Melanoma:
how to spot it, treat it and follow it up

At a glance

How commonOne of the more common cancers in Germany
DefinitionMalignant tumour of the pigment cells (melanocytes)
Early detectionABCDE rule · skin cancer screening covered by statutory health insurance from age 35, every two years
Treatment of choiceComplete removal with a safety margin, always with histology
MedicinesAdvanced disease: immunotherapy or targeted therapy · everyday life: medicines that make the skin sensitive to light
Guideline & ICD-10German S3 guideline on melanoma (AWMF 032-024OL) · C43

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Contents

  1. What is melanoma?
  2. The ABCDE rule and the self-check
  3. Types and tumour thickness
  4. Causes and risks
  5. Diagnosis and screening
  6. Treatment
  7. Follow-up care over the years
  8. Light-sensitising medicines
  9. Immunosuppression as a risk
  10. Everyday life: sun protection
  11. Common questions
  12. Related topics

1. What is melanoma?

Malignant melanoma — in Germany commonly called “schwarzer Hautkrebs”, black skin cancer — arises from the pigment cells of the skin, the melanocytes. Some melanomas grow out of an existing mole, most of them on skin that looked unremarkable. It often spreads across the surface first, but it can then grow into the depths and send out secondaries. That is why time is the decisive factor here: spotted early and removed completely, the outlook is usually very good.¹,²

Moles are normal; what is suspicious is not how many you have but change. Melanoma is often lumped together with non-melanoma skin cancer: that form is more common, grows more slowly and only rarely spreads. Melanoma is rarer, but it can metastasise earlier — which is why a new, dark, changing patch means an appointment soon.²,³

2. The ABCDE rule and the self-check

The ABCDE rule is the core of early detection. It does not replace a diagnosis, but it answers the question: do I need to take this to a dermatology practice? A patch does not have to meet every criterion — one point that clearly applies is enough.

  • A — asymmetry: folded over in your mind, the two halves do not match. Harmless moles are usually round or oval.
  • B — border: blurred, frayed or jagged edges.
  • C — colour: several shades within one patch — light brown, black, reddish, grey or whitish.
  • D — diameter: larger than about 5 millimetres. A pointer, not proof.
  • E — elevation and evolution: the patch newly rises above the skin, turns nodular or changes within months — the most important criterion, because it takes time into account.
The “ugly duckling” principle. A person’s moles usually resemble one another. If one patch stands out because it looks different from all the rest, that is exactly the suspicious one. It is not the biggest mole that counts, but the odd one out.

Self-examination step by step

Once a month, in good light, with a hand mirror and a wall mirror — systematically.

  1. Face, ears (behind them too), throat and the back of the neck.
  2. Work through the scalp parting by parting with a comb or a hairdryer.
  3. The front of the upper body, in women under the breasts; armpits.
  4. Arms, the inside of the elbows, backs of the hands, palms, between the fingers, nails.
  5. Back and buttocks with the hand mirror — or have someone look for you.
  6. Legs from every side, backs of the knees, soles of the feet, toenails.
  7. The genital area and, as far as possible, the anal area.
The three places almost everyone misses: soles of the feet, scalp, back. Melanomas there and under the nails are noticed late. A dark streak in a nail that is new or getting wider belongs in medical hands.

3. Types and tumour thickness

Melanomas are classified by their growth pattern — which matters, because not every type fits the “dark patch” picture.¹,⁴

TypeTypical appearancePreferred sites
Superficial spreadingFlat patch, irregularly colouredTrunk, back, legs — the most common type
NodularRaised, fast-growing noduleAnywhere; grows into the depths early
Lentigo malignaLarge, blurred patch developing over yearsFace, older age
Acral lentiginousBlurred patch or a streak in a nailPalms, soles of the feet, nails
AmelanoticBarely pigmented, reddishAnywhere; often mistaken for a wart
Table scrolls to the right

The report will later state the Breslow tumour thickness in millimetres — how deep the tumour has grown into the skin. It counts as the single most important prognostic factor; the safety margin and the sentinel lymph node procedure are guided by it as well. A stage is a statement of probability for groups, not a prediction for you personally.¹

4. Causes and risk factors

The most important cause you can influence is UV radiation — though not in the way many people assume: for melanoma, what counts above all is occasional, intense exposure with sunburn, rather than the lifetime total dose.²,³

  • Sunburn, especially in childhood and adolescence — every single one counts; the risk cannot be undone in retrospect.
  • Sunbeds — they raise the risk, particularly at a young age; in Germany they are banned for under-18s.
  • Many moles, and above all “atypical” ones.
  • A fair skin type — pale skin, reddish or blond hair, freckles.
  • A family history — melanoma in parents, siblings or children.
  • A previous melanoma — an increased risk of a second one; one of the main reasons for the long follow-up.
  • A permanently weakened immune system — after an organ transplant or on immunosuppressive treatment.
Medicines belong in the risk assessment. Some substances make the skin more sensitive to light, others dampen the immune system — not a direct cause, but more UV damage for the same time in the sun. More on this in medications and sun.

