Melanoma and pigmented lesions: the Australian GP approach

Melanoma in Australia — the highest incidence in the world

Australia carries the world’s highest melanoma incidence. Cancer Council Australia reports approximately 17,000 new cases per year, approximately 1,400 deaths annually, and a lifetime risk of roughly 1 in 17 for men and 1 in 22 for women. The rate is declining in younger Australians — reflecting decades of SunSmart education — but rising in older cohorts. Melanoma is the most preventable cancer death in young Australians and a condition where GP-level recognition and dermoscopy skill directly saves lives.

Risk factors include fair skin (Fitzpatrick I–II), red or fair hair, blue eyes, freckling, history of childhood blistering sunburn, high mole count (over 50), atypical naevi, family history of melanoma (approximately 10% of melanoma is familial; CDKN2A, CDK4, BAP1 mutations), immunosuppression, prior melanoma or non-melanoma skin cancer, male sex, and advancing age. Aboriginal and Torres Strait Islander people have lower melanoma incidence overall but a higher proportion of acral lentiginous and mucosal subtypes relative to their skin cancer burden.

Subtypes matter clinically. Superficial spreading melanoma (~70%) has a horizontal growth phase and favourable prognosis when thin. Nodular melanoma (~15%) grows rapidly in a vertical pattern and presents at greater depth. Lentigo maligna melanoma (~10%) occurs on chronically sun-damaged skin of older Australians. Acral lentiginous melanoma (~5%) arises on palms, soles, and nail beds — the only subtype not strongly UV-related — and is easily missed. Amelanotic melanoma is pink or red, rapidly growing, and can be mistaken for a pyogenic granuloma.

A. Core clinical — the AU general-practice framework

History and risk assessment

At every skin check, Cancer Council / Melanoma Institute Australia 2024 guidelines recommend systematic history including lesion duration, rate of change, bleeding, itch, and ulceration; sun exposure history (childhood sunburn, outdoor occupation, solarium use); skin type and mole count; personal and family history of melanoma; immunosuppression; and current medications (BRAF inhibitors paradoxically cause new SCCs and can induce melanoma; anti-PD-1 therapy causes new naevi and vitiligo).

Examination — full-body skin survey with dermoscopy

Full-body skin examination requires good lighting and systematic coverage including scalp, between fingers and toes, palms, soles, nail beds, intergluteal fold, perineum, and oral mucosa. Dermoscopy (10× polarised magnification) substantially improves diagnostic accuracy and is recommended by eTG Dermatology and Australasian College of Dermatologists as standard in Australian general practice.

The ABCDE rule and the ugly duckling sign (a lesion that looks distinctly different from the patient’s other moles) are the primary clinical tools. Dermoscopic patterns specific to melanoma include atypical pigment network, irregular streaks, blue-white veil, regression structures, atypical vessels, and asymmetric colour distribution.

High-risk sites not to miss: palms and soles (acral melanoma), nail beds (Hutchinson sign — pigmentation extending to the nail fold — demands urgent referral and biopsy), scalp, oral and genital mucosa.

Diagnosis — excision biopsy

The diagnostic standard per Cancer Council / MIA 2024 is excisional biopsy with a 2 mm clinical margin and a small cuff of subcutaneous fat. Shave biopsy is avoided because it understages Breslow thickness and can mislead treatment planning. Histopathology reports must include Breslow thickness, ulceration, mitotic rate, margins, and lymphovascular invasion.

Wide local excision margins after confirmed melanoma:

Breslow thickness	Excision margin
In situ	5 mm
≤1 mm (T1)	1 cm
1–2 mm (T2)	1–2 cm
>2 mm (T3, T4)	2 cm

Sentinel lymph node biopsy is recommended for Breslow ≥0.8 mm or T1b and above — staging decision made with the multidisciplinary melanoma team.

