NICE summary
The recommendations in this Best Practice topic are based on authoritative international guidelines, supplemented by recent practice-changing evidence and expert opinion. For your added benefit, we summarise below the key recommendations from relevant NICE guidelines.
Key NICE recommendations on diagnosis
Refer people using a suspected cancer pathway referral for melanoma if:[208]
They have a suspicious pigmented skin lesion scoring ≥3 on the following weighted 7-point checklist:
Major features of the lesions (scoring 2 points each):
Change in size
Irregular shape
Irregular colour
Minor features of the lesions (scoring 1 point each):
Largest diameter ≥7 mm
Inflammation
Oozing
Change in sensation.
Dermoscopy suggests melanoma of the skin.
Consider a suspected cancer pathway referral for melanoma in people with a pigmented or non-pigmented skin lesion that suggests nodular melanoma.[208]
Specialist assessment
All pigmented skin lesions that are either referred for assessment or identified during follow-up in secondary or tertiary care should be assessed using dermoscopy.[59]
Confocal microscopy or computer assisted diagnostic tools should not routinely be used to assess pigmented skin lesions.[59]
For a clinically atypical melanocytic lesion that does not need excision at first presentation in secondary or tertiary care, baseline photography (preferably dermoscopic) should be used.[59]
3 months after first presentation, the clinical appearance of the lesion should be reviewed and compared with baseline photographic images to identify early signs of melanoma.[59]
All suspected atypical Spitzoid lesions should be discussed at the specialist skin cancer multidisciplinary team (MDT) meeting.[59]
The diagnosis of a Spitzoid lesion of uncertain malignant potential should be made on the basis of the histology, clinical features and behaviour.[59]
If targeted systemic therapy is a treatment option, genetic testing should be offered.[59]
BRAF analysis may be considered or offered, depending on the stage of melanoma.[59]
Staging
Imaging or sentinel lymph node biopsy (SLNB) should not be offered to people who have stage IA melanoma.[59]
Imaging should not be offered before SLNB unless lymph node or distant metastases are suspected.[59]
SLNB should be considered for people who have melanoma with a Breslow thickness of:[59]
>1.0 mm or
0.8 to 1.0 mm and at least one of the following features:
Ulceration
Lymphovascular invasion
A mitotic index of ≥2.
For pregnant women, delaying SLNB until after pregnancy completion is an option.[59]
Staging with whole-body and brain imaging should be:[59]
Offered to people with stage IIC to IV melanoma
Considered for people with stage IIB melanoma.
The type of imaging used (e.g., contrast-enhanced-CT or MRI) depends on factors such as age, pregnancy, site of melanoma and mitotic index.[59]
A repeat staging scan should be considered before starting adjuvant treatment, unless imaging done within the past 8 weeks is available.[59]
Links to NICE guidance
Suspected cancer: recognition and referral (NG12) May 2025. https://www.nice.org.uk/guidance/ng12
Melanoma: assessment and management (NG14) July 2022. https://www.nice.org.uk/guidance/ng14
Key NICE recommendations on management
Refer to the full NICE guideline and your local drug formulary for further information when prescribing – including dose, contraindications, cautions, safety issues, adverse effects, drug interactions, and monitoring requirements. Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is 'off-label').
A Spitzoid lesion of uncertain malignant potential should be managed as melanoma.
The psychological and emotional impact of melanoma should be assessed (e.g., holistic needs assessment) and addressed appropriately.
Vitamin D levels should be measured at diagnosis in secondary care in all people with melanoma, and people with suboptimal levels of vitamin D should be advised on vitamin D supplementation and monitoring.
Do not withhold or change drug treatment for other conditions, except immunosuppressants and immunomodulators, on the basis of a melanoma diagnosis. Seek advice from the person’s specialist team if they are on immunosuppressive or immunomodulatory treatment.
Stages 0 to II melanoma
Topical imiquimod should be considered to treat stage 0 melanoma in adults if excision with a 0.5 cm clinical margin would cause unacceptable disfigurement or morbidity.
A repeat skin biopsy for histopathological assessment should be considered after treatment with topical imiquimod, to check whether it has been effective.
When excising stages 0 to II melanoma, a clinical margin of:
At least 0.5 cm should be considered for stage 0 melanoma
If excision does not achieve an adequate histological margin, further management should be discussed with the specialist skin cancer MDT
1 cm should be used for stage I melanoma (or when a 2 cm margin would cause unacceptable disfigurement or morbidity)
2 cm should be used for stage II melanoma.
The clinical margin should be around the histological biopsy scar and take into account the primary melanoma margin.
Stages III to IV melanoma
Options for managing stage III melanoma in selected people include:
Completion or therapeutic lymph node dissection
Adjuvant treatments after resection (systemic anticancer treatments, radiotherapy)
Topical imiquimod (to palliate superficial melanoma skin metastases)
Genomic biomarker-based therapy.
Management of in-transit metastases in stages III and IV melanoma (e.g., treatment in a regional specialist centre, surgery) should be discussed with the specialist skin cancer MDT.
People who appear to have oligometastatic stage IV melanoma should be referred to the specialist skin cancer MDT for recommendations about staging and management.
People with brain metastases should be discussed with the specialist skin cancer MDT.
People that might be suitable for surgery or stereotactic radiotherapy should be referred to the neuro-oncology MDT for a recommendation about treatment.
For guidance on diagnosing, monitoring and managing brain metastases, see the NICE guideline Brain tumours (primary) and brain metastases in over 16s (NG99).
When systemic anticancer treatment is being chosen for stage IV or unresectable stage III melanoma, treatment decisions should be made after a full assessment of the risks and benefits by the treating oncologist and discussion with the person.
See the NICE guideline for more information on systemic anticancer treatment options for stage III and IV melanoma.
People with incurable melanoma should be referred to specialist palliative care services.
Patient advice and follow-up
People with melanoma should be given information throughout their care, including on:
Preventing recurrence, and how to protect their skin from damage caused by exposure to the sun, while avoiding vitamin D depletion (see the NICE guideline Sunlight exposure: risks and benefits [NG34])
Self examination and recognising signs and symptoms of suspicious skin lesions.
People who have completed treatment for melanoma should be given direct contact details for specialist skin cancer services that can provide advice about problems or concerns.
People who have had stage 0 melanoma should be provided with advice at a clinic visit during the first year after treatment completion.
Personalised (rather than routine) follow-up should be:
Offered to people with unresectable stage III or IV melanoma
Considered for people who are at increased risk of further primary melanomas (e.g., atypical mole syndrome, previous melanoma, multiple in-situ melanomas, melanoma in first degree relatives, or other relevant familial cancer syndromes).
If personalised follow-up is not required, routine follow-up should be offered:
For 1 year to people who have had stage IA melanoma
For 5 years to people who have had stages IB to IV melanoma.
Routine follow-up will vary depending on factors such as: stage and site of melanoma; presence of metastases; whether the person is currently having adjuvant therapy; age; pregnancy; and risk of melanoma spreading.
See the NICE guideline for further information on follow-up after treatment for melanoma.
© NICE (2022) (2025) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Links to NICE guidance
Melanoma: assessment and management (NG14) July 2022. https://www.nice.org.uk/guidance/ng14
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