5. Diagnosis and skin cancer screening

  • History: how long has the patch been there, what has changed, were there sunburns or melanomas in the family, which medicines do you take?
  • Dermoscopy: an illuminated magnifier makes the pigment network and the vessel pattern visible — painless and more accurate than the naked eye. If you have many atypical moles, the images are stored and compared later on.
  • Excision and histology: if there is a suspicion, the patch is cut out completely and examined. Only this report secures the diagnosis.
  • Staging investigations: depending on tumour thickness, lymph node ultrasound, blood values or cross-sectional imaging.

People with statutory health insurance are generally entitled to a skin cancer screening every two years from the age of 35 — a whole-body examination of the skin including the hairy scalp, with no co-payment. If your risk is increased, closer checks are possible.³

Never have a suspicious patch lasered off or frozen. That leaves no tissue for the histological examination. If it was a melanoma, the tumour can keep growing in the depths while the surface looks healed. A rule without exceptions: examine first, then remove.

6. Treatment: surgery and systemic therapy

Treatment depends on tumour thickness and stage; the first step, and in early stages usually the only one, is surgery. Everything beyond that is as a rule discussed in a tumour board — and always decided together with you.¹

First step Complete removal
Excision and re-excision
The patch is removed completely and examined under the microscope. If the diagnosis is confirmed, a second procedure cuts out a safety margin that depends on the tumour thickness.
Depending on stage Sentinel lymph node and imaging
Sentinel lymph node and imaging
From a certain tumour thickness onwards, the first lymph node in the drainage area is removed and examined — it shows most reliably whether tumour cells have spread. Ultrasound is added, and cross-sectional imaging depending on the stage; in early stages the guideline says it is usually not needed.
Advanced disease Systemic drug treatment
Immunotherapy (checkpoint inhibitors)
These release the brakes on the immune system so that it attacks tumour cells again — but they do not work for everyone, and excessive immune reactions can cause serious side effects.
Targeted and adjuvant treatment
If the tumour tissue carries certain genetic changes (BRAF, for example), medicines that act precisely there come into question. In some stages, treatment is offered after surgery to lower the risk of relapse.
An honest perspective. Modern systemic therapies have clearly improved the outlook in advanced melanoma — a promise of cure they are not. Some people respond very well, others not at all. Ask about the benefit, the side effects and the alternatives.

7. Follow-up care over the years

This is the part that takes the most organising and gets talked about the least: after a melanoma, treatment does not end with the last stitch. The German S3 guideline provides for risk-adapted follow-up over around ten years — close together at the start, at longer intervals afterwards. The reason is twofold: relapses usually occur early, and anyone who has had a melanoma carries an increased risk of a second, independent one.¹

PeriodWhat usually happensWhat you contribute
First yearsShortest intervals: the whole skin, the scar and the lymph nodes, with ultrasound depending on the stageMonthly self-check, photos, noting down symptoms
Middle phaseLonger intervals, the same scope, less equipment-based diagnosticsBook appointments early — waiting times are often long
Up to around year tenMainly skin checks, to catch a second tumour earlyKeep up sun protection, keep the medication list current
Table scrolls to the right

Ask for the plan in writing and enter the appointments straight away. The most common failure is not a lack of motivation but the appointment that quietly disappears in year three. The follow-up folder should hold the histology report, the operation report, the follow-up plan, photos and an up-to-date medication list.

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8. Medicines that make the skin sensitive to light

This is where melanoma prevention and medication management touch — and it is exactly the point that regularly gets lost in consultations. A number of common medicines increase the skin’s sensitivity to light (photosensitisation): you burn faster than you otherwise would. And sunburn is the risk factor you can actually influence.²,⁵

Active substanceTypical useWhat to watch out for
DoxycyclineAntibiotic for respiratory and skin infections, acneMarked photosensitisation is possible. Avoid direct sun, use a high sun protection factor — even on short courses
IsotretinoinSevere acneThe skin becomes thinner and considerably more sensitive to light. Consistent sun protection for the whole of the treatment; on top of that, strict requirements in pregnancy
HydrochlorothiazideDiuretic for high blood pressure, often in fixed combinationsIncreases sensitivity to light. For non-melanoma skin cancer a link with long-term use has been described; for melanoma the evidence is less clear-cut — skin checks make sense
Other groupsCertain antibiotics, anti-inflammatory drugs, psychiatric medicines, St John’s wortThe package leaflet lists it under “sensitivity to light”. If in doubt, ask at the pharmacy
Table scrolls to the right

Typically this shows as a sunburn-like skin rash on exposed areas, often with itching and more severe than the time in the sun would lead you to expect. Details in the guide medications and sun.