B. Evidence appraisal — immunotherapy and targeted therapy

Stage III and IV management

The treatment landscape for advanced melanoma has transformed over the past decade. eTG Dermatology and AMH reflect the current evidence base:

Adjuvant immunotherapy for resected Stage III:

• Pembrolizumab (anti-PD-1; KEYNOTE-054 trial) and nivolumab (anti-PD-1; CheckMate 238) reduce recurrence and improve relapse-free survival compared with placebo — both PBS Authority Required for resected Stage III
• For BRAF V600-mutant Stage III: dabrafenib + trametinib (COMBI-AD trial — Long et al.) reduces recurrence — PBS Authority Required

Metastatic disease (Stage IV):

• Anti-PD-1 monotherapy (pembrolizumab or nivolumab) or combination anti-PD-1 + anti-CTLA-4 (nivolumab + ipilimumab — higher response rate ~58%, greater immune toxicity)
• Nivolumab + relatlimab (anti-LAG-3, Opdualag) — RELATIVITY-047 trial showed improved progression-free survival versus nivolumab alone with lower toxicity than nivo+ipi — PBS Authority Required
• BRAF/MEK targeted therapy for BRAF-mutant: dabrafenib + trametinib or encorafenib + binimetinib — PBS Authority Required

The MSLT-II trial (Faries et al. NEJM 2017) showed that completion lymphadenectomy after a positive sentinel node offered no survival benefit over nodal observation, changing standard practice. Observation with regular ultrasound is now often preferred by the multidisciplinary team.

Completion lymphadenectomy and MSLT-II

The current standard — nodal observation after positive sentinel node — requires the GP to support close imaging follow-up and liaise with the melanoma multidisciplinary team. Completion dissection is considered only in specific clinical scenarios discussed at multidisciplinary review.

Subsegmental considerations

For lentigo maligna (in situ or early invasive on facial sun-damaged skin), staged excision or Mohs surgery is often preferred to minimise facial defect; topical imiquimod may be used for non-surgical candidates. For acral and mucosal melanoma, specialist multidisciplinary management is required from diagnosis.

C. Prevention and surveillance

SunSmart prevention

The Nambour randomised trial (Green et al. JCO 2011) — 10 years of daily sunscreen use reduced melanoma incidence by 50% — provides the strongest evidence for primary prevention. Cancer Council SunSmart recommends: Slip on protective clothing; Slop on SPF 50+ broad-spectrum sunscreen, reapplied 2-hourly; Slap on a broad-brimmed hat; Seek shade during peak UV (UV index ≥3, typically 10 am–3 pm in summer); Slide on sunglasses. Commercial solariums have been banned in Australia since 2014. Vitamin D: sensible incidental sun exposure is sufficient for most Australians; supplement where deficient, but sun avoidance solely for vitamin D reasons is not warranted.

Post-melanoma surveillance

Cancer Council / MIA 2024 recommends:

• Stage 0 (in situ): 6–12 monthly skin examination, lifelong
• Stage I–II: every 3–6 months in first 2 years, then 6–12 monthly to year 5, then annually
• Stage III–IV: specialist-led 3-monthly protocol with staging imaging

Self-examination education at every visit — monthly whole-body including scalp and nail beds. First-degree relatives of people with melanoma are at elevated risk and should be offered systematic skin checks. High-risk patients with multiple atypical naevi or familial melanoma syndromes benefit from specialist mole-mapping (total body photography plus sequential dermoscopy).

Familial melanoma

Approximately 10% of melanoma has a familial component. CDKN2A mutation (most common), CDK4, BAP1, and MITF mutations are associated with familial melanoma, pancreatic cancer, and uveal melanoma. Genetic counselling and testing should be offered when there are three or more first-degree relatives with melanoma, multiple primaries, or young-onset melanoma. High-risk surveillance programs are coordinated through specialist familial cancer centres.

D. Australian operations

MBS items

Standard GP consults 23/36/44; excision biopsy — MBS 30071/30072 range (per lesion size and location); wide local excision — specialist items; pathology for FBC 65070, LDH 66524, LFT 66512; GPCCMP (Chronic Condition Management Plan) 965/967 for ongoing melanoma surveillance as a chronic condition + allied health (psychologist for fear of recurrence); Mental Health Care Plan 2715/2717 for psychological burden; 75+ health assessment 705; ATSI health assessment 715; practice nurse 10997.

