Melanoma

The ABCDEs of melanoma

The "ugly duckling" sign

Most people's moles look alike. A spot that looks different from all your others, darker, larger, a different shape, or a single pink spot among brown ones, deserves a check.

Other warning signs

• a new spot appearing in adulthood
• a spot that bleeds, crusts or will not heal
• redness or swelling spreading beyond the border
• itching, tenderness or pain in a mole

Types of melanoma

• Superficial spreading melanoma: the most common type. Grows outward along the skin before growing deeper. Often on the back in men and legs in women.
• Nodular melanoma: a firm, raised, dome-shaped bump that grows deeper quickly. It may be black, blue, red or skin-colored and often does not follow the ABCD rules, so "EFG" (Elevated, Firm, Growing) helps.
• Lentigo maligna melanoma: develops from a slow-growing, flat brown patch on sun-damaged skin of older adults, usually the face.
• Acral lentiginous melanoma: on the palms, soles or under nails. The most common type in people with darker skin and not linked to sun exposure.
• Amelanotic melanoma: pink or skin-colored, with little pigment, easily mistaken for something harmless.
• Mucosal and ocular (uveal) melanoma: in the mouth, nose, genital area or eye.

Melanoma in situ means the cancer cells are confined to the top layer of the skin. It has an excellent outlook after removal.

Risk factors

• UV exposure: especially blistering sunburns in childhood and intermittent intense sun
• tanning beds
• many moles (more than 50) or atypical moles (dysplastic nevi)
• fair skin, light hair and eyes, freckles and burning easily
• personal or family history of melanoma
• weakened immune system
• inherited gene changes, such as CDKN2A

People of all skin tones can get melanoma, and in darker skin it is often found later, on the palms, soles and nails.

Diagnosis

• Skin examination, often with a dermatoscope, a magnifying light that shows patterns beneath the surface.
• Biopsy: removing the whole spot with a small margin when possible, so the pathologist can measure its thickness accurately.
• Pathology report: includes Breslow thickness (depth in millimeters), ulceration, and mitotic rate.
• Sentinel lymph node biopsy: checks whether melanoma has reached the nearest lymph nodes, usually offered for melanomas thicker than about 0.8 mm or with ulceration.
• Imaging such as CT, PET-CT or brain MRI for higher-stage melanoma.
• Genetic testing of the tumor for BRAF and other mutations in advanced disease.

Stages

Treatment

Surgery

• Wide local excision: removes the melanoma with a margin of normal skin. Margin size depends on thickness, typically 0.5 to 2 cm. This is often the only treatment needed for early melanoma.
• Mohs surgery or staged excision for some facial lentigo maligna.
• Lymph node surgery in selected cases.

Systemic treatment

• Immunotherapy (checkpoint inhibitors): pembrolizumab, nivolumab, ipilimumab and relatlimab release the brakes on the immune system. Used for advanced melanoma and after surgery for stage IIB to IV to lower recurrence risk. Some people are given it before surgery.
• Targeted therapy: BRAF and MEK inhibitors for melanomas with a BRAF mutation.
• Cell-based therapy: tumor-infiltrating lymphocyte (TIL) therapy for some advanced melanomas.
• Radiation therapy: for brain metastases and some local situations.

Follow-up

Regular skin and lymph node checks, with imaging for higher stages, are recommended for years after treatment. People who have had one melanoma are at higher risk of another.

Outlook

Outlook depends mainly on stage. Thin melanomas removed early have very high cure rates. Survival for advanced melanoma has improved dramatically in the last 15 years with immunotherapy and targeted therapy, and many people with stage IV melanoma now live for years. Brain metastases are a particular risk in advanced disease.

Prevention and early detection

• seek shade, especially between 10 a.m. and 4 p.m.
• wear protective clothing, a wide-brimmed hat and sunglasses
• use broad-spectrum SPF 30 or higher sunscreen, reapplying every 2 hours outdoors
• avoid tanning beds
• protect children from sunburn
• check your skin monthly, including the scalp, soles, between toes and under nails, using mirrors or a partner
• see a dermatologist regularly if you are at high risk

Frequently asked questions

What does early melanoma look like?

Early melanoma often looks like a new or changing mole that is asymmetrical, has an irregular border, several colors, is larger than a pencil eraser, or is evolving. Some early melanomas are pink, raised or very small. A spot that looks different from your other moles is a warning sign.

Can melanoma be cured?

Yes, especially when found early. Thin melanomas removed with surgery are usually cured. Advanced melanoma is harder to cure, but immunotherapy and targeted drugs have greatly improved survival, and some people with advanced disease achieve long-term remission.

Does melanoma itch or hurt?

Melanomas are usually painless, but some itch, feel tender, bleed or crust, especially as they grow. Any new symptoms in a mole should be checked. Most itchy spots are not melanoma.

Can people with dark skin get melanoma?

Yes. Melanoma is less common in people with darker skin but is often diagnosed later and at a more advanced stage. It frequently appears on the palms, soles or under the nails, so these areas should be checked.

How fast does melanoma spread?

It varies. Superficial spreading melanoma can grow slowly over months to years, while nodular melanoma can grow and spread within weeks to months. That is why new or changing spots should be checked promptly.