suspicious lesion is identified, we focus on it through clinical observation, magnification, and lor dermoscopy, and if its pattern is benign, we move on. If the overall pattern fits the gestalt of a clear-cut MM (e.g., satisfies the ABCDE criteria), we opt for removal. If the pattern cannot be easily categorized into either, we may use analytical criteria (e.g., inspect the lesion in detail to see whether there are any suspicious dermoscopic structures). Depending on what is found, we may then decide to remove the lesion for definitive diagnosis or perform short-term mole monitoring to assess its biological nature.


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