Skin Care & Dermatology Information | Skin Care Network

Melanoma is the sixth most common cancer in the United States and the most serious form of skin cancer that begins in melanocyte cells (pigment-producing cells).1 Predisposing factors for the development of malignant melanoma include heredity, complexion (fair skin, red or blonde hair, blue eyes), and ultraviolet light exposure. Although melanomas make up only 4% of all skin cancers, they account for over 60% of deaths due to skin cancer. The incidence of malignant melanoma has increased considerably in the past two decades. The American Cancer Society projects that there will be 62,190 new cases of melanoma diagnosed in 2006. Nearly 8,000 people in the United States die of melanoma each year.2 Further statistics illustrate that one in 70 people will develop melanoma during their lifetime.3 The good news is that melanoma is often curable if it is detected and treated in its early stages.

Screening Evaluations

A thorough history should include questions about family history of melanoma or of "atypical" nevi. A family history of melanoma increases a person's risk of developing melanoma by up to eight times compared with persons who have no such history. The most predictive features for melanoma development are a history of change in an existing nevus or a new and changing pigmented lesion.3 Questions to ask during the initial visit include:

* Do you have a history of melanoma or dysplastic "atypical" moles?

* Has anyone in your family had cancerous moles or a melanoma?

* Do you have many moles that are larger than the size of a pencil eraser?

* Do you have more than 50 moles of any size?

* Did you ever get a bad sunburn that caused blisters when you were a child?

* Does your skin usually burn rather than tan?4

The American Cancer Society recommends that people 20 to 40 years of age have a skin evaluation every 3 years and people age 40 and older have one every year.2 Individuals with a previous history of melanoma should be evaluated at 3- to 6-month intervals, depending on the length of time since diagnosis and Breslow depth noted on pathologic confirmation.5 Most recurrences manifest during the first 5 years after the initial diagnosis. Patients with no recurrence after 5 years have less than a 5% chance of having a second melanoma.

Know the ABCs

Astute practitioners should be cognizant of the ABCDE mnemonic when evaluating skin lesions:

A. Asymmetrical shape (one half of the lesion is unlike the other half).

B. Border is irregular (edges irregularly scalloped).

C. Color is mottled (shades of brown, black, gray, red, blue, and white hues).

D. Diameter is usually large (greater than the tip of a pencil eraser, approximately 6 mm. Some experts believe that lesions measuring even 4 mm should be considered suspicious for melanoma).

E. Elevation/Enlargement/Evolving/Evolution tendency and change from baseline appearance should be assessed.

This proposed mnemonic is used to describe the most common characteristics of a melanoma. However, healthcare providers must appreciate the fact that early melanomas may be less than 6 mm in diameter and symmetric in color and contour. Further, pruritus, ulceration, and bleeding in a mole are common warning symptoms. Thus, any one of the above features should prompt further evaluation.

The classic malignant melanoma is a black or purple nodule, but it may be flat or pedunculated, pink, red, tan, brown, or amelanotic (no color) (see Figure: "The ABCDEs of Malignant Melanoma"). A change in a recent or longstanding skin lesion should arouse suspicion, including change in size or shape, border irregularity, color variations, bleeding tendency, and ulceration. Melanoma may be difficult to diagnose accurately on a clinical basis alone. Patients presenting with a lesion that is clinically suspect for melanoma should undergo a biopsy.6

Four Major Types

The four major types of melanoma are:

* Superficial spreading melanoma (accounts for 70% of diagnosed cases) develops from an insitu lesion. It grows slowly with a resulting good prognosis. It is found primarily on the backs of men and legs of women.

* Nodular melanoma (about 15% of diagnosed cases) grows rapidly and has a poorer prognosis. Most often noted on males.

* Lentigo maligna melanoma (average about 10% of diagnosed cases) develops from a lentigo maligna that occurs mainly on the forearms and face of elderly individuals. It grows slowly and has a high survival rate.7

* Acral lentiginous melanoma is the least frequent type (5% of diagnosed cases). Occurs on the palms, soles, around nails, perioral, and perirectal. It is the most common type seen in African Americans. This type of melanoma ulcerates and metastasizes rapidly, leading to a poor prognosis.8

Presenting the Diagnosis

Goldstein and Goldstein 3 offer the helpful mnemonic THREE for giving the diagnosis of melanoma: "THREE: Time, Hope, Repetition, Empathy, and Education". It is critical that the healthcare provider allow sufficient time to talk with the patient and family members when giving the diagnosis. In addition, the clinician must be prepared to offer hope, to repeat key information, to be empathetic, and to continue the education process.3 Further, patients should be offered a second opinion and referral to a dermatologist or surgeon who specializes in the treatment of melanomas (see Table: "Provider and Patient Resources").

Although melanoma is a serious disease, it can be treated and cured if detected early. Everyone can play an important role in detecting skin cancers. Examination of the entire surface of the skin is critical for de tecting cutaneous melanoma.9 Patients and family members should be given information related to skin self-examinations. In addition, primary care providers should incorporate skin health histories followed by full body examinations during yearly health maintenance visits. Further, national skin cancer screening programs should be promoted because they are critical to community awareness and prevention of skin cancers (visit http://www.aad.org to locate the nearest skin cancer screening facility).