Clinical Guides
Melanoma
A clinically focused guide to recognising cutaneous, acral and mucosal melanoma, obtaining an adequate diagnostic specimen, staging by Breslow thickness, and coordinating multidisciplinary treatment in India.
MedNext Academy | 15 min read
Melanoma
A clinically focused guide to recognising cutaneous, acral and mucosal melanoma, obtaining an adequate diagnostic specimen, staging by Breslow thickness, and coordinating multidisciplinary treatment in India.
Summary
Melanoma is a malignant tumour of melanocytes. Most arises in skin, but melanoma can develop in acral sites, nail units, mucosa and the eye, where presentation, staging and specialist pathway differ. Cutaneous melanoma may appear as a new lesion or a changing pre-existing naevus. Asymmetry, border irregularity, colour variation, evolution and a lesion that looks different from the patient's other moles are useful prompts, not a diagnostic algorithm. Amelanotic lesions may be pink or red, and acral melanoma can be mistaken for trauma, infection or a benign pigmented macule. Darker skin reduces population incidence of UV-related cutaneous melanoma but does not eliminate melanoma or justify dismissing palm, sole, nail or mucosal change.
Diagnosis is histological. A suspicious cutaneous lesion is generally removed by complete excision biopsy with a narrow clinical margin and adequate depth, oriented and documented for the pathologist. Partial sampling may be necessary at anatomically difficult sites but risks missing the deepest component. The report should include Breslow thickness, ulceration, mitotic activity where relevant, margin status and other staging features. Definitive wide local excision margins and consideration of sentinel lymph-node biopsy are based on confirmed pathology and specialist discussion, not visual appearance alone. Routine imaging is not appropriate for every thin, localised melanoma.
Treatment can include surgery, nodal staging, adjuvant therapy, immunotherapy, BRAF/MEK-targeted therapy for eligible BRAF-mutant disease, radiotherapy or symptom-directed care. Molecular results, stage, resectability, performance status, autoimmune disease, organ function, pregnancy and access shape decisions. Immune-related toxicity can be delayed and multisystem. This guide is an educational draft quarantined following MedNext Clinical Team review; it cannot diagnose a lesion, prescribe treatment or replace dermatology, pathology and oncology assessment.
How Common Is It?
Cutaneous melanoma is far less common in India than in high-incidence predominantly fair-skinned populations, but low population frequency does not make an individual suspicious lesion safe. IARC's 2025 analysis attributed more than four-fifths of global cutaneous melanoma cases in 2022 to ultraviolet radiation and highlighted large geographic variation. WHO estimated 325,000 new cutaneous melanomas globally in 2020. These figures use different reference years and methods and should not be combined as if they describe one cohort. National Indian burden is modelled from incomplete registration and cannot substitute for a state or city population-based cancer registry.
Indian clinical literature describes cutaneous, acral lentiginous, subungual, mucosal and ocular presentations, but hospital series are affected by referral selection and cannot determine national subtype proportions. Acral lesions receive particular attention because palms, soles and nail units are easy to overlook and UV exposure does not explain all such disease. Later presentation may reflect low suspicion, limited dermatopathology access, treatment fragmentation or misattribution to trauma and infection. Incidence also varies with age, phenotype, genetics, latitude, altitude, occupation and patterns of intermittent or chronic UV exposure.
Prevalence, incidence, mortality and stage distribution are different measures. A low incidence can coexist with poor outcome if disease is diagnosed thick or metastatic. Conversely, a modelled global attributable fraction does not prove that UV caused a particular person's tumour, especially at acral or mucosal sites. For clinicians, evolution and lesion-specific features determine urgency. For public-health planning, prevention messages should be proportionate and inclusive while access to biopsy and specialist pathology remains essential. For patients, prognosis depends mainly on anatomical site, Breslow thickness, ulceration, nodal or distant spread, tumour biology and response to treatment rather than India's overall rank.
