The ABCDE Skin Cancer Guide for Quick Melanoma Detection

Melanoma is a cancer type that, though rare, has the highest mortality among all skin malignancies. The condition is markedly aggressive and often has an unpredictable course, even after removal. Everyone is at risk, though some are more vulnerable than others. One way for people to protect themselves from melanoma’s severe consequences is to have it treated while still in its early stages.

The ABCDE skin cancer recognition guide can help clinicians and patients detect melanoma. How do you use this tool? Is it reliable? What should you do if you find a suspicious skin lesion that fits the ABCDE criteria? What can you expect from melanoma treatment? This article answers these questions and more.

What Is Melanoma?

The skin is composed of various cells supporting its structure and function. For example, keratinocytes are the typical skin cells that make up the skin barrier. Pilomatrix cells comprise the hair follicle matrix. Merkel cells are crucial to the sense of touch. Melanocytes are special cells in the skin barrier that produce the UV-protective pigment melanin.

Normal growth of these cells makes your skin look radiant and maintains functions like moisture loss prevention and environmental protection. However, excessive exposure to agents like the sun’s UV rays, which can alter skin DNA, can cause abnormal growth, leading to cancer.

Basal and squamous cell carcinoma are keratinocyte cancers. Merkel cell carcinoma arises from tumorous Merkel cells. Malignant pilomatricoma develops from abnormal hair follicle matrix cells.

Melanoma, which looks like an unusual or atypical mole, is a cancer involving melanocytes. Other names for this tumor include “malignant melanoma”—a misnomer since there’s no such thing as “benign melanoma”—and “melanoma skin cancer,” which is a redundant term.

Most melanoma lesions are highly pigmented, with a black, brown, blue, or gray color. However, some tumors are “hypomelanotic” or “amelanotic,” with little to no melanin. These lesions may appear white, skin-colored, pink, or red.

Some of these light-colored tumors represent melanoma regression due to the body’s immune reaction to the cancer cells, but others possibly have more aggressive growth. Thus, the keen clinical eye of a board-certified dermatologist is indispensable when evaluating these lesions.

Melanoma tumors typically grow in sun-exposed skin areas. However, susceptible individuals, like those with poor immunity or a strong family history, may have melanomatous growth in hidden mucosal areas like the nostrils and internal organs. The tumors may be flat or raised, depending on the type and stage.

Vital organ involvement can cause dysfunction. For example, melanoma spreading to the brain can lead to stroke-like symptoms, such as numbness, muscle weakness, and behavioral changes. Involvement of the heart can manifest as potentially fatal abnormal heart rhythms.

What Are the Types of Melanoma, and Why Does It Matter to Know?

Melanoma has many subtypes, most of which are beyond the scope of this article. However, the more common ones include the following:

• Superficial spreading melanoma

This melanoma subtype is the most common, comprising 70% of all skin melanoma cases. Lesions usually grow in sun-exposed areas, commonly the lower limbs in women and the upper back in men. Superficial spreading melanoma tumors typically are highly pigmented (black or blue-gray) and have all the ABCDE features. Tumors may be flat or slightly raised, frequently arising from preexisting benign moles.

• Nodular melanoma

Nodular melanoma is the second most common form, constituting 15-30% of all cases. The lesions are typically dark in color (bluish-red or blue-black) and may be raised or rounded. Ulceration (open sore formation) may signify advanced growth. The trunk is the site most frequently affected. Nodular melanoma exhibits rapid growth—enlarging within weeks to months—and may appear without a preexisting benign mole.

• Lentigo melanoma and lentigo maligna melanoma

Lentigo melanoma is a form of early-stage melanoma (melanoma in situ) with shallow, horizontal growth. Lentigo maligna melanoma is essentially lentigo melanoma with deeper tissue involvement. These tumors most commonly appear in the head, especially the face. Most individuals with these lesions are aged 70 or older. Lentigo melanoma and lentigo maligna melanoma are rare before age 40.

• Acral lentiginous melanoma

This subtype affects both fair skin and skin of color and is the most common melanoma variant among people of color. Most individuals with this form of skin cancer develop the condition in their 60s. Acral lentiginous melanoma most commonly affects the foot soles, palms, and areas under the nails. Most lesions are brown to black. Some may be mistaken for plantar warts.