PBS immunotherapy and targeted therapy

Per PBS (verified 2026-06-04): pembrolizumab, nivolumab, ipilimumab — Section 100 Authority Required for melanoma stages as above; nivolumab + relatlimab (Opdualag) — Authority Required advanced melanoma; dabrafenib + trametinib, encorafenib + binimetinib — Section 100 Authority Required for BRAF-mutant disease; topical imiquimod 5% — general schedule for lentigo maligna in non-surgical candidates.

Medico-legal obligations

Failure to biopsy a suspicious pigmented lesion is the dominant melanoma medico-legal risk. Document dermoscopy findings, body diagrams with lesion locations, and clinical photographs at every surveillance visit. Counsel and document SunSmart advice at every encounter, and offer first-degree relative screening.

E. Special populations

Skin of colour (Fitzpatrick IV–VI): Melanoma is less common but acral lentiginous and mucosal subtypes predominate and are frequently delayed in diagnosis. Examine palms, soles, nail beds, and mucosal surfaces specifically at every opportunistic encounter.

Immunosuppression (transplant recipients, biologics, HIV): Risk of melanoma and non-melanoma skin cancer is substantially elevated. Annual or 6-monthly full-body skin examination is appropriate; coordinate with transplant physician before any planned cessation of immunosuppression for melanoma management.

Pregnancy: Excision biopsy and wide local excision are safe in pregnancy. Staging imaging involves radiation considerations. Adjuvant systemic therapy (immunotherapy, BRAF/MEK) is generally deferred until postpartum where feasible; specialist oncology input is required.

Mental health and fear of recurrence: Anxiety and fear of recurrence are common after melanoma. A Mental Health Care Plan (MBS 2715/2717) provides access to CBT through Better Access; Melanoma Patients Australia provides peer support.

When to escalate

Refer urgently (within days) when:

• Suspected melanoma on clinical or dermoscopic assessment — for excision biopsy
• Confirmed melanoma — to multidisciplinary melanoma clinic for staging and treatment planning
• New lump near melanoma scar or unexplained lymphadenopathy — recurrence workup
• Subungual pigmentation with Hutchinson sign — suspected subungual melanoma

Refer routinely for:

• Familial melanoma or multiple atypical naevi — specialist genetics and high-risk surveillance
• Lentigo maligna on challenging anatomical site — dermatology/surgical oncology
• Significant psychological distress post-diagnosis — psychology via MHCP

What this article is and is not

This is general health information drawn from the Cancer Council Australia / Melanoma Institute Australia 2024 guidelines, eTG Dermatology, AMH, and the Nambour, MSLT-II, KEYNOTE-054, COMBI-AD, and RELATIVITY-047 trials. It does not constitute personal medical advice and does not create a doctor–patient relationship. Biopsy decisions, staging, and treatment are determined with your treating GP, dermatologist, and multidisciplinary melanoma team.

For Australian consumer resources: HealthDirect — Melanoma, Melanoma Institute Australia, Melanoma Patients Australia, Better Health Channel.

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Sources cited

1. Cancer Council Australia / Melanoma Institute Australia — Melanoma 2024 guidelines
2. Melanoma Institute Australia
3. Australasian College of Dermatologists
4. Therapeutic Guidelines (eTG) — Dermatology
5. Australian Medicines Handbook
6. Cancer Council SunSmart
7. PBS — melanoma systemic therapy
8. HealthDirect — Melanoma
9. Better Health Channel — Melanoma
10. Melanoma Patients Australia
11. Green et al. — Nambour sunscreen trial (JCO 2011)
12. Faries et al. — MSLT-II completion lymphadenectomy (NEJM 2017)
13. Long et al. — COMBI-AD adjuvant dabrafenib/trametinib