Risk Factors
Ultraviolet radiation from sunlight and artificial tanning sources is the principal preventable cause of cutaneous melanoma globally. Risk reflects intensity, intermittency, cumulative exposure, childhood and adolescent exposure, sunburn history, phenotype and behaviour. Fair skin, light eyes, freckling, tendency to burn, numerous common naevi, atypical naevi and a personal history of melanoma increase risk. Family history and pathogenic variants in melanoma-predisposition genes can be relevant, particularly with multiple affected relatives, multiple primary melanomas or associated pancreatic cancer. Most people with one risk factor will not develop melanoma, and some patients have no obvious risk factor.
Immunosuppression after organ transplantation, haematological disease or immunomodulatory treatment can increase skin-cancer risk and complicate therapy. Previous melanoma confers risk of recurrence and another primary lesion. Giant congenital melanocytic naevi carry a risk that varies with phenotype and size and require specialist counselling rather than casual numerical prediction. Ocular melanoma has distinct risk associations; mucosal and acral melanoma are not adequately explained by routine sun-exposure narratives. A dark skin tone provides partial protection against UV-induced cutaneous disease but not immunity, and it must not lower concern about an evolving palm, sole or nail lesion.
Risk assessment should also anticipate treatment. Document autoimmune disease, organ transplant, chronic viral infection, immunosuppressive drugs, endocrine disease, cardiac status, pregnancy potential and baseline bowel, liver, lung, renal, neurological and skin symptoms before immunotherapy. Record performance status and all medicines. Ask about occupation and access to shade or protective clothing without stigmatising outdoor work. Family history can trigger genetics evaluation, but a negative panel does not erase clinical risk. Sunscreen is one component of protection, not permission for prolonged exposure, and vitamin D concerns should be addressed without recommending intentional sunburn.
Diagnosis
History
Ask when the lesion appeared and whether size, shape, thickness, colour, sensation, surface or bleeding has changed. Determine whether it is new, an outlier among other lesions or associated with persistent itch, pain, crusting or ulceration. For nails, ask about trauma, pigmentation spreading onto periungual skin, nail dystrophy and duration; a trauma history does not end assessment if a band widens or persists. Enquire about pigmented or bleeding oral, genital or anorectal symptoms and visual disturbance where a non-cutaneous primary is possible. Record previous melanoma or skin cancer, sunburn and UV exposure, naevi, immunosuppression and family history.
Examination
Examine the lesion with good light, measurement and a body-site diagram. Assess asymmetry, border, multiple colours, nodularity, ulceration and evolution, and compare with the patient's background naevus pattern. Dermoscopy by a trained clinician improves secondary-care assessment but does not replace histology. Examine palms, soles, interdigital spaces and nail units when clinically indicated; inspect regional nodal basins and the rest of the skin for another primary or satellite/in-transit disease. Respect consent, privacy and cultural preferences for full-skin examination. A lesion can be clinically bland or amelanotic.
Investigations
Obtain complete excision biopsy of a suspicious accessible cutaneous lesion with a narrow margin and full dermal depth, avoiding a wide definitive margin before staging. Incisional, punch or other targeted biopsy may be appropriate for large facial, acral, nail or mucosal lesions when complete excision would be mutilating, but the sample must target the most suspicious area and limitations must be documented. Specialist histopathology should report Breslow thickness, ulceration, margins, mitotic and microsatellite features as applicable. BRAF analysis is offered or considered according to stage and potential treatment relevance. Sentinel lymph-node biopsy is a staging discussion for selected melanomas based on thickness and adverse features; it is not treatment of the primary. Imaging is stage- and symptom-directed: Current guidelines advises no routine imaging or SLNB for stage IA and escalating cross-sectional staging for higher-risk stages. Clinical-pathological discordance requires review or repeat sampling.
Differential Diagnosis
Common acquired melanocytic naevi, congenital naevi, seborrhoeic keratoses, lentigines and dermatofibromas can resemble melanoma. Benign lesions are often stable and symmetric, but no single visual rule is sufficiently reliable when evolution or an outlier appearance is present. Pigmented basal-cell carcinoma, squamous-cell carcinoma, Bowen disease and pigmented actinic keratosis enter the differential on sun-exposed skin. Pyogenic granuloma and other vascular lesions can mimic amelanotic melanoma by bleeding readily. Dermoscopy refines probability in trained hands; it does not provide histological certainty.