• Desmoplastic melanoma

Desmoplastic melanoma lesions are firm, thick, and scarlike, and half of them are light-colored. Most tumors of this kind are found in the head and neck. This skin cancer type often manifests at age 60 or older.

• Mucosal melanoma

As its name implies, this skin cancer subtype grows in mucosal surfaces, mostly in the head, neck, and genital areas. Mucosal melanoma tumors bleed easily and are irregularly shaped and deeply pigmented. Most lesions are hard to find due to their hidden locations, except for those growing in the eye.

Rare types include nevoid and spitzoid melanoma, which mimic benign pigmented lesions, and highly aggressive variants, such as metaplastic, myxoid, and balloon-cell melanoma. Correctly identifying skin cancer types is crucial, as each requires different treatments.

Tumors that resemble benign conditions, grow in unexposed areas, or affect specific patient groups, such as older individuals who may develop unusual symptoms, may be treated inappropriately if misdiagnosed.

Is Melanoma Fatal?

As previously mentioned, melanoma is rare but is the most fatal of all skin cancers. The tumor can invade deeper tissues and spread widely in the body within months. Internal organ involvement often leads to various complications, including bone pain, liver failure, bowel obstruction, and kidney disease, to name a few.

Individuals with widespread or metastatic disease may have poor quality of life owing to pain and other symptoms of vital organ involvement. In patients experiencing remissions, melanoma has an unpredictable course, potentially recurring even decades after the first tumor is removed.

Melanoma is the 5th most common cancer in the United States and continues to rise in incidence in countries predominated by fair-skinned populations. The most frequently affected patient groups are whites and older men, with an average age of 65 at diagnosis.

The length of survival depends on the timing of detection and subsequent treatment. About 83% of cases are diagnosed and treated at Stage I or II, where nearly all patients (99.4%) live at least 5 years after diagnosis. For Stage III, 68% of people live at least 5 years after diagnosis, while for Stage IV, only 29.8% do.

Mortality from melanoma has decreased by 30-60% in recent years. The above statistics show that this trend is due to early detection more than skin cancer treatment advances, which primarily target poorly responsive, late-stage disease. Knowledge of the ABCDE method, regular self-skin checks, and avoidance of risk factors, such as excessive UV exposure, contribute to better outcomes for this condition.

What Are the Biggest Melanoma Risk Factors?

Chronic, excessive UV radiation exposure, whether from the sun or indoor equipment, is the most significant risk factor for the evolution of skin cancers, including melanoma. UV light causes skin DNA mutations that are passed on to younger, multiplying skin cells. Abnormal growth leads to cancer if the body’s DNA repair mechanisms fail. Melanin protects against UV rays, reducing skin cancer risk for most people of color.

Poor immunity is another melanoma risk factor, as the immune cells are people’s first line of defense against cancer. Conditions and medications that weaken the immune system, such as HIV and steroids, can make people prone to melanoma formation.

Genetics also plays a huge role in melanoma development. Individuals with a family history of melanoma or any skin cancer usually grow tumors at a young age. People born with fair skin, a tendency to sunburn or freckle, blue or green eyes, an inability to tan, and blond or red hair have an increased risk of skin cancer.

The tendency to form multiple moles, especially atypical ones, also increases melanoma susceptibility and is often inherited. Familial atypical multiple mole melanoma syndrome comprises a condition where members of the same family develop multiple melanomatous tumors and other cancers. Inborn conditions like xeroderma pigmentosum, which makes the skin UV-sensitive, also raise melanoma risk.

Obesity increases melanoma proneness, particularly when the body mass index is over 30. Excess body fat induces DNA changes that promote melanoma formation. A prior history of melanoma and other skin cancers and receiving chemotherapy also elevates melanoma risk.

What Are the ABCDEs of Melanoma?

The ABCDE melanoma acronym stands for the following characteristics of this malignant skin growth:

• Asymmetry: The skin lesion has an uneven or lopsided shape.
• Border irregularity: The tumor’s margins are not smooth, unlike in normal moles.
• Color heterogeneity: The lesion’s color is uneven or varies within the same area.
• Diameter large: The tumor has a diameter greater than 6 millimeters, larger than that of a pencil eraser. 

Evolution: The pigmented lesion changes in size, shape, or color over time.

