More than half of Australian dermatologists receive lesion referrals without photographs, while almost half have referrals sometimes arrive without any accompanying information, according to a national study that highlights ongoing challenges in skin cancer care.

Researchers said the findings highlighted a persistent challenge in skin cancer care, where accurately identifying a lesion of concern is  critical to diagnosis and treatment.

“Procedurally, the ability to precisely convey suspicious lesions is important in preventing wrong-site surgery,” the authors wrote.

The survey, published in the Australasian Journal of Dermatology [link here], collected responses from 154 Australian dermatologists between January and April 2025, representing around 22% of the national dermatology workforce.

Overall, 54% of respondents reported receiving lesion referrals without images, while 47% said referrals sometimes arrived without any documented reason for referral.

Speaking with the limbic, Dr Nicholas Muller and Dr Samuel Tan, dermatology research fellows at the University of Queensland Dermatology Research Centre, said the issue first came into focus through a patient referred for Mohs surgery.

The referral did not specify which lesion required excision. The accompanying photographs were low quality, the patient could not identify the lesion herself and the original biopsy site had healed.

“This is an unfortunately common situation,” Muller and Tan told the limbic.

“The question of lesion identification is a constant issue, both from third-party referrals but also simply identifying a lesion yourself from one review to the other.”

The experience prompted a broader examination of referral quality and lesion identification.

The researchers found substantial variation in the information accompanying skin cancer referrals.

While dermatologists themselves typically used multiple methods to document lesions when referring patients onward – including written descriptions (90%), images (69%) and annotated diagrams (14%) – many reported receiving significantly less information from referring clinicians.

“Dermatologists frequently reported receiving referrals for skin cancer without clinical images, and occasionally with no documented reason for referral, yet are still expected to diagnose and manage lesions,” the authors wrote.

“This exposes the patient, referrer and dermatologist to the risks of wrong-site treatment or misdiagnosis.”

Dr Muller and Dr Tan said several findings were unexpected.

Among them, only 43% of dermatologists reported having systems in place to ensure patients attended appointments after being referred, while 64% said they had never received formal medicolegal education.

“They were definitely surprising,” they said.

The finding was particularly notable given the study’s focus on referral management and follow-up. While nearly two thirds of respondents reported never receiving formal medicolegal education, the paper notes that medical defence organisations generally regard referral management as part of a clinician’s ongoing duty of care.

“In practice, we must clearly explain to the patient why tests or referrals are required, outline the risks of non-adherence, document that discussion – including refusal or non-compliance – and revisit the issue at subsequent reviews,” the authors wrote.

What drives poor-quality referrals remains uncertain.

Dr Muller and Dr Tan said the issue was likely multifactorial, although time pressure was probably an important contributor.

“As with so many issues in medicine, time pressure is certainly paramount,” they said.

“Though the fact that dermatologists receive many referrals with insufficient information is probably multifactorial, and there is always an individual relationship between each referrer and specialist underpinning each of these interactions.”

They stressed that while referral information plays an important role in identifying lesions and communicating specific concerns, responsibility for assessment ultimately rests with the receiving specialist.

“Ultimately, identification of lesions is the dermatologist’s domain, so while the referrer’s information is helpful to address particular issues, the dermatologist must perform their own history and examination and then refer back to the GP/clinician if there are any open questions,” they told the limbic.

The study also highlighted challenges beyond lesion identification.

More than half of respondents reported having no system to ensure patients attended referred appointments, a finding the authors said could create risks where important investigations or treatment are delayed.

“We emphasise the importance of enacting follow-up/referral assurance mechanisms given that missed diagnosis or delayed management of a high-risk lesion could prove catastrophic,” they wrote.

When referral information is insufficient, dermatologists may need to contact the original clinician, rely on patient photographs, obtain new images or use marking techniques to help re-identify lesions.

To reduce the risk of wrong-site errors, Dr Muller and Dr Tan recommend a simple three-step approach:

• a written clinical description of the lesion
• a high-quality colour photograph and
• documentation of any previous procedures or histopathology results.

For anatomically challenging sites, sketches or measurements to nearby landmarks may also be useful.

“The above three are already enough to preclude the vast majority of wrong-site errors, and thereby protect both the patient and yourself,” they said.

The researchers acknowledged the survey’s limitations, including its self-reported and cross-sectional design.

However, they concluded the findings supported greater standardisation of referral practices, wider use of clinical photography and stronger systems to ensure patients complete recommended follow-up.