What are the symptoms of melanoma on black skin?

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

When should I see a doctor about melanoma on black skin?

Get a dermatology referral, not a wait-and-see, for any of these: A dark nail streak on a single finger or toe that appeared after childhood, especially if it is widening, darkening unevenly, or distorting the nail; Pigment that has crossed from the nail bed onto the surrounding skin (Hutchinson's sign); A new pigmented spot on the palm or sole in an adult, or an existing spot that has changed; A foot lesion or ulcer that has not healed in two months despite reasonable care; A pigmented lesion in the mouth or genital area that you did not have before; Any pigmented lesion that bleeds, itches, ulcerates, or is rapidly enlarging; If a primary care visit ends with reassurance and you are still worried, ask for a dermatology referral by name. If insurance or access is a barrier, teledermatology platforms and Federally Qualified Health Center dermatology clinics are alternatives. Bring photographs taken in good light with a ruler or coin for scale.

What are the treatments for melanoma on black skin?

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 trea

What questions should I ask my doctor about melanoma on black skin?

Should I be examined for melanoma on my palms, soles, and nail beds at every annual skin check, even if I am told my skin tone makes melanoma unlikely?; If you find a pigmented lesion on my foot or nail, what is the biopsy protocol, and how quickly can I get a result?; If melanoma is confirmed, is SLNB recommended based on the tumor thickness, and what do positive nodes mean for next steps?; Is my tumor being tested for BRAF mutation, and how does the result change treatment options?; Are there clinical trials open to me, particularly trials focused on acral lentiginous melanoma or on increasing immunotherapy response in Black patients?; What should I be examining at home, and how often?;

Dermatology Last reviewed: May 22, 2026

Melanoma on Black Skin

Also known as: malignant melanoma, acral lentiginous melanoma, ALM, subungual melanoma

Reviewed by the Black Health editorial team Last reviewed May 2026

71% vs 94%

5-year melanoma survival, Black vs white Americans (ACS, Cancer Facts & Figures 2025)

Overview

Melanoma is rare in Black people compared to white people -- but when it occurs, it kills at a dramatically higher rate, and the gap is not explained by biology alone. It is explained by late diagnosis. Black patients are more than three times as likely to be diagnosed at an advanced stage as white patients, and a 70 percent five-year survival rate versus 94 percent for white patients is the statistical result of that delay.^[1] This page covers the type of melanoma most common in Black skin (acral lentiginous melanoma), where to look for it, what treatment looks like, and why the Bob Marley story is a lesson that still applies today.

How Melanoma on Black Skin affects Black patients

The melanoma that shows up in Black patients is usually not the kind on the textbook cover. Acral lentiginous melanoma (ALM), a histologic subtype that arises on palms, soles, fingers, toes, and nail beds, accounts for roughly 36 percent of all cutaneous melanomas in Black Americans, compared with under 1 percent in non-Hispanic whites (Bradford et al., Acral Lentiginous Melanoma: Incidence and Survival Patterns in the United States, 1986-2005, Archives of Dermatology, 2009). In that SEER analysis, about 78 percent of ALMs occurred on the lower limbs, with feet and soles accounting for the majority. The cancer concentrates on weight-bearing plantar surfaces, which is part of why patients and providers misread it as a callus, a blood blister, a fungal nail, or a sports injury.

Subungual melanoma, the variant Marley had, presents as a longitudinal pigmented band in the nail (longitudinal melanonychia) that widens over time, darkens unevenly, distorts the nail plate, or bleeds. The classic warning is Hutchinson's sign: pigment that creeps from the nail bed onto the surrounding skin of the cuticle or nail fold, reflecting radial growth of the tumor. Hutchinson's sign is not pathognomonic (it appears in benign racial melanonychia, drug-induced pigmentation, and Laugier-Hunziker syndrome), but in an adult-onset, single-digit, asymmetric pigmented band, it earns a biopsy.

The survival gap is not biology, it is delay. In the Bradford SEER cohort, ALM 5-year melanoma-specific survival was 82.6 percent in non-Hispanic whites and 77.2 percent in Black patients, with Black patients presenting at thicker Breslow depth and more advanced AJCC stage. Three structural reasons sit behind this. First, dermatology training is calibrated to light skin: a 2018 content audit of major textbooks found dark skin tones underrepresented across nearly every diagnosis, and trainees report low confidence identifying skin cancer on Black patients. Second, Black patients are less likely to have a dermatologist and more likely to face cost and access barriers. Third, screening exams routinely skip the regions where Black melanoma actually lives. The American Academy of Dermatology's position on skin of color is explicit: full-skin exams should include palms, soles, between toes, nail beds, mouth, and genital area. Dr. Susan Taylor, who founded the Skin of Color Society in 2004 after creating the country's first Skin of Color Center at St. Luke's-Roosevelt in 1999, has spent two decades arguing the obvious: dermatology cannot keep treating Black skin as an afterthought.