My previous article, “Mole vs. Melanoma: Knowing the Difference Could Save Lives,” compares the physical features of common moles with melanoma. You may read the article and check out its pictures to help you distinguish melanoma from one of its closest mimics.

How Reliable is the ABCDE Melanoma Detection Guide?

The ABCDE melanoma guide catches 30% to 90% of cases, depending on the skill of the person using it. Patients with specific risks are encouraged to use this tool, coupled with regular self-skin exams, to enhance their ability to spot these malignant moles.

The ABCDE skin cancer guide becomes more reliable when real lesion changes are observed over time, and multiple ABCDE features are found in one spot. Skin cancer experts like board-certified dermatologists use a special magnifying tool called a “dermoscope” to enhance their ability to identify these tumors when examining patients.

No single feature is 100% reliable in diagnosing or ruling out melanoma. However, color and size changes and the appearance of a new pigmented lesion are the earliest symptoms most patients notice.

Are There Alternatives to the ABCDE Skin Cancer Guide?

Alternatives to the ABCDE melanoma detection tool include the following:

• 7-point checklist: This expanded version of the ABCDE tool is used by clinicians. This guide takes note of 7 tumor features, including size and sensation changes, shape and color irregularity, the presence of inflammation and oozing, and a diameter greater than 7 millimeters.
• Ugly duckling sign: Moles generally look similar in one person or family. The ugly duckling sign means a pigmented lesion looks different from other pigmented lesions on your skin. 
• SCAN: This acronym stands for “Sore, Changing, Abnormal, New,” describing a suspicious mole in simple terms.

However, these tools are either too complex or too simple for patients to use when identifying melanoma. Still, regardless of the recognition tool you choose, keep in mind that most melanoma cases are self-detected by patients or their close contacts, thus contributing to the continued drop in melanoma mortality.

How Do You Screen Yourself for Melanoma?

Regular self-skin examinations are still your most reliable measures for detecting melanoma early. The American Cancer Society suggests an easy way to check your skin at home.

Start by standing in front of a large mirror and inspect your face, ears, neck, chest, and belly. Women should lift their breasts to check underneath. Look at your underarms, both sides of your arms, hands, fingers, and under your fingernails.

While seated, check the front of your thighs, shins, feet, toes, and beneath your toenails. Use a hand mirror to see the soles of your feet, calves, and backs of your thighs, as well as your genital area, buttocks, back, neck, and ears. For your scalp, use a comb or hair dryer to part your hair and check the skin beneath. Use the ABCDE tool when inspecting suspicious lesions.

If you’re unsure of your findings, you may use a self-skin check app, ask a partner for help, take photos to document lesion changes, or consult a dermatologist ASAP. Consulting with a medical professional is pivotal for highly at-risk individuals requiring an evaluation for possible mucosal involvement, which cannot be detected easily at home.

When Should You See a Doctor for a Skin Growth?

The following features should prompt you to have a skin growth checked and treated:

• Changes in shape, color, or size, especially if occurring within weeks or months
• Strange colors like gray or blue
• Bleeding or forming an open sore
• Pain, itching, or swelling
• Affecting function, such as finger or eye movement
• Unresponsiveness to over-the-counter or prescribed skin treatments

Seeing a board-certified dermatologist right away can help you identify and address the skin issue promptly. Timely melanoma therapy can add symptom-free years to a patient’s life.

What Can You Expect from Your Dermatologist Consultation for a Suspected Melanoma?

The dermatologist’s clinical evaluation typically starts with history taking. They will ask about your initial observations of the lesion and the subsequent changes. They will also inquire about your past medical, family, and social history to look for clues critical to their diagnosis and the overall treatment plan.

After taking the clinical history, the dermatologist will perform a physical examination. A skin cancer suspicion typically warrants a complete skin examination, including the mucosal surfaces in the head and genitals. But don’t worry. Your skin specialist is trained to perform physicals in a professional manner, with the utmost regard for patient privacy and confidentiality.

After the clinical evaluation, your dermatologist will explain their findings. For some patients, the lesion may not be skin cancer at all but a non-malignant mimic, such as seborrheic keratosis, skin tags, sun spots, warts, and benign moles. You can talk to your physician about treatments for these conditions right away.

However, the dermatologist typically orders a lesion biopsy for confirmation if melanoma is highly suspected. Once confirmed, they may order imaging tests, such as computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI), and a lymph node biopsy to look for sites of spread—an important step in determining treatment.

