Melanoma

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 21 Apr 2025

Last updated: 07 Feb 2025

Melanoma is among the most common forms of cancer, and causes of cancer-related death, in young adults.

Reducing exposure to ultraviolet light is critical for primary prevention of melanoma.

Clinical features of lesion asymmetry, border irregularity, color variability, diameter >6 mm, and evolution over time should raise suspicion for melanoma and prompt further assessment with dermoscopy.

The prognosis depends on the stage at diagnosis. Over 99% of patients with in-situ melanoma will be cured with simple excision.

Targeted therapies such as immune checkpoint inhibitors and BRAF inhibitors have revolutionized the treatment of metastatic melanoma. Five-year survival rates have improved since the approval of these therapies and are now approaching 30%.

Definition

Melanoma is a malignant tumor arising from melanocytes. It is among the most common forms of cancer in young adults and typically presents as a new or changing pigmented (brown or black) skin lesion, but there are other presentations (amelanotic or desmoplastic) with a different clinical picture.[1] The incidence of melanoma peaks in adults more than 70 years of age.[1]

Lesions are often on sun-exposed anatomic locations and more often in people with Fitzpatrick type I (white) skin.

Noncutaneous melanomas may arise from melanocytes in the uvea, meninges, or mucosal membranes. Their management is beyond the scope of this topic.

History and exam

Key diagnostic factors

altered pigmented lesion (ABCDE signs)
melanocytic lesion that does not resemble surrounding melanocytic nevi ("ugly duckling")
spontaneous bleeding or ulceration of a pigmented lesion
constitutional symptoms
nail sign: persistent single-nail melanonychia striata
nail sign: Hutchinson sign
atypical dermoscopy findings
fixed lymphadenopathy
in-transit metastases

Full details

Risk factors

sun exposure
family history of melanoma
personal history of melanoma
personal history of skin cancer (including actinic damage)
history of atypical nevi
Fitzpatrick skin type I or II (white skin)
red or blond hair color
high freckle density
sun bed use
light eye color
increased numbers of benign-appearing melanocytic nevi
large congenital nevi
immunosuppression
xeroderma pigmentosum

Full details

Diagnostic tests

1st tests to order

dermoscopy
skin biopsy
immunohistochemistry

Full details

Tests to consider

sentinel lymph node biopsy
chest/abdominal/pelvic CT scan
whole-body PET scan
brain imaging (CT or MRI)
BRAF mutational analysis
NRAS mutational analysis
serum lactate dehydrogenase (LDH)

Full details

Emerging tests

CDKN2A mutational analysis

Treatment algorithm

ACUTE

early stage melanoma (melanoma in situ, stage I, stage II)

stage III melanoma with negative sentinel nodes

stage III melanoma with positive sentinel nodes

stage III melanoma with clinically positive nodes: resectable

stage III melanoma with satellite/in-transit metastases: limited resectable disease

stage III melanoma with satellite/in-transit metastases: borderline resectable or unresectable disease

stage IV metastatic melanoma

Contributors

Authors

Yin Wu, MRCP(UK), PhD

Wellcome Trust Clinical Research Career Development Fellow and Honorary Consultant Medical Oncologist

Peter Gorer Department of Immunobiology

King's College London

Department of Medical Oncology

Guy's and St Thomas' NHS Foundation Trust

London

Disclosures

YW is funded by the Wellcome Trust, and consults for PersonGen Therapeutics, and Biotherapeutics.

Amanda Fitzpatrick, MRCP(UK), PhD

Medical Oncologist and Honorary Senior Lecturer

Guy's Cancer Centre

King's College

London

Disclosures

AF declares she has no competing interests.

Pablo Fernandez-Peñas, MD, PhD, FACD

Professor of Dermatology

The University of Sydney

Sydney

Australia

Disclosures

PF-P declares that he has no competing interests with the topic Melanoma. PF-P has advisory roles with Amgen, Boehringer Ingelheim, Bristol Meyers Squibb, Leo, Novartis, Lilly, Abbvie, Janssen, Celgene (psoriasis, atopic eczema, hidradenitis), Roche, Merck Sharp & Dohme, Sun Pharmaceuticals, Novartis, and Sanofi. He has been paid to do research for Incyte Europe Sarl, and clinical trials for Arena, Akaal Pharma, Xoma, Kyowa Hakko Kirin, AbbVie, OncoSec, Lilly, CSL Behring, Boehringer Ingelheim, Pfizer, mRage, Eisai, Jiansu Hengrui, Bristol-Myers Squibb, Sun Pharma, Novartis, Roche, Galderma, Regeneron, UCB, GlaxoSmithKline, and Amgen.

