What's New

This pathway has been produced by representatives from both primary and secondary care to support the management of dermatological conditions. These guidelines accompany the publication of new referral criteria from GHFT. The pathway is based on both PCDS guidance on the management of dermatological conditions, GHFT guidelines and the current CCG commissioning policies and supports the local guidance agreed by experts throughout the healthcare system.

Benign Asymptomatic / Congenital Naevi Care Pathway Overview

A mole is a common benign skin lesion due to a local proliferation of pigment cells (melanocytes). It is more correctly called a melanocytic naevus.

A mole can be present at birth (congenital naevus),  or appear later (acquired naevus). There are various kinds of congenital and acquired naevi.

About 1% of individuals are born with one or more congenital melanocytic naevi. This is usually sporadic, with rare instances of familial congenital naevi. Fair-skinned people tend to have more moles than darker skinned people.

Moles that appear during childhood (aged 2 to 10 years) tend to be the most prominent and persistent moles throughout life. Moles that are acquired later in childhood or adult life often follow sun exposure.

Although the exact reason for local proliferation of naevus cells is unknown, it is clear that the number of moles a person has depends on genetic factors, on sun exposure, and on immune status. People with many moles tend to have family members that also have many moles, and their moles may have a similar appearance.

They may be flat or protruding, ranging in size from a couple of millimetres to several centimetres in diameter. Although mostly round or oval in shape, moles are sometimes unusual shape and vary in colour from pink or flesh tones to dark brown, steel blue, or black. Light skinned individuals tend to have light-coloured moles and dark skinned individuals tend to have dark brown or black moles.

A huge range of benign mole types exist – see http://www.dermnetnz.org/topics/moles/ for pictures.

Please click the relevant flowchart box to be taken directly to textual information



Most patients will present because they have noticed a new mole, or a change in a mole. Any changing mole must be assessed for possible melanoma. Any new mole in a patient over the age of around 40 should be assessed carefully as it is more likely to be a melanoma.

It is common for patients to present with a mole that has become inflamed, itchy, or crusted, particularly at a site where it rubs on clothing.

It is also common for people to request moles be removed for cosmetic reasons.

Red Flags
The concern with moles is whether they may be melanomas. A score of 3 or more on the weighted 7 point checklist (below) suggests melanoma and should be referred via the 2ww Skin Cancer Pathway.
Differential Diagnosis

The main differentials are;

Initial Assessment

Any changing mole should be assessed with the following risk factors in mind.

1. Over 100 moles or >50 moles on the trunk.

2. Fair skin, blue eyes and freckles.

3. Atypical moles (large irregular moles).

4. Large permanent lentigines on shoulders (giant freckles) indicative of solar damage.

5. Moles on the buttocks, palms and soles.

6. >40 years old.

7. Family history of atypical mole syndrome or MM.

8. Large (>5 cm diameter) congenital moles.

1. Changing Mole:

  • Change in shape
  • Change in colour
  • Change in size

2. Does it have a ragged outline? Ordinary moles are smooth and regular.

3. Does it have a variable pigmentation within it? Shades of brown and black. Ordinary moles may be brown or black but usually are of one shade. Moles surrounded by an area of depigmentation are called halo naevi and are benign. A new halo naevus occurring on an adult is rarely a sign of a immunological response to a MM and should prompt a search of other skin sites.

Major features of the lesions (scoring 2 points each):

  • change in size
  • irregular shape
  • irregular colour

Minor features of the lesions (scoring 1 point each):

  • largest diameter 7 mm or more
  • inflammation
  • oozing
  • change in sensation.

Practice Point

Many seborrhoeic keratoses will score 3 or more on the weighted 7 point checklist, and may often be easily distinguished by dermoscopy. If the GP feels a seborrhoeic keratosis is a likely diagnosis, and has access to dermoscopy, they can photograph the lesion and ask for advice via the Advice and Guidance Service. When doing so, it is important to send a close up macro picture and an overview clinical picture along with the dermoscopy photo – please see the Seborrhoeic Keratoses Pathway for further information.