Tests for melanoma indicators in the blood may be ordered to get an initial value, which is critical for monitoring tumor remission or progression during and after treatment. Additional tests may be ordered for people of advanced age or with chronic medical conditions for medical clearance before melanoma therapy. Deep or remote spread often requires referrals to other specialists, such as general or oncologic surgeons, otolaryngologists, and oncologists.

What Are the Treatment Options for Melanoma?

Wide local excision (WLE) is the standard of care for melanoma. The tumor is manually removed along with wide margins, the span of which is determined based on lesion depth. Lymph nodes may also be cut out, depending on tumor size, imaging results, and other findings.

Mohs micrographic surgery is an alternative procedure that may be considered for early-stage melanoma. The procedure is performed under local anesthesia and entails stepwise removal of the tumor, microscopically examining each slice, and taking out a thin layer of the surrounding normal skin.

This thin skin layer is also examined under a microscope to make sure it’s cancer-free. A Mohs surgeon is a dermatologist specially trained and board-certified to perform this procedure.

Mohs surgery offers better cure rates and cosmetic outcomes than WLE for treating early-stage melanoma. The procedure also offers slightly better survival rates in advanced melanoma than in WLE. However, Mohs surgery is not typically used for advanced melanoma cases due to various technical challenges.

For advanced melanoma, surgical removal of the primary tumor may be combined with at least one of the following:

• Lymph node dissection: This procedure entails removing lymph nodes where cancer spread is likely or has been detected.
• Radiation therapy: Areas where lymph nodes have been dissected are exposed to high-energy radiation to kill off hidden cancer cells and prevent recurrence or further spread. 
• Electrochemotherapy: This treatment involves applying electrical pulses to the lesion site before injecting a cancer drug, typically cisplatin or bleomycin. The electric pulses make the cancer cells sensitive to the injected drug.
• Isolated limb infusion: This therapy may be considered when the tumors are confined to one extremity. The cancer drugs melphalan and actinomycin D are delivered to the affected limb at high doses.
• Metastasectomy with radiotherapy: This combined procedure is performed only to improve patient comfort and not prolong survival. Solitary metastatic lesions in vital organs are removed, and the surgical area is subsequently exposed to radiation. One important use of this treatment is to relieve bowel obstruction due to melanoma spread in the gut.
• Chemotherapy: Dacarbazine and temozolomide are FDA-approved agents for metastatic melanoma treatment. However, these drugs produce only modest responses and do not improve survival. Thus, their replacement by immunotherapy.

• Immunotherapy: Agents that enhance immune responses against melanoma cells offer better survival rates than chemotherapy for advanced disease. Non-targeted agents like interferon-alpha boost various immune cells. Immune checkpoint blockers work only on specific cell types, often the T-cells, and include nivolumab and pembrolizumab.
• Mutant DNA inhibitors (targeted therapy): These drugs prevent the actions of the mutant genes that initiate melanoma formation. FDA-approved medications belonging to this class include vemurafenib and dabrafenib. Patients live up to 8 months without the cancer getting worse, while their overall survival is up to 18 months.
• Adoptive T-cell therapy: This procedure involves extracting T-cells from a patient, modifying them in a lab to better fight cancer, and injecting them back into the patient’s body. This treatment boosts the immune system’s ability to target and destroy melanoma cells effectively.

Regular dermatologist follow-up is crucial after any melanoma treatment to monitor for recurrence or progression and treat complications immediately.

What Is the Prognosis for Melanoma?

The prognosis for melanoma depends on various factors, the most important of which is the clinical stage at the time of diagnosis. The clinical stage is determined by tumor thickness, lymph node involvement, and the presence of spread to other organs. The outlook generally gets worse with increasing stages.

Other factors that can worsen the condition’s prognosis include advanced age (i.e., older than 60), open sores, and aggressive tumor features like blood vessel invasion, which allows cancer cells to spread through the bloodstream. Women generally have better survival rates than men. The presence of immune cells in the area of the tumor potentially prolongs survival.

How Do You Prevent Melanoma?

UV protection is the best way to prevent any skin cancer. Dermatologists encourage the use of both physical and chemical forms of UV protection.