Acral and nail differentials require particular care. Subungual haematoma may grow out distally with the nail, but repeated trauma history is not proof; a broadening irregular longitudinal band, nail destruction or pigment on adjacent skin needs specialist assessment. Tinea nigra, acral naevus, wart, foreign body, diabetic ulcer and post-inflammatory pigmentation can mimic acral melanoma. Persistent foot lesions should not undergo repeated debridement or antifungal treatment without reconsidering diagnosis. In India, practical barriers and lower baseline incidence can amplify anchoring on infection or trauma.
Mucosal pigmentation includes physiological pigmentation, melanotic macule, amalgam tattoo and drug-related change; melanoma is uncommon but consequential. Ocular pigmented lesions require ophthalmic expertise. Metastatic melanoma can present in skin or nodes without an obvious primary, while another poorly differentiated malignancy can mimic it histologically. Pathology sometimes requires immunohistochemistry, molecular testing and expert review, especially for spitzoid, desmoplastic, acral, mucosal or amelanotic lesions. If clinical appearance, dermoscopy and pathology do not agree, the case should be reconciled rather than accepting the least concerning interpretation. Infection and melanoma can coexist, and apparent improvement of inflammation does not validate a benign lesion beneath it.
Management
Localised cutaneous melanoma is treated with definitive wide local excision after diagnostic pathology. Margin width is stage- and thickness-dependent, balancing local control with anatomical function; the operating team should use a current protocol rather than extrapolating from the initial biopsy margin. Sentinel lymph-node biopsy provides prognostic staging for selected patients, including many with Breslow thickness above 1 mm and some 0.8–1.0 mm lesions with adverse features under current guidelines guidance. It requires discussion of false-negative results, complications and the fact that a negative node does not eliminate recurrence risk. Routine completion lymph-node dissection is no longer automatic after a microscopic positive sentinel node; nodal management is specialist and surveillance capability matters.
Stage III or resected high-risk stage II disease may warrant adjuvant systemic therapy after pathology, imaging and biomarker review. Unresectable stage III or stage IV disease can be treated with immune checkpoint inhibition or, for eligible BRAF V600-mutant melanoma, BRAF/MEK-targeted therapy. Sequence and combination depend on disease tempo, symptoms, brain metastases, comorbidity, toxicity tolerance, prior therapy, regulatory approval and access. Oligometastatic and brain disease should be reviewed with site-specific surgical, radiation and neuro-oncology teams. Surgery or radiotherapy may control selected metastases or symptoms; palliative care should be integrated according to need, not reserved for the last days of life.
Acral, mucosal and ocular melanomas need subspecialty pathways; evidence from common cutaneous melanoma cannot always be transferred directly. Follow-up is stage-adapted and includes skin and nodal examination, education in self-examination, management of treatment toxicity and selective imaging. Survivorship addresses lymphoedema, scars, function, anxiety, fertility and return to work. Prevention counselling includes avoiding sunburn, shade, clothing, hats, eye protection and properly applied broad-spectrum sunscreen when UV exposure is significant. It must not imply that recurrence results from inadequate sunscreen or that acral disease could have been prevented by sun avoidance.
Prescribing Information
Melanoma systemic therapy must be prescribed by an oncology team using current stage, biomarker and regulatory criteria. Before immune checkpoint inhibition, document performance status, autoimmune and transplant history, infections, pregnancy potential, baseline bowel pattern, respiratory symptoms, skin findings and endocrine, hepatic, renal and cardiac function. Check full blood count, biochemical profile and protocol-specific endocrine tests. Immune-related adverse events can involve almost any organ, may emerge after treatment stops and may initially appear nonspecific. Patients need a treatment card, a functioning 24-hour contact and instructions to tell any emergency clinician about prior immunotherapy.