Acknowledgements

Dr Yin Wu, Dr Amanda Fitzpatrick, and Dr Pablo Fernandez-Peñas would like to gratefully acknowledge Dr Prachi Bhave, Dr Robyn P.M. Saw, Dr Sophie E. Papa, Dr Alexander M. Menzies, Dr Philip Friedlander, Dr Hobart W. Walling, and Dr Brian L. Swick, previous contributors to this topic.

Disclosures

PB has received honoraria from Bristol-Myers Squibb, MSD and Novartis and sponsorship from MSD and Novartis. RPMS is on the advisory board for Novartis, MSD, and Qbiotics and has previously been on the advisory board for Amgen; he has received honoraria from BMS and Novartis. SEP has received honoraria from BMS, MSD, and Novartis to attend conferences; she has participated in advisory boards for BMS, MSD, Amgen, Roche, and GSK. AMM has received honoraria from Novartis and BMS; he is on the advisory boards of MSD and Chugai. PF is a consultant for Genentech. HWW and BLS declare that they have no competing interests.

Peer reviewers

David Cassarino, MD, PhD

Assistant Professor

Department of Pathology and Laboratory Medicine

University of California

Los Angeles

Disclosures

DC declares that he has no competing interests.

James DeBloom, MD

Dermatologist/Dermatologic Surgeon

President of the South Carolina Skin Cancer Center

Greenville

Disclosures

JB declares that he has no competing interests.

Mai Brooks, MD, FACS

Associate Director

JCCC Women's Cancers Program Area

Jonsson Comprehensive Cancer Center at UCLA

Los Angeles

Disclosures

MB declares that she has no competing interests.

Karol Sikora, MA, MBBCh, PhD, FRCR, FRCP, FFPM

Medical Director

CancerPartnersUK

London

Disclosures

KS declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: melanoma - cutaneous [internet publication].Full text

National Institute for Health and Care Excellence. Melanoma: assessment and management. Jul 2022 [internet publication].Full text

Michielin O, van Akkooi ACJ, Ascierto PA, et al. Cutaneous melanoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2019 Dec 1;30(12):1884-901.Full text Abstract

Seth R, Agarwala SS, Messersmith H, et al. Systemic therapy for melanoma: ASCO guideline update. J Clin Oncol. 2023 Oct 20;41(30):4794-820.Full text Abstract

Vogelbaum MA, Brown PD, Messersmith H, et al. Treatment for brain metastases: ASCO-SNO-ASTRO guideline. J Clin Oncol. 2022 Feb 10;40(5):492-516.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Benign/dysplastic melanocytic nevi
- Seborrheic keratosis
- Pigmented basal cell carcinoma
More Differentials
Guidelines
- NCCN clinical practice guidelines in oncology: melanoma - cutaneous
- NCCN clinical practice guidelines in oncology: management of immunotherapy-related toxicities
More Guidelines
Patient information
Skin cancer (melanoma): what is it?
Skin cancer (melanoma): how is it diagnosed and treated?
More Patient information
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Melanoma

Summary

Definition

History and exam

Key diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

early stage melanoma (melanoma in situ, stage I, stage II)

stage III melanoma with negative sentinel nodes

stage III melanoma with positive sentinel nodes

stage III melanoma with clinically positive nodes: resectable

stage III melanoma with satellite/in-transit metastases: limited resectable disease

stage III melanoma with satellite/in-transit metastases: borderline resectable or unresectable disease

stage IV metastatic melanoma

Contributors

Authors

Yin Wu, MRCP(UK), PhD

Disclosures

Amanda Fitzpatrick, MRCP(UK), PhD

Disclosures

Pablo Fernandez-Peñas, MD, PhD, FACD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

David Cassarino, MD, PhD

Disclosures

James DeBloom, MD

Disclosures

Mai Brooks, MD, FACS

Disclosures

Karol Sikora, MA, MBBCh, PhD, FRCR, FRCP, FFPM

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice