In a case-control study in the Midlands of England, 195 subjects with superficial spreading or nodular melanoma were compared to age- and sex-matched controls chosen from all inpatients or outpatients in hospitals serving the defined source population. Significant increases in melanoma risk, after adjustment for other factors, were seen in association with total naevi on the arms (odds ratio (OR), for 15+ naevi compared to none = 3.8), intense freckling as an adult (OR = 6.2), and as a child (OR = 6.0), and higher social class (OR = 2.4). Positive single factor associations were also seen with light or red hair colour, tendency to sunburn easily, and a history of sunburn at ages 8-12, although these were not significant when adjusted for the other factors. No significant effect was seen with naevi greater than 6 mm, or with raised naevi, when adjusted for total number of naevi. Total arm naevi and density of freckling had independent effects, consistent with a multiplicative effect, the OR in those with 10+ naevi and heavy freckling being 20.8. The risk associated with red hair was independent of naevi, but associated with freckling. The strongest association with sunburn history was seen with a history of sunburn in childhood, with sunburn at later times, having smaller effects, or none. These results shows that freckling and social class as well as naevi are strong and independent risk indicators for melanoma. These associations were generally consistent by type of melanoma, sex, age, and extent of regular exposure of the body site affected, although the social class gradient was observed neither for nodular melanoma nor for melanomas occurring on the most exposed body sites.

As part of a national campaign to combat the rising incidence of and mortality from cutaneous malignant melanoma, a programme of improved clinical services and professional and public education was set up in Nottingham in January to July 1987. The public education campaign in July led to an immediate increase in the weekly number of referrals to the pigmented lesion clinic from 10 to 54. The effect on general practitioner workload was less dramatic, the weekly number of consultations for discrete pigmented lesions rising from 0.5 to 3. In materials sent to GPs, we recommended that patients with three or more of seven specified signs should be referred for specialist opinion. Only 40% of the patients referred to the pigmented lesion clinic fulfilled this criterion, but 6% of these patients had a melanoma, compared to only 0.4% of those who did not meet the criterion. In the 6 months following the campaign, 64% of melanomas diagnosed in Nottingham residents had a Breslow thickness of less than 1.5 mm whereas only four (16%) were greater than 3.5 mm. However, this distribution was not significantly different from that seen in the three and a half years before the campaign. These results suggest that attempts to improve early diagnosis of the disease by health education are justified, but, in view of the service implications, full evaluation of such campaigns by large scale and long-term studies is essential. Future campaigns should give greater stress to referral criteria.

bodies against neutrophils and monocytes. Tools for diagnosis and marker of disease activity in Wegener's granulomatosis. Lancet 1985;i:425-9. 2 Ludemann G, Gross WL. Autoantibodies against cytoplasmic structures of neutrophil granulocytes in Wegener's granulomatosis. Clin Exp Immunol 1987;61:350-7. 3 Goldschmeding R, Tetteroo P, Van der Borne AEGK, Kallenberg CGM. Antineutrophil cytoplasm antibodies in Wegener's granulomatosis are not directed against alkaline phosphatase. Lancet 1987;i: 1489. 4 Rasmussen N, Wilk A, Hoier-Madsen M, Borregaard N, Van der Woude F. Antineutrophil cytoplasm antibodies. Lancet 1988;i: 706-7.