Symptoms

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

When to see a doctor

Get a dermatology referral, not a wait-and-see, for any of these:

A dark nail streak on a single finger or toe that appeared after childhood, especially if it is widening, darkening unevenly, or distorting the nail
Pigment that has crossed from the nail bed onto the surrounding skin (Hutchinson's sign)
A new pigmented spot on the palm or sole in an adult, or an existing spot that has changed
A foot lesion or ulcer that has not healed in two months despite reasonable care
A pigmented lesion in the mouth or genital area that you did not have before
Any pigmented lesion that bleeds, itches, ulcerates, or is rapidly enlarging

If a primary care visit ends with reassurance and you are still worried, ask for a dermatology referral by name. If insurance or access is a barrier, teledermatology platforms and Federally Qualified Health Center dermatology clinics are alternatives. Bring photographs taken in good light with a ruler or coin for scale.

Screening

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 overview

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.

Questions to ask your doctor

Bring this list to your next appointment.

Should I be examined for melanoma on my palms, soles, and nail beds at every annual skin check, even if I am told my skin tone makes melanoma unlikely?
If you find a pigmented lesion on my foot or nail, what is the biopsy protocol, and how quickly can I get a result?
If melanoma is confirmed, is SLNB recommended based on the tumor thickness, and what do positive nodes mean for next steps?
Is my tumor being tested for BRAF mutation, and how does the result change treatment options?
Are there clinical trials open to me, particularly trials focused on acral lentiginous melanoma or on increasing immunotherapy response in Black patients?
What should I be examining at home, and how often?

Find care for melanoma on black skin

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The numbers

Black patients have a five-year melanoma survival rate of 70 percent, compared to 94 percent for white patients -- a 24-percentage-point gap.^[1]
52 percent of non-Hispanic Black patients are diagnosed with advanced-stage (regional or distant) melanoma, versus 16 percent of non-Hispanic white patients.^[1][2]
Acral lentiginous melanoma (ALM) accounts for approximately 16 to 60 percent of melanomas diagnosed in Black patients, compared to 1 to 3 percent in white patients.^[3][4]
Among Black patients with stage IV melanoma in one JAMA Dermatology 2024 cohort study, 92 percent died and none responded to immunotherapy -- a finding that underscores how much stage at diagnosis determines outcome.^[5]
Melanoma incidence in Black people is low (1.1 per 100,000 men; 0.9 per 100,000 women), but that low base rate contributes to a false sense of immunity that delays self-examination and dermatology referrals.^[6]
Among Black patients with stage III melanoma, 5-year survival was 42 percent for men versus 71 percent for women, highlighting additional sex-based disparities within the Black patient population.^[7]

What it is

Melanoma is a skin cancer that originates in melanocytes -- the pigment-producing cells found in the skin, eyes, and nail beds. It is distinct from basal cell carcinoma and squamous cell carcinoma (the most common skin cancers) because it spreads aggressively to lymph nodes and distant organs if not caught early. The behavior of melanoma is stage-dependent: localized melanoma has a near-100 percent five-year survival rate; distant metastatic melanoma drops to 34 percent.^[6]

In the general population, most melanoma is linked to ultraviolet radiation exposure, which is why lighter skin carries higher risk. But the type most commonly seen in Black patients -- acral lentiginous melanoma -- is not UV-driven. Its incidence is similar across racial groups in absolute terms, which means the lower overall melanoma rate in Black people does not protect against ALM. The risk is equal; the awareness is not.

Sources: NIH/NCI SEER data,^[6] StatPearls/NIH.^[3]

How it looks in Black skin: acral lentiginous melanoma

Acral lentiginous melanoma grows on hairless skin: palms of the hands, soles of the feet, under and around the nails (subungual). It begins as a flat, irregularly bordered macule -- a patch of uneven light-brown to dark pigment that slowly expands over months or years. On the nail, it appears as a dark streak running the length of the nail (melanonychia striata); the key warning sign that distinguishes melanoma from benign nail pigmentation is that the band widens toward the cuticle (Hutchinson's sign).

Because ALM grows in places routinely covered by shoes and socks, and because the early lesion is easily mistaken for a bruise, fungal infection, or trauma mark, diagnosis is frequently delayed. Bob Marley -- the reggae artist who died in May 1981 at age 36 -- was diagnosed with ALM on his right great toe after initially attributing the dark spot to a soccer injury. Doctors recommended amputation of the toe; he declined due to religious belief. The cancer spread to his brain, liver, and lungs. His death is cited by the Skin Cancer Foundation as a case where earlier, more aggressive intervention could have changed the outcome.^[8]

Key presentation details:

Location: soles (plantar foot), palms, nail beds (especially thumbs and big toes)
Appearance: irregularly bordered brown-to-black macule, often with color variation; nail-bed lesions appear as a dark longitudinal band
Growth: slow in the radial (outward) phase, aggressive once vertical growth begins
Not UV-related: sun protection does not prevent ALM

Use the CUBED framework for acral surfaces: Colored lesion, Uncertain diagnosis, Bleeding, Enlargement, Delayed healing.^[3] Any lesion meeting one or more criteria warrants urgent dermatology evaluation.

