In size of lesion irregular pigmentation irregular border minor features inflammation itch/altered sensation lesion larger than others oozing/crusting of lesion table 4: the abcde lesion system a geometrical asymmetry in two axes b irregular border c at least two different colours in lesion d maximum diameter >6 mm e elevation of lesion clinical diagnosis of melanoma is difficult and the accuracy of diagnosis may vary according to a clinician’s level of experience, with reports of considerable variation in sensitivity from 50 to 86% and an inverse relationship between sensitivity and experience. 41, 42, 43 evidence level 3 high magnification dermatoscopy is more sensitive than non-dermatoscopic diagnosis when used by clinicians with experience of the technique. buy viagra online 44 high magnification requires more sophisticated equipment than the current widely-used hand held dermatoscopy. Evidence level 1+ training clinicians to be ‘experts’ in hand held dermatoscopy improves diagnostic accuracy but it may diminish the sensitivity of the diagnosis of ‘non-expert’ or untrained dermatologists. viagra soft foro 45, 46, 47 observational studies have compared excision and pathological assessment to using other preoperative assessment methods of diagnosis including magnetic resonance imaging (mri), high resolution ultrasound (us) and digital imaging of possible melanomas. 48, 49, 50, 51 these studies failed to show significant benefit and require specialist equipment that is unlikely to be widely available. Evidence level 1+,3 clinicians should be familiar with the 7 point or the abcde checklist for assessing lesions. viagra tadalafil lilly Clinicians using hand held dermatoscopy should be appropriately trained. viagra canada online A flow chart showing the suggested management of cutaneous melanoma is given at the end of this chapter. viagra soft avis 3. 2. viagra online 1 the unknown primary when melanoma presents as a metastasis and no primary melanoma site can be identified the patient should be referred to the appropriate regional specialist (see section 8 ). viagra viagra online 3. real viagra online without prescription 3 delay in diagnosis nine observational studies exploring delay were identified. viagra without prescription 41, 52, 53, 54, 55, 56, 57, 58, 59 significant delays (>three months) in diagnosis of invasive melanoma are usually patient- rather than physician-related. viagra viagra online 41, 52, 53, 54, 55, 56, 57, 58, 59 delay was defined differently in each study, with some including both patient and physician components. viagra viagra online Evidence level 3. viagra no prescription demographics of viagra users