New diarrhoea, abdominal pain, jaundice, cough, dyspnoea, chest pain, severe rash, weakness, headache, visual change, confusion, polyuria or unusual fatigue may reflect immune toxicity. Evaluation and corticosteroid or other immunosuppressive treatment are grade- and organ-specific; indiscriminate steroids can obscure infection. Endocrine injury may require long-term hormone replacement even when immunotherapy is withheld. Organ-transplant recipients face rejection risk and need explicit multidisciplinary assessment. Vaccination, fertility, contraception and interactions with immunosuppressants or complementary products require individual review.
BRAF and MEK inhibitors require validated tumour mutation testing and product-specific monitoring for fever syndromes, skin toxicity, cardiac function, ocular effects, liver tests and interactions. A BRAF inhibitor should not be used for BRAF-wild-type disease. Cytotoxic chemotherapy has a limited modern role but retains regimen-specific marrow, organ and infection risks. Supportive medicines, analgesia and bone treatment are prescribed for defined indications. Drug selection from current guidelines technology appraisals does not establish Indian approval, availability or reimbursement, and product indications change. This guide omits doses and schedules deliberately: safe treatment requires current Indian product information, institutional protocol, pharmacy checks, toxicity grading and documented hold, rechallenge and escalation rules.
When to Refer
Refer a changing or clinically suspicious pigmented or non-pigmented lesion promptly to a clinician experienced in skin cancer and dermoscopy. Features increasing concern include evolution, asymmetry, irregular border or colour, nodularity, ulceration, unexplained bleeding and a lesion unlike the patient's others. Any persistent widening nail band, periungual pigment, nail destruction or non-healing acral lesion deserves specialist assessment, particularly when empirical trauma or infection treatment has failed. A suspicious lesion should not be shaved superficially, destroyed or treated cosmetically before a diagnostic plan because this can compromise Breslow measurement and staging.
After histological diagnosis, refer to a specialist skin-cancer multidisciplinary team. The referral should include the original clinical size and site, photographs where consented, biopsy orientation and method, complete pathology report, slides or blocks availability, margin status and examination of nodes. Thick, ulcerated, incompletely excised, recurrent, acral, nail, mucosal, ocular, spitzoid, desmoplastic or pathologically uncertain disease needs appropriate expert review. Sentinel-node assessment, staging imaging, definitive excision and adjuvant therapy should be coordinated rather than commissioned independently.
Emergency assessment is needed for acute neurological deficit, seizure, severe headache with vomiting, spinal-cord compression features, airway compromise, major bleeding, severe dehydration or treatment-related shock. Urgent oncology review is required for suspected immune-related pneumonitis, colitis, hepatitis, myocarditis, adrenal crisis or severe cutaneous reaction. In India, identify a centre with dermatopathology, surgical oncology or plastic surgery, nuclear-medicine mapping where SLNB is contemplated, and medical and radiation oncology. Do not promise that every centre offers every modality. Transfer pathology material and imaging, confirm appointment feasibility and provide interim safety advice; a generic cancer referral without a named destination or records can prolong diagnostic delay.
Red Flags
A rapidly changing, enlarging or newly nodular lesion is concerning, especially when it bleeds, ulcerates, becomes persistently painful or differs strikingly from surrounding naevi. A new firm regional node, satellite papules around a scar or pigmented nodules between a primary site and nodal basin may represent regional spread. On palms, soles and nails, persistent non-healing ulceration, an irregular widening pigment band, destruction of the nail plate or pigment extending to adjacent skin should override repeated assumptions of trauma or fungal infection. Lack of dark pigment is not reassuring because melanoma can be amelanotic.
Systemic red flags include new focal neurological deficit, seizure, severe progressive headache, persistent vomiting, altered behaviour, severe back pain with weakness or sphincter symptoms, acute breathlessness, haemoptysis, jaundice or rapidly declining performance. Melanoma has a clinically important propensity for brain metastasis, but symptoms still require imaging and differential diagnosis rather than assumption. Severe bleeding or airway, bowel or urinary obstruction from mucosal disease needs emergency specialist care.
