Melanoma does not always play fair

Most melanomas I see look funky and problematic before a biopsy is ever done. However, recently I had another scary case that took me by surprise and served as a reminder that melanoma does not always play by the rules.  I had a patient come in to see me concerned about a new spot on their back. At a quick glance I thought it may be simply an inflamed flesh colored mole or possibly a Basal Cell type of skin cancer. The picture below is not a picture of my patient, but it is very similar to the spot.


If you are not too familiar with skin cancers, in general, Basal Cell and Squamous Cell skin cancers are more common and generally less aggressive. They can become a big problem locally, but they do not commonly kill you. Melanoma, by comparison, is much more serious and more likely to be fatal.

Now back to the patient. During the exam I noticed two other areas that were much more atypical looking, but thankfully we still performed a biopsy on that initial pink spot. I ended up doing three biopsies on this patient and all biopsies came back as skin cancer, but the one that looked “not s0 concerning” came back as a melanoma metastasis that was very deep. I was quite surprised.  As always, the worst part was having to tell the patient that not only do they have melanoma, but a very serious one that was already at an advanced stage.

The ABCDE’s of Melanoma are a helpful tool when looking at your own spots.  Like I said earlier, most melanomas follow these rules and look abnormal. The more uniform a spot is, the better. The more variety in color and pattern in the lesion, the more likely it needs to be checked.


However, as the story above illustrates, melanoma does not always play fair. And our patient had an amelanotic variant, which means it didn’t have a brown or black color from melanin in the skin.  Amelanotic melanaoma, in my opinion, is the scariest melanoma because it lacks pigment, making it look more like a basal cell carcinoma, acne, or even like nothing at all.  Luckily, these are not too common.

Now, not every mole is a perfect brown round circle.  In fact, most of them are not and yet most of them are still benign. This is where something called the “ugly duckling” rule comes in to play. The ugly duckling sign refers to how similar the moles look to each other. If you have a mole that looks a little funny, but happens to look pretty similar to other spots then that is usually a good sign. If you have a mole that does not follow the rules and you can not find another spot on your body that appears similar, then it is an ugly duckling and deserves further evaluation.

The key is early detection for all types of skin cancers, and when it is all said and done any new or changing spot should be evaluated by a dermatologist.  No one will fault you for coming in for a spot that was benign. I always tell my patient’s that it is better to be safe than sorry. If you never have had your skin checked, now is as good a time as any. Also, if you go get your skin checked then you might as well really get it checked. That means don’t be afraid to get naked and show your skin, and make sure that whoever is doing your exam checks everywhere because some types of Melanoma occur where the sun does not shine.

Lindsey Smart Smith  PA-C

References: American Academy of Dermatology, Spot Skin Cancer

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