the number of yearly deaths from melanoma continues to increase , and the overall melanoma mortality rate is one of the few cancer mortality rates not on the decline .
these realities combined with increasing evidence of the lack of efficacy of the abcde criteria have necessitated ongoing efforts to enhance the earlier clinical detection of melanoma [ 38 ] .
most approaches to melanoma diagnosis have included some predominant emphasis or combination of emphases on recognition of changing lesions , recognition of outlier (  ugly - duckling  ) lesions , and specific melanoma characteristics , with the most utilized criteria being the abcde criteria (  a  for  asymmetry ,   b  for  border irregularity ,  
d for 6 mm diameter ,  and  e  for  evolving lesions  ) .
many recently published strategies have rejected the diameter criterion as well as abandoned all or portions of the abcde mnemonic [ 3,5,912 ] .
many of these proposed strategies , including the  d  for  dark  proposal i offered , have also added emphasis on recognition of darkness as a particular feature of concern in pigmented lesions [ 5,1012 ] .
i have recently reviewed the compelling rationale for both an increased emphasis on darkness and rejection of the diameter criterion in the clinical diagnosis of melanoma .
the georgia approach to melanoma diagnosis uniquely incorporates many elements of these strategies in a complementary manner to increase the sensitivity of diagnosis of early melanoma   ( figure 1 ) .
in their review of melanoma diagnosis , marghoob and scope discuss the concepts of a screening examination to identify lesions of possible concern and then the specific lesion assessment that follows .
this distinction is important because the screening examination determines the sensitivity of melanoma recognition , and it is the screening examination that really describes how most practitioners examine patients and how patients examine each other .
first , the georgia approach places increased emphasis on the screening examination by initial , distinct discussion and clarification of its function .
second , the approach includes both of the two screening strategies that have been used in most melanoma educational materials , change and ugly duckling identification .
third , the approach adds the easily perceived , easily communicated , highly sensitive , specific ( compared to change and ugly duckling identification ) screening feature of darkness .
a major tenet of physical diagnosis , particular for early diagnosis , is that one sees what one looks for .
a strategy based on recognition only of any lesion that changes or differs from other lesions inadequately considers this principle .
the added benefit of looking specifically for dark lesions as part of a screening examination for melanoma can not be overstated ; many melanomas , particularly small melanomas , can be recognized because of , and only because of , their intensity of pigment .
nonetheless , with melanoma , as with screening features for nearly every disease , no one feature has 100% sensitivity .
the description of the screening examination for melanoma detection includes the instruction to examine the skin in order to detect any lesion that stands out because of being dark , different , or changing .
each of the three screening features has non - redundant as well as complementary importance in the recognition of melanoma .
the screening examination should usually include two looks , one for any lesion that stands out at all , which should allow detection of changed or ugly duckling lesions , and a second look to identify lesions of any size that stand out because of appearing , even focally , dark .
consequently , the emphasis on darkness as a screening feature should only enhance the sensitivity of diagnosis of melanoma .
though the impact of the abcde criteria on melanoma detection has been uncertain , the publication and utilization of these criteria are ubiquitous , and the criteria have many supporters . as marghoob and scope
help elucidate , however , the role of the abcde criteria is not as a screening approach , as they have been utilized , but as a spot evaluation , and the criteria can also help to assess the level of concern when comparing similar lesions .
thus , the criteria have value , but one that requires this more precise explanation .
the meanings of the a , b , c , and e in the georgia approach are unchanged from usual use :  a  for  asymmetry ,
  c  for  color variation ,  and  e  for  evolving  unlike other lesions .
what is critical to the utility of the abcde criteria , however , is the change of the  d  to signify  dark  and not  6 mm diameter .  with this change , and without altering the familiar mnemonic ,
the criterion never present in the earliest melanomas is replaced by the single criterion that characterizes many early melanomas .
it can now be stated more accurately that most melanomas have one or more of the abcde criteria and that the criteria are relevant to the diagnosis of early melanomas . as a criterion of an individual lesion , similar to its utilization as a screening feature
, the characteristic of darkness has non - redundant value and , in addition , enhances the application of other criteria .
