“It’s just a scab that won’t heal — I keep knocking it. It’ll sort itself out, won’t it?”

A lesion that does NOT HEAL over weeks to months — enlarging, crusting, bleeding and repeatedly breaking down — on a sun-exposed site in an older, sun-damaged person is a keratinocyte skin cancer until proven otherwise, and "I keep knocking it, so it won’t heal" is the classic explanation that masks malignancy: normal skin and benign knocks heal, a persistently non-healing lesion does not. Differentiate SQUAMOUS CELL CARCINOMA (rapidly growing, often tender, scaly/crusted/keratotic nodule or non-healing ulcer on ear/face/scalp/lip/hands, with metastatic potential — especially ear and lip) from BASAL CELL CARCINOMA (slow, pearly, telangiectatic, rolled edge, central ulceration, rarely metastasises), keeping keratoacanthoma and amelanotic melanoma in mind; rapid growth, tenderness and breakdown favour SCC. Take the sun-damage/occupational history (outdoor work, fair skin, cumulative UV, prior skin cancers, surrounding actinic keratoses/solar elastosis), which raises pre-test probability, and look at the lesion on camera, then arrange a face-to-face examination documenting the lesion AND the draining regional nodes (pre-/post-auricular, parotid, cervical) given the metastatic risk of ear SCC. NICE NG12 (Suspected cancer: recognition and referral, last updated April 2026): consider a suspected cancer pathway referral for a lesion suggesting SCC (suspected melanoma is also referred on the suspected cancer pathway); BCC is usually a routine referral, suspected cancer pathway only where delay could have a significant impact because of site or size — so this SCC-favouring lesion on a high-risk site (ear, BAD 2020) goes on the suspected cancer pathway. Nodes cannot be palpated on video, so arrange a prompt face-to-face examination. Do not be deflected by the incidental "just a scab" framing in a patient who came about something else: take the mention seriously, gently correct the "it’ll heal itself" belief, refer on the suspected cancer pathway, give sun-protection/actinic-keratosis advice (BAD actinic keratosis guideline 2017), address the original complaint too, and safety-net — never "leave it to heal".