During immunotherapy, fever, hypotension, chest pain, dyspnoea, profuse diarrhoea, severe abdominal pain, jaundice, confusion, marked weakness, visual symptoms or extensive blistering rash can signal life-threatening immune toxicity or infection. These events may occur after the last dose. Targeted therapy can cause significant pyrexia, dehydration and organ-specific toxicity. Following surgery, expanding haematoma, wound infection, flap compromise or acute lymphoedema with erythema needs review. A process red flag is pathology that lacks Breslow thickness because of transection, superficial sampling or fragmented tissue; the multidisciplinary team must determine how staging uncertainty will be resolved rather than assigning false precision.
Indian Clinical Context
Melanoma care in India is shaped by low population incidence, diverse skin phenotypes and uneven access to dermoscopy, specialist excision, dermatopathology, sentinel-node mapping, molecular testing and modern systemic therapy. Low incidence can reduce clinician and public suspicion; it must not justify dismissing an evolving lesion. Acral and subungual sites deserve deliberate inspection because they are less visible and may be mislabelled as trauma, wart, fungal disease or diabetic ulcer. Mucosal melanoma may present to dental, ENT, gynaecology, colorectal or urology services, requiring cross-specialty awareness.
current guidelines guidance supplies useful transparent principles for biopsy, staging and multidisciplinary management, but its referral pathways, surveillance resources, technology appraisals and UK medicine licences are not Indian national policy. Use current Indian regulatory approval, institutional tumour protocols, pathology capability and patient access. If sentinel-node mapping or molecular testing is unavailable locally, referral decisions should be explicit; substitutes should not be represented as equivalent without evidence. Costs, travel, loss of work and the need for repeated infusions or toxicity review can make continuity difficult. Government and charitable schemes vary, so confirm eligibility rather than promising funding.
Sun-protection messages should be accurate and culturally practical. Outdoor workers need shade, clothing, hats and scheduling strategies, not unrealistic avoidance of livelihood. Darker skin remains vulnerable to UV injury and melanoma, while acral and mucosal tumours may not be UV-driven. Avoid imported messaging that centres tanning beds while ignoring delayed foot and nail diagnosis. India-specific evidence gaps include national subtype distribution, stage at presentation, outcomes and comparative effectiveness or affordability of modern sequences. Preserve diagnostic photographs, pathology blocks, molecular reports and treatment summaries for transfer. Language-concordant consent should address visible scars, grafts, nodal procedures, fertility, immune toxicity and uncertainty without using fear or blame.
NMC Competency Mapping
The NMC CBME 2024 curriculum supports melanoma learning across dermatology, surgery, pathology and pharmacology. Surgery competency SU18.3 addresses skin cancers including melanoma within the evaluation of skin and soft-tissue lesions. Related undergraduate outcomes include describing pigmented lesions, recognising malignant change, understanding biopsy and referral principles, and applying neoplasia concepts such as invasion and metastasis. Pathology learning supports specimen handling, tumour thickness, ulceration, margins and nodal staging. Pharmacology provides principles of anti-cancer treatment and adverse-reaction recognition. Institutions should confirm the current wording and integration before formal logbook use.
A graduating learner should take a lesion history centred on evolution, examine systematically with consent, compare the lesion with the patient's background pattern and recognise acral, nail, mucosal and amelanotic presentations. They should know that dermoscopy is a trained assessment tool, not a substitute for histology; that suspicious accessible lesions generally need complete full-thickness excision biopsy with a narrow margin; and that superficial destructive treatment can compromise Breslow staging. They should interpret Breslow thickness, ulceration and margin status at a conceptual level and understand why sentinel-node biopsy and imaging are selective.
Management knowledge should cover wide local excision, stage-adapted nodal evaluation, the broad roles of immunotherapy and BRAF/MEK-targeted treatment, and integrated supportive care. Learners must recognise brain or spinal metastasis symptoms and immune-related toxicity as urgent. Communication includes explaining uncertainty before pathology, obtaining consent for full-skin and intimate-site examination, using non-stigmatising sun-exposure counselling and making an actionable referral. Reading this guide does not certify dermoscopy, biopsy, pathology reporting, wide excision, sentinel-node procedures or immunotherapy prescribing. Assessment should prioritise safe clinical reasoning over memorising a drug sequence that changes with evidence and jurisdiction.