The 60 to 75 percent of melanomas in Black patients that occur on palms, soles, and nail beds are the reason that monthly self-examination must include those sites.^[1]

Treatment, plainly

Treatment depends on stage at diagnosis, which is why every week of delay matters.

Stage I and II (localized disease): Wide local excision with margins determined by tumor thickness (0.5 cm for melanoma in situ; up to 2 cm for tumors greater than 2 mm thick). For nail unit melanoma, conservative excision of the nail unit -- without digit amputation -- achieves equivalent disease-free survival and is now standard of care at most melanoma centers.^[3][9] Sentinel lymph node biopsy (SLNB) is performed for tumors 0.8 mm or thicker to detect microscopic regional spread.

Stage III (lymph node involvement): Surgical removal of involved lymph nodes (lymph node dissection) plus adjuvant systemic therapy. Current options include adjuvant pembrolizumab (anti-PD-1 immunotherapy) or, for BRAF-mutant tumors, targeted combination therapy with a BRAF inhibitor (dabrafenib) plus MEK inhibitor (trametinib).^[10]

Stage IV (distant metastasis): Treatment has been transformed by immunotherapy. First-line options include: - Pembrolizumab (Keytruda) monotherapy: anti-PD-1 checkpoint inhibitor - Nivolumab (Opdivo) monotherapy: anti-PD-1 checkpoint inhibitor - Combination ipilimumab (anti-CTLA-4) plus nivolumab for higher-risk disease - BRAF-targeted therapy for the approximately 50 percent of melanomas that carry a BRAF V600 mutation: dabrafenib + trametinib or vemurafenib + cobimetinib^[10]

A critical caveat for Black patients: the JAMA Dermatology 2024 cohort study found that among 13 Black patients who progressed to stage IV, none responded to immunotherapy.^[5] This is a small sample, but it signals a research gap. Current immunotherapy data comes overwhelmingly from clinical trials where Black patients are underrepresented. The most effective intervention available today is earlier diagnosis -- not better drugs.

Mohs micrographic surgery is used for select anatomic sites where tissue preservation matters; for nail unit and acral sites, a multi-specialty approach (dermatologic surgeon, Mohs surgeon, or hand/orthopedic surgeon) is often appropriate.^[9]

Sources: NCCN guidelines,^[10] StatPearls/NIH,^[3] PMC management review.^[9]

How to find care

Find a dermatologist in our directory (60+ Black dermatologists listed, filter by specialty)
Black women's health hub
Black men's health hub
Related condition: Atopic dermatitis in Black skin

Sources

Skin Cancer Foundation. "Skin Cancer in Skin of Color." https://www.skincancer.org/skin-cancer-information/skin-cancer-skin-of-color/
CDC / Preventing Chronic Disease. "Melanoma Among Non-Hispanic Black Americans." 2019. PMC6638592. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6638592/
Oakley A, et al. "Acral Lentiginous Melanoma." StatPearls. NIH/NCBI. Updated 2023. https://www.ncbi.nlm.nih.gov/books/NBK559113/
Melanoma Research Alliance. "Learn About Acral Lentiginous Melanoma." https://www.curemelanoma.org/about-melanoma/types/acral-melanoma
Wix SN, et al. "Distinct Presentation of Melanoma in Black Patients." JAMA Dermatology. 2024. doi:10.1001/jamadermatol.2023.5789. https://pubmed.ncbi.nlm.nih.gov/38436625/
National Cancer Institute SEER. "Cancer Stat Facts: Melanoma of the Skin." https://seer.cancer.gov/statfacts/html/melan.html
ASCO Post. "Disparities in Melanoma Outcomes Among Black Patients." May 2024. https://ascopost.com/news/may-2024/disparities-in-melanoma-outcomes-among-black-patients/
Skin Cancer Foundation. "Bob Marley Should Not Have Died from Melanoma." https://www.skincancer.org/blog/bob-marley-should-not-have-died-from-melanoma/
Garbe C, et al. "Management of Acral Lentiginous Melanoma: Current Updates and Future Directions." PMC10882087. https://pmc.ncbi.nlm.nih.gov/articles/PMC10882087/
American Journal of Managed Care. "NCCN Melanoma Guideline Update: It's About Immunotherapy and Targeted Therapy." https://www.ajmc.com/view/nccn-melanoma-guideline-update-its-about-immunotherapy-and-targeted-therapy

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Medical disclaimer

This content is for informational and educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about a medical condition. If you are experiencing a medical emergency, call 911 or your local emergency number immediately.

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