The Skin Lesion That Had Been There for Ten Years, and the Trigger Finger That Came With It
In my 21 years practising at Clinique Alpa here in Palmers Green, the cases that stay with you are the ones that almost slipped past on a busy Tuesday morning. This was one of them. An older patient, brought in by her daughter to have a look at a lesion on the back that had been sitting there for ten years. Long-standing does not mean benign, and that single sentence is the entire reason this case ended in a two week wait dermatology referral, not in routine reassurance.
The presentation, and the family advocate in the room
The patient attended with her daughter. Both contributed to the history. The skin lesion on the back had been there for approximately ten years, slowly enlarging over time. There was a family history of similar-looking lesions in the patient’s father, the outcome ambiguous in family memory. There was a separate concern in the same visit: the left ring finger had become crooked and was getting stuck on flexion, with inflammation in the surrounding tissue.
The patient’s general medical record was helpful and reassuring on the larger questions. Previous endoscopy was normal. Previous CT scan of the abdomen was normal. Recent bowel cancer screening was negative. Long-standing supplementation with vitamin D, no recent blood tests in the previous 10 months. Continuing supportive medication for stomach symptoms. The history was complete enough to focus today’s visit on the two presenting concerns: the back lesion, and the hand.
Why the lesion changed the pathway
Most lesions on the backs of older patients are seborrhoeic keratoses. Most stay benign. The features that move a lesion from a routine referral to a two week wait pathway are well described and clinically important. In this case the lesion was 2 cm by 1 cm, raised, broadly spherical. The edges were partly poorly demarcated. There were two to three smaller satellite lesions in the surrounding skin. The lesion had been slowly enlarging over a decade.
Any one of those features in isolation is not enough. The combination is. Poorly demarcated edges, satellite lesions, and steady enlargement, in combination, mean the senior dermatology eye is the right next step, not a primary care best guess. NICE NG12, the suspected cancer recognition and referral guideline, frames the pathway and the timeline. The referral made today goes through the suspected skin cancer two week wait pathway, with a guaranteed consultant review.
Clinical anomaly: what was almost missed
First, what was almost missed. The lesion is, on probability, a seborrhoeic keratosis. Most lesions like this are. The features that move this case from reassurance to referral are easy to skip in a short appointment: the poorly demarcated margins, the satellite lesions, and the steady enlargement over a decade. A reassuring quick look would have been the predictable outcome of an 8 minute slot, and the wrong outcome.
Second, where the standard NHS pathway would have gone. Standard primary care, on a busy day, would in many cases take a photograph and send a routine dermatology referral, sometimes a non-urgent one. The deviation here is the specific use of the suspected skin cancer two week wait pathway, framed by the morphology rather than by the surface diagnosis. The two week timeline matters. Same day private GP access here also offered a guaranteed consultant review through the clinic’s relationships, removing the bottleneck of triage at the receiving end. NICE NG12 is the guideline that frames the language of the referral letter; getting the framing right is part of the job, because that framing is what triages the letter properly when it lands.
Third, what differentials were ruled out. For the back lesion, pigmented basal cell carcinoma was kept on the differential and surfaced explicitly to the dermatology team in the referral letter. Atypical melanocytic naevus was on the list and is, similarly, a senior dermatology call to make in the clinic, not a primary care call. For the hand, Dupuytren contracture was excluded by the absence of a palmar nodule and palmar cord; the deformity here was at the digit, not the palm. Rheumatoid involvement was reduced by the absence of synovitis at the metacarpophalangeal and proximal interphalangeal joints, no early morning stiffness pattern, and no other small joint involvement; bloods were organised regardless, including vitamin D and a full blood count.
The trigger finger, and why it was not an afterthought
Trigger finger, or stenosing tenosynovitis, is a clinical diagnosis at the A1 pulley, where the flexor tendon catches on a thickened pulley as the finger bends. The result is the digit catching, locking, and sometimes releasing with a snap. The visible deformity at rest, the inflammation around the affected area, and the catching on movement, all point to the diagnosis.
The management today was conservative first. A topical anti-inflammatory cream was prescribed to settle the local inflammation. Steroid injection, which is the next step if conservative measures do not settle the issue, was held in reserve and explained to the patient. Hand surgery is the third step, only relevant if the steroid injection does not solve the catching. The reason for sequencing matters: most trigger fingers respond to the topical and the injection; surgery is the last resort.
The same visit also organised a comprehensive blood profile, including vitamin D, full blood count, and inflammatory markers. The reason for the blood test is to keep the rheumatological differential properly closed and to keep the supplementation properly monitored. Vitamin D level is worth knowing in any patient on long-standing supplementation, because the dose may need to be adjusted up or down over time.
Why having a family member in the room mattered
An older patient brought to clinic by a family member often has two or three concerns at once. The skill, in a same day private GP setting, is doing right by all of them in one appointment. The daughter in this case provided continuity of history, helped with translation of nuance, and was the person who would chase the appointment if it did not arrive. That is the practical reality of how same day private GP care happens for older patients: it is, often, family-supported. The clinic’s job is to use the visit fully, not to ration it across three separate visits over six weeks.
What a 2WW dermatology referral involves
The two week wait pathway, also called the urgent suspected cancer pathway, is the NHS commissioned route for any patient with features that raise the suspicion of skin cancer. The patient is offered a consultant dermatology appointment within two weeks of the referral being received. The dermatology team will examine the lesion in detail, often with dermoscopy, which uses a specialist hand-held lens with cross-polarised light to inspect the lesion’s architecture below the skin surface. If the lesion is benign on inspection, the patient is reassured and discharged. If the lesion needs sampling, an excision biopsy is performed under local anaesthetic, with histology read by a dermatopathologist. The aim of the pathway is not to confirm cancer; the aim is to exclude it, with the senior eye, on a timeline that makes the exclusion useful.
When to see a same day private GP about a skin lesion
Long-standing does not mean safe. Several thresholds should move a patient towards a same day private GP appointment rather than a wait-and-see at home. Any new lesion in an adult that has been growing in the last 6 months. Any lesion with poorly demarcated edges. Any lesion with satellite lesions developing around it. Any lesion that itches, bleeds, ulcerates, or changes colour. Any lesion in a patient with a family history of skin cancer or with extensive sun exposure. The point of the same day appointment is the time to look properly, the time to use the right pathway language, and the time to organise the imaging and the bloods alongside, in one visit.
What Clinique Alpa offers
Same day access. Live record review. Time to inspect a lesion properly. The discipline to use the right pathway when the morphology calls for it, rather than defaulting to a routine referral. Time to manage the trigger finger at the same visit, with the right sequence of options explained, not a single line of advice. Time to organise the blood tests in a single appointment, not across three separate ones. No prescription only medicine names in our public writing, because the rule is the right rule. What the patient and the family leave with is a referral, a prescription, blood test forms, and a clear plan, in one visit.
Read more on this theme on our pillar page: Same Day Private GP, Palmers Green.
Clinique Alpa. Same day private GP, Palmers Green, North London.