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Melanoma is a skin cancer that affects cells that give color to the skin. It may begin as a mole that grows, changes in color or size, or develops irregular borders; or it may start as a flat or raised area of skin. The melanoma may be painless or feel sore or become irritated, scaly, crusty, or itchy. It may bleed easily.
A melanoma may be almost any color, including red, blue, tan, brown, black, gray, or white. At first, it may be dark or bluish; later, it may change to a paler color.
A melanoma can occur anywhere on the body, most commonly on the areas exposed to the sun, such as the shoulders, head, trunk, or lower legs. If caught and treated early, it can be easily cured. But it's dangerous if the cancer spreads to another part of the body.
Older adults are most likely to get melanoma, but healthy young people can get it too. You're at risk if:
* you're fair-skinned or freckled, with blue eyes and light-colored hair
* you work outside in the sun
* your skin burns and doesn't tan
* you've had bad sunburns in the past, even as a child
* you have many moles, large moles, or unusual- looking moles
* you or a close relative has had melanoma.
If your health care provider suspects melanoma, he'll remove some of the tissue for biopsy. Along with microscopic examination, the biopsy will show how thick the melanoma is and whether it has spread to nearby skin. He may also test a lymph node to learn if the melanoma has spread to other parts of the body.
Your health care provider will discuss the best treatment for you based on your test results. This depends on the size and depth of the melanoma and whether it has spread. If the melanoma is small and shallow, he can just remove it. (You may need a skin graft if he has to remove a large area of skin.) If the melanoma is large or deep, or has spread to lymph nodes, you may also need chemotherapy (drugs to kill cancer cells) or radiation therapy.
Your health care provider will give you regular checkups to make sure the melanoma doesn't come back. He'll closely watch your lymph nodes and skin and may also want you to have blood tests or X-rays.
You can protect yourself by checking your skin at least once a month, using good lighting, a full-length mirror, a hand mirror, and a magnifying glass, if necessary. Remember to check your scalp, or have a family member check it for you.
Ask your health care provider to check anything that looks suspicious, especially a mole that's changing size, shape, or color or that bleeds or itches. The ABCDE method can help you spot problems.
A: Asymmetry. Half of a mole or birthmark doesn't match the other half.
B: Borders. Melanoma usually has irregular edges.
C: Color. Melanoma can be almost any color, including red, blue, white, gray, and black, but the color isn't the same all over.
D: Diameter (size). Tell your health care provider if the growth is larger than a pencil eraser.
E: Elevated. Although some melanomas are flat, most are raised above the skin surface.
Because sun exposure can trigger melanoma, limit your time outside between 10 a.m. and 4 p.m. during the summer and avoid tanning beds or lying out in the sun to get a tan.
If you must be out in sunshine, wear clothes that protect you: wide-brimmed hats, long-sleeved shirts, long pants, and sunglasses that block ultraviolet rays.
About 30 minutes before going outside, apply a sunscreen with an SPF of 15 or higher. Try to use a sunscreen that blocks both types of ultraviolet light (UVA and UVB) and reapply it often. Remember to protect your skin against the sun in winter too.
Tell your health care provider if you have any new symptoms, such as pain, cough, weight loss, tiredness, or loss of appetite.
The cause of melanoma isn't fully understood, but many of the same risk factors exist for melanoma as for other skin cancers (see Risk factors for malignant melanoma). People with very dark skin rarely develop melanoma; when they do, it generally occurs under the fingernails or on the soles of the feet or palms of the hands.
Exposure to UV radiation plays a role in the risk for melanoma. A history of one or more severe, blistering sunburns as a child or teenager significantly increases a person's risk of developing melanoma. Other factors include a family history of melanoma, a weakened immune system, and prior history of melanoma.
Moles, although common, play a role in the risk for melanoma. Moles can be present at birth or develop as we age, usually by age 40. They tend to fade with aging. Having a large number of moles increases the chances of developing melanoma. Dysplastic nevi (large, atypical moles that appear different than other moles on a person's body) are more likely to develop into melanoma than an ordinary mole. They're usually irregularly shaped and colored, and have irregular or nondistinct borders.
Reducing exposure to UV rays, both natural and artificial, is critical to reducing melanoma risk. Sunscreen with an SPF of 15 or higher is important, as is protection for the eyes. Wraparound sunglasses that block UVA and UVB rays are best (most sunglasses sold in the United States meet these standards).
The most common presentation of melanoma is a change in appearance of a mole, or development of a new mole. Changes in size, shape, color, border, or the actual feel of a mole when palpated are signs of melanoma. The center of a melanoma may change to a blue or black color.
In men, the most common sites for melanoma are the trunk, head, and neck. Women with melanoma more commonly have lesions on the extremities, usually the legs.
When assessing a patient's mole, the ABCDE method is helpful but not foolproof (see The ABCDE method of examining a mole for melanoma). Some moles exhibit only one change and are melanoma. When a lesion or mole looks suspicious for melanoma, shave biopsy or cauterization should never be used. An experienced dermatologist or surgeon should thoroughly examine it and perform an excisional biopsy. After biopsy, a pathologic examination can confirm melanoma.
