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Development of a practical guide for the early recognition for malignant melanoma of the foot and nail unit



Malignant melanoma is a rare but potentially lethal form of cancer which may arise on the foot. Evidence suggests that due to misdiagnosis and later recognition, foot melanoma has a poorer prognosis than cutaneous melanoma elsewhere.


A panel of experts representing podiatry and dermatologists with a special interest in skin oncology was assembled to review the literature and clinical evidence to develop a clinical guide for the early recognition of plantar and nail unit melanoma.


A systematic review of the literature revealed little high quality data to inform the guide. However a significant number of case reports and series were available for analysis. From these, the salient features were collated and summarised into the guide. Based on these features a new acronym "CUBED" for foot melanoma was drafted and incorporated in the guide.


The use of this guide may help clinicians in their assessment of suspicious lesions on the foot (including the nail unit). Earlier detection of suspicious pedal lesions may facilitate earlier referral for expert assessment and definitive diagnosis. The guide is currently being field tested amongst practitioners.

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The incidence of malignant melanoma (MM) continues to rise in the UK and Europe [1]. Despite being an uncommon form of skin cancer it is responsible for the majority of skin cancer deaths [2]. Health education campaigns have increased public awareness of the problem and there is evidence to show that sectors of the population are presenting earlier with their suspicious skin lesions [35]. Despite these improvements, mortality and morbidity still remains high, particularly within subsets of the population such as older adults [6, 7], males [810], the less affluent [11] and less well educated [12, 13].

Around 3-15% of all cutaneous MM arise on the foot [14, 15]. However, MM arising on the foot holds a poorer prognosis than melanoma elsewhere [16, 17]. The reasons for this are not certain, but there are several possible explanations. The basic prognostic indicator for melanoma at all sites is the thickness of the tumour as measured under the microscope in millimetres. This is known as the Breslow thickness. The greater the thickness of the tumour, the more likely that the patient will die in the following five years. Thick lesions on the hands and feet have been shown to have a worse prognosis than tumours of a similar thickness elsewhere [18]. Some investigators have attributed this to pedal lesions being more aggressive in nature [19], though others have disputed this as a statistical anomaly due to the small numbers involved [20]. Other authors have suggested that the Breslow thickness grading in plantar and nail melanoma is often more difficult to determine or inconclusive [21].

Delay in diagnosis is a further factor, where the length of history of the melanoma has a correlation with Breslow thickness and hence deterioration of prognosis. Foot lesions are often detected by health care practitioners later than lesions elsewhere. A tumour on the face is more likely to result in prompt action by the patient and practitioner than one on the foot. Furthermore, lesions between the toes, beneath the nail or on the sole are further concealed. As a result, delayed presentation results in thicker, more advanced tumours [2224]. Secondly, foot melanoma, possibly because of its rarity, is frequently misdiagnosed as a more common foot disorder such as tinea pedis [2529], onychomycosis [30], warts [3136], haematoma [25, 3739], paronychia [40], ingrowing toe nail [4143], bacterial infection [44], ischaemia or necrosis [14, 40], blisters, ganglions, callus [42], benign tumours [45, 46] and ulceration [4754]. Misdiagnosis rate for foot lesions have been reported to be between 25%-66% [14, 25, 40] compared with much lower rates of around 12-16% for melanoma in other anatomical locations [27, 55, 56]. This is probably a reflection of the fact that patients do not initially suspect the diagnosis of skin cancer at these sites and therefore consult healthcare professionals other than dermatologists with lesions who may not be so aware of the possibility of a malignant lesion.