there is increasing support for the strategy of melanoma recognition based on the concept that a melanoma will differ in appearance from one s usual moles , referred to as the  ugly - duckling  rule .
the possible utility in this concept is reflected in the georgia approach both as a screening feature (  different  ) and in the  e  for  evolving  description (  has a mole . .
unlike others on your body ?  ) . in the third component of the georgia approach , the  ugly - duckling  sign
is specifically defined , conveying additional emphasis on and understanding of this strategy and its application .
nodular melanomas represent a minority of melanomas but contribute disproportionately to melanoma mortality , and the final portion of the georgia approach is devoted to specific education about the diagnosis of this melanoma subtype .
the varied presentations of nodular melanomas , including as amelanotic lesions , are specifically discussed , as is the particular relevance of change and ugly duckling recognition to the diagnosis of these melanomas .
the inclusion of the nodular melanoma pictured adds further emphasis on both the diagnosis of nodular melanomas and of the relevance of change recognition to their diagnosis .
nonetheless , as nodular melanomas have metastatic potential both in a shorter time frame and when smaller in diameter than other melanomas , the previously discussed addition of dark as a screening feature and the  d  for  dark  change may have particular impact on decreasing mortality by enhancing the earlier diagnosis of this melanoma subgroup .
in addition to the potential impact on the diagnosis of earlier nodular melanomas by removing any diameter consideration , many early nodular melanomas , similar to other melanoma subtypes , are characterized by their dark pigment .
in their review of melanoma diagnosis , marghoob and scope discuss the concepts of a screening examination to identify lesions of possible concern and then the specific lesion assessment that follows .
this distinction is important because the screening examination determines the sensitivity of melanoma recognition , and it is the screening examination that really describes how most practitioners examine patients and how patients examine each other .
first , the georgia approach places increased emphasis on the screening examination by initial , distinct discussion and clarification of its function .
second , the approach includes both of the two screening strategies that have been used in most melanoma educational materials , change and ugly duckling identification .
third , the approach adds the easily perceived , easily communicated , highly sensitive , specific ( compared to change and ugly duckling identification ) screening feature of darkness .
a major tenet of physical diagnosis , particular for early diagnosis , is that one sees what one looks for .
a strategy based on recognition only of any lesion that changes or differs from other lesions inadequately considers this principle .
the added benefit of looking specifically for dark lesions as part of a screening examination for melanoma can not be overstated ; many melanomas , particularly small melanomas , can be recognized because of , and only because of , their intensity of pigment .
nonetheless , with melanoma , as with screening features for nearly every disease , no one feature has 100% sensitivity .
the description of the screening examination for melanoma detection includes the instruction to examine the skin in order to detect any lesion that stands out because of being dark , different , or changing .
each of the three screening features has non - redundant as well as complementary importance in the recognition of melanoma .
the screening examination should usually include two looks , one for any lesion that stands out at all , which should allow detection of changed or ugly duckling lesions , and a second look to identify lesions of any size that stand out because of appearing , even focally , dark .
consequently , the emphasis on darkness as a screening feature should only enhance the sensitivity of diagnosis of melanoma .
though the impact of the abcde criteria on melanoma detection has been uncertain , the publication and utilization of these criteria are ubiquitous , and the criteria have many supporters . as marghoob and scope
help elucidate , however , the role of the abcde criteria is not as a screening approach , as they have been utilized , but as a spot evaluation , and the criteria can also help to assess the level of concern when comparing similar lesions .
thus , the criteria have value , but one that requires this more precise explanation .
the meanings of the a , b , c , and e in the georgia approach are unchanged from usual use :  a  for  asymmetry ,  
  c  for  color variation ,  and  e  for  evolving  unlike other lesions .
what is critical to the utility of the abcde criteria , however , is the change of the  d  to signify  dark  and not  6 mm diameter .  with this change , and without altering the familiar mnemonic ,
the criterion never present in the earliest melanomas is replaced by the single criterion that characterizes many early melanomas .