A dermoscopic and clinical picture can be sent to dermatology via the Advice and Guidance Service. This is especially true if:

  • A new mole develops in adult life (> 40 years)
  • It appears different from the person’s other moles (a so-called ugly duckling)
  • It has ABCD characteristics (Asymmetry, Border irregularity, Colour variation, Diameter > 6 mm)
  • It is bleeding, crusted or itchy
  • It scores 3 or more on the weighted 7 point checklist

Most skin lesions with these characteristics are actually harmless when evaluated by an expert using dermoscopy.

Practice Point

Occasionally, flat (non-palpable) moles can be monitored by dermoscopic photographs at an interval of 3 months. If doing this, it is always helpful to take a picture through the dermoscope on the patient’s own camera/phone so that if they are referred to dermatology subsequently, the dermatologist has a baseline dermoscopic photograph. 

Initial Primary Care Management

Most melanocytic lesions can be ignored, as they are harmless. Sun exposure increases the number and degree of atypicality of moles, a good reason for encouraging sun protection (see Ongoing Primary Care section for advice).

Moles may be removed in primary care if they are symptomatic and thought to be benign.

Surgical removal may entail:

  • Shave biopsy
  • Excision biopsy

The coarse hair that sometimes grows in a mole can be removed by shaving. Plucking may cause inflammation resulting in a painful lump under the mole. The hair can only be removed permanently by electrolysis, laser epilation or excision of the whole mole.

Key Point

Skin lesions that have been removed surgically should always be sent for pathology.

If there is concern that a lesion could be a melanoma, it should be referred via the 2ww Skin Cancer Pathway to be completely excised with 2-3 mm margin. 

When to Refer

Moles that are very symptomatic and causing distress for (non-cosmetic) reasons may be referred to intermediate care services such as community GPSI clinics. Please see the Services and Referrals section for further information and inclusion/exclusion criteria.

Referral to Secondary Care should be reserved for cases where there is diagnostic doubt. Dermoscopy and clinical photographs sent by the Advice and Guidance Service will allow the patient (and GP) a much quicker response, and allow many patients to be reassured much more quickly than a face to face referral. This is the optimum process for moles where the GP needs more help or advice.

If melanoma is suspected please refer via the 2ww Skin Cancer Pathway.


Individual Funding Requests

Surgical treatment for removal of symptomatic skin lesions is funded for patients that meet the criteria set out in Gloucestershire CCG's Effective Clinical Commissioning Policy. Funding approval for eligible patients must be sought from the CCG via the Prior Approval process prior to treatment. Please see this link for details of access criteria and funding arrangements.

Secondary Care Management - GHNHSFT

Benign moles cannot be removed in secondary care. Only where there is suspicion of malignancy can a mole be removed. Please see the IFR Section for further information on the GCCG's Clinical Commissioning Policy.

Ongoing Primary Care

Provide advice for those patients at risk of melanoma (people with freckles, red hair, skin which burns in the sun, those with previous melanoma or family history of skin cancer, people with more than 50 moles and immunosuppressed people. Patients can access the Cancer Research SunSmart campaign which provides information on sunscreens, sunburn, moles and skin cancer, vitamin D and winter sports.

Encourage patients to perform monthly self-examinations and advice on when to access medical advice. The American Academy of Dermatology website provides useful information for patients.


Patient Resources

Please see the Patient & Carer Information & Leaflets section.

Resources for Professionals

National Standards

Please see the National and NICE Guidance section.

Other Online Resources

Pathway Leads





Zain Patel

Commissioning Manager


Gloucestershire Clinical Commissioning Group


Dr Chin Whybrew


Gloucestershire Clinical Commissioning Group


Dr James Milne

Consultant Dermatologist

Gloucestershire Hospitals Foundation Trust


Reason for Pathway Selection

This pathway has been produced by representatives from both primary and secondary care to support the management of dermatological conditions. These guidelines accompany the publication of new referral criteria from GHFT. The pathway is based on both PCDS guidance on the management of dermatological conditions, GHFT guidelines and the current CCG commissioning policies and supports the local guidance agreed by experts throughout the healthcare system.

Completion Date

December 2016

Review Date

December 2017