The priority of skin cancer has been highlighted by the Government in its strategy to reform Cancer Services in the UK [57]. Through the "SUNSMART" campaign, the government aims to increase public awareness of the disease and stress the importance of seeking professional opinion. On the professional side, guidelines issued from the National Institute for Clinical Excellence (NICE) stress the importance of health care professionals being aware of the modified 7-point checklist [58] for assessment of pigmented skin lesions and where any patient presenting with a skin lesions should be referred to a specialist skin care team [59]. Some guidelines have been published in the UK and Australasia, specifically for medical practitioners for melanoma [6062] but none are known to exist specifically for lesions arising on the foot. A review of cases in one district [25], demonstrated a significant number of melanoma cases were seen by foot specialists prior to diagnosis.

The need for greater awareness to permit earlier recognition of foot melanoma amongst health care practitioners has been expressed [22]. In turn this could lead to faster recognition, referral and diagnosis. Authors have commented that the traditional melanoma screening algorithms, the ABCDE system & 7-point checklist may be less effective when applied to the foot [25, 40, 63]. The plantar surface with its thickened epidermis is subject to trauma and hyperkeratotic changes which are not found elsewhere and may disguise critical signs.

In conjunction with the Society of Chiropodists and Podiatrists (Faculty of Podiatric Medicine and General Practice), a panel was convened to draft guidance for its members to raise awareness of the condition. The guide development group consisted of a team consisting of a podiatrist and four dermatologists each with a special interest in skin cancer.


Initially the panel compiled a list of clinical questions relevant to the topic of foot and nail melanoma to help inform a search strategy. A literature search was undertaken using the National Library of Medicine (NLM) PubMed database to identify literature on foot and nail melanoma. A range of search terms was devised (see below):

  1. 1:

    foot OR feet OR "lower extremity" OR acral OR plantar OR nail OR leg OR ankle OR sub-ungual (233864)

  2. 2:

    melanoma (74768)

  3. 3:

    Diagn* OR recogn*OR screen* (2518063)

Limits: English Language & Human

Total of combination: 843

From the initial sweep (n = 843), papers whose primary focus fell outside of the topic (i.e. did not discuss recognition, detection, diagnosis and features) were discarded, typically these included papers solely discussing prognosis and survival, surgery and management. Papers which also made brief mention of the foot with no subset analyses were excluded. The remaining papers were reviewed, by both authors, using guidance as outlined by the National Institute for Clinical Excellence [64](Table 1). Papers were classified according to their level of evidence and reviewed for content. In addition, a separate search was undertaken to establish if previous, relevant guidelines had been published elsewhere.

Table 1 Levels of evidence (adapted from [64])


The review of the literature identified a lack of high level evidence to inform the development of a guide. Based on the NICE grading system, a small number of case-control studies were identified examining aetiology, incidence and clinical features (level 2). Most of the published literature pertaining to foot melanoma was ranked at level 3, being predominantly case reports (n = 44), literature reviews/discussions (n = 21) and case series (n = 14) of foot melanoma. On this basis, it was accepted that the paper would be drafted on the strength of the available evidence with informed consensus methods amongst the group to develop guidance.

All case reports and case series were examined by the authors. The hierarchy of evidence places such literature at a low level, just above that of medical opinion. However, case studies have the capacity to report rare diseases or the manifestations of disease which can be a useful learning tool in medical education [65]. The authors reviewed these papers looking for common themes, key messages and learning points. The focus of such papers was often around misdiagnosis, delay and deterioration of the lesion. Based on this data, a new acronym was proposed specific for foot melanoma. An existing ABCDE acronym was included for nail melanoma [66].

Subsequent to drafting the paper was reviewed by the panel. External reviewers were identified. These included practising podiatrists and chiropodists, a general practitioner, a diabetologist and other specialists involved in foot care. To facilitate a simple and rapid feedback mechanism, participants were electronically e-mailed a copy of the draft guidelines and then asked to respond by an online feedback website. Respondents were asked to comment on the draft including content, readability and clarity of the draft document. Following the consultation, amendments were made and the guidelines have been reviewed and have been submitted for publication.


The development and use of a guide may help clinicians in their assessment of suspicious lesions on the foot (including the nail unit). Earlier detection of suspicious pedal lesions may facilitate earlier referral for expert assessment and definitive diagnosis. The guide has been tested amongst practitioners and has been submitted for publication.