Research has identified genetic predisposition to melanoma in some families. The absence of a gene that resides on chromosome 9p increases the likelihood that potentially mutagenic DNA damage will escape repair before cell division to cause melanoma.
Melanoma can be cured if treatment is started early. When a melanoma lesion is superficial, it can be fully removed without spreading to deep tissues and other organs.
Surgery is usually the first and best treatment for melanoma. The goal of surgery is to remove all the melanoma cells. The extent of the surgical excision depends on the width and depth of the lesion. Wide excisions may require reconstruction and/or skin grafting. Sentinel lymph node biopsy or lymph node dissection is usually performed if the lesion is deep.
Adjuvant therapy (therapy in addition to surgery) is recommended for patients whose disease has spread beyond the original lesion. Chemotherapy and biological therapy can help kill any cancerous cells remaining in the body. Studies have shown that with more advanced melanoma, some adjuvant therapy has increased the time of disease recurrence but not overall survival time. The best survival rates are found in patients who have diagnosis of melanoma in the early stages and have had full surgical removal.
Radiation therapy usually isn't effective to treat melanoma. Palliative radiation is sometimes used to reduce the symptoms of advanced disease. Patients with metastasis to the brain, spinal cord, and bone may have some pain relief when they receive radiation to those areas.
When it comes to skin cancer, prevention is a key concept to emphasize to your patients. The biggest risk factor for both nonmelanoma skin cancer and melanoma is UV radiation: the sun and its harmful rays. Avoidance of the sun is nearly impossible, but patients can develop many habits to avoid the sun's damage.
The sun's rays are strongest in the middle of the day: 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. during daylight savings time). Advise patients to perform outdoor activities during this time in the shade, such as under a porch. Encourage them to wear protective clothing such as hats, long sleeves, and long pants. Teach them to use sunscreen lotion whenever they're going outdoors. Sunscreen rated at an SPF of 15 to 30 will block most of the sun's harmful rays. Advise parents to develop the habit of using sunscreen on their children whenever they're outdoors.
Encourage your patients to do self-skin assessments periodically; provide them with a handout that instructs them how to assess their skin and what to look for. Remind them that early detection and treatment (which is usually only surgery if detected early enough) is the key to staying healthy. (See Sun safety for a list of tips to share with your patients.)
About 20% of Americans will develop some form of skin cancer in their lifetime. If left untreated, it can spread and result in serious, if not fatal, consequences. Teaching your patients how to lessen their risk of getting skin cancer can help them avoid potential problems.
* Fair-skinned or freckled, blue-eyed, light-haired people of eastern European descent
* People who burn and don't tan or who have a significant history of severe sunburn
* Environmental exposure to intense sunlight (older Americans retiring to the southwestern United States appear to have a higher incidence)
* History of melanoma (personal or family)
* Skin with giant congenital nevi
* Remember to use sunscreen when you plan to spend time outdoors.
* Your sunscreen should be a broad-spectrum sunscreen that protects from both UVA and UVB rays and have an SPF of 15 to 30 or more.
* Apply two generous coats (like paint) of sunscreen to all exposed skin before going outdoors. Reapply every 2 hours, especially after swimming or perspiring.
* Wear protective clothing such as long-sleeved shirts, pants, a wide-brimmed hat, and sunglasses when possible.
* Seek shade when appropriate, remembering that the sun's rays are strongest between 10 a.m. and 2 p.m. Umbrellas offer shade, but the sun's harmful rays can still bounce off of nearby water sources, sand, and porch decks.
* Use extra caution near water, snow, and sand because they reflect the damaging rays of the sun, which can increase your chance of sunburn.
* Avoid tanning beds at all times. Their UV light causes skin cancer and wrinkling. If you want to get a sun-kissed look, consider using a self-tanning product that doesn't expose you to UV light.
* Every year on your birthday, take a good look at your birthday suit. If you notice anything on your skin that's changing, growing, or bleeding, see a dermatologist. Skin cancer is very treatable when caught early.
American Academy of Dermatology: http://www.aad.org
National Cancer Institute: http://www.cancer.gov
The Skin Cancer Foundation: http://www.skincancer.org
American Cancer Society: Cancer facts and figures 2007. http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf. Accessed February 29, 2008.
Masso M. Policy and practice for preventing skin cancer in children. Public Health Nurse. 23(4):361-365, July/August 2006.
Prager R, Khachemoune A. Basal cell carcinoma. Dermatology Nurse. 8(6):584-585, December 2006.
Reynolds PL, Strayer SM. Treatment of skin malignancies. Journal of Family Practice. 52(6):456-464, June 2003.
Smeltzer SC, et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2008.
Vargo N. Cutaneous malignancies: BCC, SCC, and MM. Dermatology Nurse. 18(2):183, 200, April 2006.
Weber J, Kelley J. Health Assessment in Nursing, 3rd edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2007.
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