it can now be stated more accurately that most melanomas have one or more of the abcde criteria and that the criteria are relevant to the diagnosis of early melanomas . as a criterion of an individual lesion , similar to its utilization as a screening feature , the characteristic of darkness has non - redundant value and , in addition , enhances the application of other criteria .
there is increasing support for the strategy of melanoma recognition based on the concept that a melanoma will differ in appearance from one s usual moles , referred to as the  ugly - duckling  rule .
the possible utility in this concept is reflected in the georgia approach both as a screening feature (  different  ) and in the  e  for  evolving  description (  has a mole . .
unlike others on your body ?  ) . in the third component of the georgia approach , the  ugly - duckling  sign
is specifically defined , conveying additional emphasis on and understanding of this strategy and its application .
nodular melanomas represent a minority of melanomas but contribute disproportionately to melanoma mortality , and the final portion of the georgia approach is devoted to specific education about the diagnosis of this melanoma subtype .
the varied presentations of nodular melanomas , including as amelanotic lesions , are specifically discussed , as is the particular relevance of change and ugly duckling recognition to the diagnosis of these melanomas .
the inclusion of the nodular melanoma pictured adds further emphasis on both the diagnosis of nodular melanomas and of the relevance of change recognition to their diagnosis . nonetheless , as nodular melanomas have metastatic potential both in a shorter time frame and when smaller in diameter than other melanomas , the previously discussed addition of dark as a screening feature and the  d  for  dark  change may have particular impact on decreasing mortality by enhancing the earlier diagnosis of this melanoma subgroup .
in addition to the potential impact on the diagnosis of earlier nodular melanomas by removing any diameter consideration , many early nodular melanomas , similar to other melanoma subtypes , are characterized by their dark pigment .
whatever changes occur in terms of melanoma diagnosis because of screening recommendations or technology , no strategy will reach its potential without the earliest possible clinical recognition of melanoma .
the components of the georgia approach accomplish the following : 
 first component : clarifies and emphasizes the role of a screening examination ; adds dark to both change and ugly duckling identification as screening features ; communicates the screening features simply and succinctly.second component : continues to utilize but more precisely defines the role of the abcde criteria and changes the meaning of the  d  to 
dark.third component : discusses both the ugly duckling sign as a general rule as well as specific issues relevant to the diagnosis of nodular melanomas .
first component : clarifies and emphasizes the role of a screening examination ; adds dark to both change and ugly duckling identification as screening features ; communicates the screening features simply and succinctly .
second component : continues to utilize but more precisely defines the role of the abcde criteria and changes the meaning of the  d  to  dark . 
third component : discusses both the ugly duckling sign as a general rule as well as specific issues relevant to the diagnosis of nodular melanomas .
each of these three components has non - redundant potential to enhance the diagnosis of melanoma . by unifying and integrating all of the components in a logical manner , however , the georgia approach uniquely prioritizes and maximizes the sensitivity of diagnosis of early melanomas . during this period of transition in the clinical diagnosis of melanoma ,
i encourage other practitioners , departments , and societies to consider and adapt the georgia approach , as well .
 current clinical approaches to melanoma diagnosis have not been associated with a decrease in mortality from this cancer . 
 the components of the new approach presented are , first , a screening examination to look for any lesion that stands out because of being dark , different , or changing ; second , when a single lesion is recognized to be of concern for any reason , that lesion is then evaluated in more detail utilizing the abcde criteria , with the  d  signifying  dark  and not  6 mm diameter  in this mnemonic ; and , third , additional discussion of the  ugly duckling  sign and of the recognition of nodular melanomas . 
 since the georgia society of dermatology and dermatologic surgery was the first state or national society to endorse this approach , i refer to it as the georgia approach . 
Introduction
Discussion of the approach
First component: Screening examination for dark, different, or changing lesions
Second component: Application of the ABCDE criteria to specific lesions, either those lesions identified to be of concern on the screening examination or specific lesions being examined for any reason, with D for Dark in the ABCDE criteria
Third component: Discussion of the ugly duckling rule and specific discussion of nodular melanoma recognition
Summary