Melanoma on Black Skin

In July 1977, Bob Marley was 32 years old when he noticed a dark spot under the nail of his right great toe. The first doctor he saw told him it was a soccer injury. By the time a second doctor biopsied the lesion and called it acral lentiginous melanoma, the cancer had already started its run. Marley refused full amputation, took a wide excision with a skin graft instead, and was dead at 36. The story is a fixture of dermatology lectures for a reason: it is the cleanest illustration of how melanoma kills Black patients. Not by being more common, but by being missed.

Melanoma is a cancer of melanocytes, the pigment-producing cells in the skin, nail bed, and mucous membranes. Black Americans get it less often than white Americans by a wide margin (lifetime risk roughly 1 in 1,000 vs 1 in 33, per the American Cancer Society), and that lower risk has produced a dangerous folk belief that Black skin doesn't get skin cancer. The mortality data say otherwise. Five-year relative survival from 2013 to 2019 was 71 percent for Black patients and 94 percent for white patients (ACS, Cancer Facts & Figures 2025). The driver of that 23-point gap is stage at diagnosis. Black patients are far more likely to present with thick, advanced, regional or distant disease than localized tumors that a dermatologist could have cut out at the office.

For cutaneous lesions, the standard ABCDE rule still applies: Asymmetry, irregular Borders, Color variation, Diameter over 6 mm, and Evolution over time.

For acral lesions (palms, soles, fingers, toes, nails), Bristow and colleagues developed the CUBED criteria specifically because ABCDE underperforms on these sites (Clinical guidelines for the recognition of melanoma of the foot and nail unit, Journal of Foot and Ankle Research, 2010). Refer if two or more of the following are present:

• Coloured lesion where any part is a different colour to the others
• Uncertain diagnosis for any acquired lesion
• Bleeding lesion on the foot or under the nail (including chronic granulation tissue)
• Enlargement or deterioration of a lesion or ulcer despite therapy
• Delay in healing of any lesion beyond two months

Specific patterns worth knowing:

• A dark streak in the nail (longitudinal melanonychia) that is wider than 3 mm, irregular in color, on a single digit, of adult onset, or progressing
• Pigment extending from the nail onto the cuticle or nail fold (Hutchinson's sign)
• Nail plate splitting, dystrophy, or bleeding under an apparently pigmented nail
• A new or changing pigmented spot on the sole or palm in an adult, especially if asymmetric or multicolored
• A pigmented lesion in the mouth, on the gums, or in the genital area
• A non-healing sore on the foot that does not look like a typical diabetic ulcer or fungal lesion

There is no recommended universal melanoma screening program for the general adult population in the United States: the US Preventive Services Task Force concluded in 2023 that evidence is insufficient to assess the benefits and harms of visual skin examination by a clinician for asymptomatic adults. That guidance is not an argument against examining yourself, and it is not an argument against examining Black patients, where the issue is missed disease, not over-screening.

Practical floor for self-exam:

• Look at your palms, the soles of your feet, between your toes, and your nails every month, in addition to the rest of your skin. Use a hand mirror for soles or ask a partner.
• Photograph any pigmented lesion on the palms, soles, or nails so you can track change. Date the photo.
• Ask your primary care provider to look at suspicious lesions, and push for a dermatology referral if a lesion fits CUBED or ABCDE.

Higher-risk Black patients (personal or first-degree family history of melanoma, prior atypical nevi, immunosuppression including HIV or transplant, xeroderma pigmentosum) should have a baseline dermatology exam and a clinician-determined surveillance interval, typically annually. Albinism dramatically increases sun-driven skin cancer risk and warrants dermatology follow-up regardless of overall melanoma epidemiology.

Treatment is staged by depth and spread, and is best delivered at a center with experience treating melanoma in skin of color. The components:

• Wide local excision is the standard surgical treatment for primary cutaneous and acral melanoma. Margins are dictated by Breslow thickness (typically 0.5 to 2 cm) per National Comprehensive Cancer Network guidelines. For subungual melanoma, modern practice has moved away from routine ray amputation toward function-sparing distal amputation or, in selected in-situ cases, wide excision of the nail unit.
• Sentinel lymph node biopsy is offered for tumors of intermediate thickness (typically Breslow greater than 0.8 to 1 mm, or thinner with high-risk features) to identify regional nodal spread and guide staging.
• Adjuvant systemic therapy for high-risk resected disease includes immune checkpoint inhibitors (anti-PD-1 agents nivolumab and pembrolizumab) and, for BRAF-mutant melanoma, targeted therapy with BRAF and MEK inhibitors. BRAF V600 mutations are far less common in acral and mucosal melanoma than in sun-driven cutaneous melanoma, so molecular testing matters before assuming a targeted-therapy pathway.
• Advanced or metastatic disease is treated with immune checkpoint inhibition (combination ipilimumab and nivolumab, anti-PD-1 monotherapy, or relatlimab plus nivolumab), with or without targeted therapy, and increasingly with tumor-infiltrating lymphocyte therapy (lifileucel, FDA-approved 2024) for refractory cutaneous disease.

One caveat that matters: Black and African-ancestry patients have been underrepresented in pivotal melanoma immunotherapy trials, and acral and mucosal melanoma respond less robustly to checkpoint inhibition than sun-driven cutaneous subtypes (Si Lin, ASCO Educational Book; recent first-line immunotherapy reviews). Ongoing trials funded by the NCI through institutions including Roswell Park and Wilmot Cancer Institute are specifically enrolling Black patients to close that evidence gap. Ask whether a clinical trial is open to you.