Key Exam Pearls for NEET PG
Melanoma arises from melanocytes and may occur on skin, acral sites, nail units, mucosa or the uvea. The ABCDE prompt is asymmetry, border irregularity, colour variation, diameter as a contextual clue and evolution; evolution and the ugly-duckling sign are especially useful. Amelanotic melanoma may be pink or red. Hutchinson sign describes periungual extension of pigment and raises concern in the right context. A subungual haematoma tends to move distally with nail growth, whereas an irregular widening longitudinal band or nail destruction needs assessment. Dark skin lowers UV-related population risk but does not exclude acral or other melanoma.
Excision biopsy should be full thickness with a narrow clinical margin when anatomically feasible. Breslow thickness measures vertical tumour depth and is a major staging and management variable. Ulceration worsens stage. Clark level has less contemporary staging importance. Definitive wide local excision follows diagnostic histology; its margin is not the same as the biopsy margin. Sentinel lymph-node biopsy is a staging procedure for selected patients, not routine for every thin melanoma and not treatment of the primary lesion. Routine imaging is inappropriate for stage IA under current guidelines guidance.
BRAF mutation testing can guide targeted therapy; BRAF and MEK inhibition are combined to reduce resistance and toxicity compared with unopposed BRAF inhibition. Immune checkpoint inhibitors can cause colitis, hepatitis, pneumonitis, endocrinopathy, myocarditis, nephritis and neurological toxicity, including after treatment cessation. Brain metastasis is clinically important in advanced melanoma. Local recurrence, satellites, in-transit metastases, regional nodes and distant disease represent different patterns. Core exam safety points are to avoid superficial shave destruction of a suspicious lesion, refer discordant pathology, inspect acral and nail sites, and urgently evaluate neurological symptoms or systemic immune-toxicity features.
Frequently Asked Questions
Can melanoma occur in darker skin or on areas that receive little sun?
Yes. Darker skin lowers the population risk of many UV-related cutaneous melanomas but does not confer immunity. Melanoma can occur on palms, soles, nail units and mucosal sites, and some of these tumours are not explained by ordinary sun exposure. A changing or persistent suspicious lesion requires assessment regardless of skin tone.
Should a suspicious mole be removed with a wide margin immediately?
Usually the first step is a complete full-thickness excision biopsy with a narrow clinical margin when feasible. This preserves accurate Breslow measurement and diagnosis. Definitive wide local excision is planned after pathology, using stage- and thickness-appropriate margins. Anatomically difficult lesions may need a specialist targeted biopsy strategy.
Does a negative sentinel lymph node biopsy guarantee that melanoma will not return?
No. Sentinel-node biopsy improves staging and prognostic information for selected melanomas, but no test eliminates recurrence risk. False-negative results and distant or local recurrence remain possible. Follow-up depends on the primary tumour's stage and features, treatment, symptoms and the specialist team's surveillance plan.
Why can immunotherapy side effects occur after treatment has stopped?
Checkpoint inhibitors alter immune regulation rather than acting only while drug is circulating. Immune activation can therefore emerge or persist after the last dose and affect bowel, liver, lungs, endocrine organs, skin, heart, kidneys or nervous system. New concerning symptoms require prompt oncology contact and disclosure of previous immunotherapy.
Inside MedNext for this topic
- 411 MedNext-authored chapters
- 80,000+ MCQ bank
- 15 study modes
- a growing library of visual revision sheets
Study modes
- Notes
- MCQ
- Audio
- Video
- Visual
- 3D Anatomy
- Trace
- Flashcards
- Mnemonics
- Image Bank
- Clinical
- Microscopy
- Audio QBank
- Cadaver
- Book Match
Continue reading
Clinical GuidesAll Clinical Guides
Browse all clinical management guides for Indian medical practice.
Test your knowledge
Attempt structured MCQs on this topic to consolidate your understanding and connect the guide to exam-focused practice.
Try MCQs on this topic