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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

Change 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, incl. 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 5–10 mm

    • – melanoma <1 mm thick—margin 1 cm

      1–4 mm thick—margin 1–2 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.

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Table M1 Features and associations of melanoma subtypes

Melanoma subtype

Frequency %


Average age

Superficial spreading


Trunk (back), limbs (legs)




Trunk, limbs


Lentigo maligna


Head, neck


Acral lentiginous


Palms, soles, mucosae

Not known

Reproduced with permission of J Kelly


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


image 194


The menopause is the cessation of the menses for longer than 12 months. Up to 80% of women experience vasomotor symptoms for an average of 5 yrs (range 1–10); 20% will be severely affected.


  • Vasomotor, e.g.:

    • – hot flushes (80%)

    • – night sweats (70%)

    • – palpitations (30%)

  • Psychogenic, e.g.:

    • – tearfulness/depression

    • – irritability

    • – anxiety/tension

  • Urogenital (60%), e.g.:

    • – atrophic vaginitis

    • – vaginal dryness ...

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