More Than Moles: When Melanoma Doesn’t Look Like You Think It Should

You’re diligently checking your skin for new or changing moles when you see it: a large, multicolored spot with a jagged border. It’s a textbook example of an atypical mole, exhibiting several of the ABCDE signs of melanoma. The next steps are obvious: Call your dermatologist and make an appointment to get it checked.

But what if the spot doesn’t look like the images of skin cancer you’ve seen? Sometimes identifying a potential skin cancer isn’t so straightforward. Skin cancer comes in many forms, and tumors don’t always display the most well-known characteristics of the disease.

An Unexpected Diagnosis

When determining whether a particular mole is concerning, the ABCDE acronym, which stands for Asymmetry, Border irregularity, Color variations, Diameter over 6 mm (about ¼”) and Evolution or change, is a powerful tool. Knowing what each of the letters stands for and learning to recognize these warning signs is a great first step in making sure that your self-exams are productive. But relying solely on the ABCDEs isn’t the best self-exam strategy.

“You could miss something,” says Darrick Antell, MD, a board-certified plastic and reconstructive surgeon practicing in New York. “That can be a dangerous mistake.”

The ABCDEs are meant to help identify only melanomas, not any of the other types of skin cancer, and even so, some melanomas can’t be recognized with the ABCDEs.

“I had a patient who had an amelanotic melanoma,” Dr. Antell says. “Some people aren’t even aware they exist. It was just a little white spot.”

Amelanotic melanomas are missing the dark pigment melanin, which gives most moles their color. They can appear pinkish, white, red, or even essentially clear.

Dr. Antell says his patient was insistent that the spot, which had appeared on his chest, was new. Dr. Antell performed a biopsy of the area — “when in doubt, cut it out” — and both he and his patient were surprised to learn it was melanoma. The spot didn’t look like a typical cancerous lesion, but it proved dangerous nonetheless.

Beyond The ABCDEs

One early recognition strategy that goes beyond the ABCDEs is the Ugly Duckling concept. Generally, moles on one individual tend to resemble each other. A mole that looks significantly different than others on the body — whether it fits the ABCDEs or looks suspicious in some other way — should be considered a worrisome outlier. For example, if a person has many large, dark moles and comes across a smaller reddish mole, they should take care to get that spot evaluated.

Finally, some forms of skin cancer show up in lesions that aren’t even considered moles. Basal cell carcinoma, the most common form of skin cancer, may occur in a shiny bump of almost any color— including seemingly nonthreatening hues like pearly white, clear, and pink. Squamous cell carcinoma sometimes appears as a crusty patch or bleeding, open sore.

Dr. Antell says the most important thing to consider when evaluating a spot on the skin is evolution, even if the area doesn’t display other typically troublesome characteristics. His patient with amelanotic melanoma trusted his feeling that the spot hadn’t been there before. He made an appointment to get it looked at, and it most likely saved his life.

“If it’s new, changing size or shape, or bleeding, don’t ignore it,” he says. “When in doubt, get it looked at by a professional.”