Do not stop anything on your own. Dropping a blood pressure tablet because of the sun trades a small risk for a bigger one. Speak to your practice or your pharmacy instead. More on this in medication side effects.

9. Immunosuppression as a risk

The immune system clears out degenerate cells continuously. If it is permanently dampened, that works less well — which is why people on long-term immunosuppression develop skin tumours more often. The effect is clearest after organ transplantation; it is better established for non-melanoma skin cancer than for melanoma.²,⁴

  • Methotrexate: at a low dose in rheumatoid arthritis and psoriasis; it increases sensitivity to light and dampens the immune system.
  • Prednisolone and other steroids: used briefly, they are not a skin cancer issue. On years of continuous treatment at a higher dose, immune defence is measurably dampened.
  • After an organ transplant: the risk is highest here; regular dermatological checks are a fixed part of follow-up.

These medicines are given for good reasons, and the benefit usually clearly outweighs the risk. The right response is not to stop them but closer skin checks plus UV protection. Say at your appointment that you take them — that often changes the interval between checks.

10. Everyday life: sun protection without fear

  • Shade beats cream — the midday hours spent in the shade work more reliably than any amount of reapplying. Clothing and a hat are the second step.
  • Apply enough, and in good time — most people use too little. A high sun protection factor, about 20 minutes beforehand, reapplied after swimming. Reapplying does not extend the time you are protected.
  • No sunbeds — “pre-tanning” does not protect to any relevant degree and raises the total UV dose.
  • Check new medicines for light sensitivity — above all before a holiday or outdoor sport.
  • Tie the self-check to a fixed date — experience shows that what is not scheduled does not happen. Collect your questions the way the guide preparing for a doctor appointment describes.

And a word about the mind: after a melanoma diagnosis, fear of every new patch is normal. What helps is a clear framework — a fixed self-check, fixed follow-up appointments, and deliberately not looking all the time in between. If worry starts to run your day, psycho-oncological support is part of the treatment.

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FAQ: Common questions about melanoma

A stands for asymmetry, B for a blurred border, C for several colours, D for a diameter over about five millimetres, and E for elevation or evolution, meaning change over time. A patch does not have to meet every criterion — one point that clearly applies is reason enough for an appointment. The ugly duckling principle helps as well: the suspicious patch is the one that looks different from all the others.
People with statutory health insurance are generally entitled to a standardised whole-body examination of the skin every two years from the age of 35, with no co-payment, at qualified GP or dermatology practices. If your risk is increased — many atypical moles or a previous melanoma, for example — closer checks are possible.
Non-melanoma skin cancer is considerably more common, grows more slowly and only rarely spreads to other organs. Melanoma is rarer, but it can form secondary tumours earlier and is therefore more urgent. A new, dark, changing patch should be looked at soon, not at the next routine appointment.
No. Lasering or freezing leaves no tissue for the histological examination. If the patch was a melanoma, the tumour can keep growing in the depths. Suspicious patches are cut out and examined under the microscope — only that report secures the diagnosis.
The guideline provides for risk-adapted follow-up over around ten years, with the shortest intervals at the start. The whole skin, the scar and the lymph node stations are examined, supplemented by ultrasound depending on the stage. The exact plan is set by the treating centre — ask for it in writing.
Well-known examples are the antibiotic doxycycline, the acne medicine isotretinoin and the diuretic hydrochlorothiazide; certain anti-inflammatory drugs, psychiatric medicines and St John’s wort can belong here too. People affected burn faster than they otherwise would. Do not stop anything on your own — speak to your practice or your pharmacy and protect your skin particularly consistently.
Yes. When immune defence is permanently dampened — after an organ transplant, say, or on long-term treatment with methotrexate or high-dose steroids — skin tumours occur more often; the evidence is strongest for non-melanoma skin cancer. The right response is not to stop the treatment but closer skin checks and UV protection.

Sources

  1. German S3 guideline on the prevention, diagnosis, treatment and follow-up of melanoma (German Guideline Programme in Oncology, AWMF reg. no. 032-024OL). awmf.org
  2. gesundheitsinformation.de, German Institute for Quality and Efficiency in Health Care (IQWiG): Melanoma and skin cancer prevention. Accessed 2026. gesundheitsinformation.de
  3. gesund.bund.de (German national health portal): Skin cancer and skin cancer screening. Accessed 2026. gesund.bund.de
  4. MSD Manual, Consumer Version: Melanoma. Accessed 2026. msdmanuals.com
  5. German Federal Institute for Drugs and Medical Devices (BfArM): Summaries of Product Characteristics for the substances mentioned. Accessed 2026. bfarm.de

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Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or treatment. A new or changing patch of skin should be assessed by a dermatologist soon — suspicious moles must never be lasered or frozen off, because that leaves no tissue for histology. Do not stop medicines that make you sensitive to light or that suppress the immune system on your own initiative. The choice of medicine is always determined individually by the treating practice. Last updated: August 2026.