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Early diagnosis is vital to outcome. Thickness of a melanoma when it is removed is the major factor determining prognosis: it is vital to detect melanomas when they are in the thin stage and look like an unusual freckle. An irregular border or margin is characteristic of the tumour.

Clinical features

  • Typical age range 30–50 yrs (av. 40)

  • Can occur anywhere on the body. More common:

    • lower limb in women

    • upper back in men

  • Often asymptomatic

  • Can bleed or itch


The sign of major importance is a recent change in a ‘freckle’ or mole:

  • change in size: at edge or thickening

  • change in shape

  • change in colour: brown, blue, black, red, white, inc. combinations

  • change in surface

  • change in the border

  • bleeding or ulceration

  • other symptoms (e.g. itching)

  • development of satellite nodules

  • lymph node involvement

Beware of the non-pigmented melanoma, esp. on the sole of the foot.

Pitfalls/traps in diagnosis

  • Nodular melanomas

  • Small melanoma

  • Amelanotic melanoma

  • Regressing melanoma

  • Rapidly growing melanoma

The early nodular melanoma problem

The ABCD rule often does not apply. Early nodular melanomas tend to be symmetrical, non-pigmented, even in colour, small diameter, firm and grow vertically, i.e. elevated. They are often mistaken for a haemangioma or a pyogenic granuloma. Refer if suspicious.


  • Early diagnosis and referral to specialist unit is vital.

  • Surgical excision with a narrow but significant margin is the treatment.

  • Guidelines for excision margins:

    • suspicious lesion—margin 2 mm

    • melanoma in situ—margin 5 mm

    • melanoma <1 mm thick—margin 1 cm

          >4 mm thick—margin 2 cm

  • Follow-up is based on the tumour thickness:

    • ≤1 mm—6 mthly for 2 yrs

    • >1 mm—regularly for 10 yrs

    • yearly chest X-ray.

Table M1

Features and associations of melanoma subtypes

Melasma (chloasma)

Treat with topical 2% hydroquinone in sorbolene cream (long course). Limit sun exposure.

Menopause syndrome

The menopause is the cessation of the menses for longer than 12 months. Some women experience adverse effects.


  • Vasomotor, for example:

    • hot flushes (80%)

    • night sweats (70%)

    • palpitations (30%)

  • Psychogenic, for example:

    • tearfulness/depression

    • irritability

    • anxiety/tension

  • Urogenital (60%), for example:

    • atrophic vaginitis

    • vaginal dryness (45%)

    • dyspareunia

  • Musculoskeletal, e.g. non-specific ...

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