Physical forms include avoiding sun exposure or tanning equipment use, seeking shade, and wearing wide-brimmed hats and clothes with good body coverage. Sunblock provides chemical UV protection. People receiving UV phototherapy may talk to their health providers about limiting treatments to the minimum effective dose.

Everyone, especially highly at-risk individuals, can benefit from regular self-skin exams, applying the ABCDE melanoma guide when inspecting suspicious lesions. Regular dermatologist visits and adherence to dermatologist-recommended skincare regimens also help prevent melanoma or, in patients previously treated for the condition, its recurrence.

Patients with a prior melanoma or skin cancer history must follow up with their dermatologist every 3-6 months after treatment or as advised. Individuals with poor immunity, chronic occupational sun exposure, or a strong family history of skin cancer are also advised to seek frequent dermatologist consults. Annual dermatology visits for skin cancer screening are recommended for people with low skin cancer risk.

The ABCDE Skin Cancer Guide: A Tool That Empowers Patients

Melanoma is a deadly skin cancer, though patient outcomes have vastly improved in recent years. Most modern melanoma treatments primarily target late-stage disease, which poorly responds to therapy. However, 83% of these tumors are diagnosed early, when they’re still highly treatable.

Thus, the most critical factor in improved melanoma outcomes is early detection. That also means that the outlook for this condition is well within patients’ control.

One of the best tools patients and clinicians can use to identify early melanoma is the ABCDE melanoma recognition guide. Individuals concerned about their skin cancer risk can use this guide during their regular self-skin checks. Early diagnosis and treatment reduce complications and prolong disease-free survival.

Finally, if you or a loved one has concerns about a suspicious mole, it’s best to consult with a board-certified dermatologist with a solid reputation. Only a bona fide skin disease expert can identify melanoma reliably and treat it appropriately.

Frequently Asked Questions

What Conditions Can Mimic Melanoma?

Most melanoma lesions are hyperpigmented and have all the ABCDE features. However, some of these tumors, like amelanotic and desmoplastic melanoma, have traits that can make them look like other skin conditions.

Thus, besides the mimics already mentioned above, a long list of skin disorders can resemble melanoma. Benign ones include bruises, raised scars, atypical moles, and hemangioma. Malignant types include squamous and basal cell carcinoma. A dermatology consult is highly recommended for skin lesions that are difficult to identify.

Can You Live a Long Life After Having Melanoma?

Many patients live for many years after being diagnosed with melanoma, but the likelihood of long-term survival generally depends on the melanoma stage at the time of diagnosis and treatment. Melanoma in situ—or very early-stage melanoma—rarely recurs after complete surgical removal. In contrast, advanced melanoma tends to come back more quickly compared to earlier-stage disease.

About 2-20% of patients previously treated for melanoma experience a recurrence in the first 5 years, most within 2-3 years after surgery. Vigilant monitoring and early treatment of recurring lesions are vital to prolonging survival.

Recurrence rates significantly decline 5 years after melanoma treatment. However, melanoma is a treacherous disease, with some patients experiencing a relapse even decades after having the first tumor removed. Patients treated for early-stage melanoma who survive until old age are more likely to die from cardiovascular disease than melanoma complications.

Can You Get Melanoma from Smoking?

Oddly, smoking is associated with a reduced melanoma incidence. However, current smokers with melanoma are more likely to die from the condition than former and nonsmokers.

Bothered by a Suspicious Skin Lesion? Let LA’s Top Skin Cancer Specialists Help

Melanoma is a rare but potentially fatal skin tumor. Easy-to-use detection tools, like the ABCDE guide, can help diagnose the condition early. But what should you do if you find a new skin growth but aren’t sure what it is?

The answer: Leave it to BHSkin Dermatology’s specialists. Our award-winning skin disease experts are some of California’s best. Our board-certified dermatologists have helped many people in LA regain their peace of mind by getting rid of melanoma and other skin cancers for good. Visit us at our Glendale or Encino clinic or use our telederm platform for your first consultation.

Book your appointment today!

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Author: Don Mehrabi

Don Mehrabi, MD, FAAD, is LA’s leading board-certified dermatologist who treats patients, builds the BHSkin clinics, and raises three kids. This blog builds on medical studies combined with Dr. Mehrabi's first-hand experiences from practicing in Encino-Tarzana, Glendale, and online