  1. 1.

    Karim-Kos HE, de Vries E, Soerjomataram I, Lemmens V, Siesling S, Coebergh JW: Recent trends of cancer in Europe: A combined approach of incidence, survival and mortality for 17 cancer sites since the 1990s. Eur J Cancer. 2008, 44: 1345-1389. 10.1016/j.ejca.2007.12.015.

    Article  PubMed  Google Scholar 

  2. 2.

    UK Skin Cancer mortality statistics. []

  3. 3.

    Buettner P, Leiter U, Eigentler T, Garbe C: Development of prognostic factors and survival in cutaneous melanoma over 25 years. Cancer. 2005, 103: 616-624. 10.1002/cncr.20816.

    Article  PubMed  Google Scholar 

  4. 4.

    Harman KE, Fuller LC, Salisbury JR, Higgins EM, du Vivier AW: Trends in the presentation of cutaneous malignant melanoma over three decades at King's College Hospital, London. Clin Exp Dermatol. 2004, 29: 563-566. 10.1111/j.1365-2230.2004.01620.x.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    MacKie RM, Hole D: Audit of public education campaign to encourage earlier detection of malignant melanoma. BMJ. 1992, 304: 1012-1015. 10.1136/bmj.304.6833.1012.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Payette MJ, Katz M, Grant-Kels JM: Melanoma prognostic factors found in the dermatopathology report. Clin Dermatol. 2009, 27: 53-74. 10.1016/j.clindermatol.2008.09.006.

    Article  PubMed  Google Scholar 

  7. 7.

    Rex J, Paradelo C, Mangas C, Hilari JM, Fernandez-Figueras MT, Ferrandiz C: Management of primary cutaneous melanoma of the hands and feet: a clinicoprognostic study. Dermatol Surg. 2009, 35: 1505-1513. 10.1111/j.1524-4725.2009.01265.x.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Downing A, Yu XQ, Newton-Bishop J, Forman D: Trends in prognostic factors and survival from cutaneous melanoma in Yorkshire, UK and New South Wales, Australia between 1993 and 2003. Int J Cancer. 2008, 123: 861-866. 10.1002/ijc.23495.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Phan A, Touzet S, Dalle S, Ronger-Savle S, Balme B, Thomas L: Acral lentiginous melanoma: a clinicoprognostic study of 126 cases. Br J Dermatol. 2006, 155: 561-569. 10.1111/j.1365-2133.2006.07368.x.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Swetter SM, Johnson TM, Miller DR, Layton CJ, Brooks KR, Geller AC: Melanoma in Middle-aged and Older Men: A Multi-institutional Survey Study of Factors Related to Tumor Thickness. Arch Dermatol. 2009, 145: 397-404. 10.1001/archdermatol.2008.603.

    PubMed  Google Scholar 

  11. 11.

    Ortiz CA, Goodwin JS, Freeman JL: The effect of socioeconomic factors on incidence, stage at diagnosis and survival of cutaneous melanoma. Med Sci Monit. 2005, 11: RA163-172.

    PubMed  Google Scholar 

  12. 12.

    Baumert J, Plewig G, Volkenandt M, Schmid-Wendtner MH: Factors associated with a high tumour thickness in patients with melanoma. Br J Dermatol. 2007, 156: 938-944. 10.1111/j.1365-2133.2007.07805.x.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Schmid-Wendtner MH, Baumert J, Stange J, Volkenandt M: Delay in the diagnosis of cutaneous melanoma: an analysis of 233 patients. Melanoma Res. 2002, 12: 389-394. 10.1097/00008390-200208000-00012.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Bennett DR, Wasson D, MacArthur JD, McMillen MA: The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanomas of the foot. J Am Coll Surg. 1994, 179: 279-284.

    CAS  PubMed  Google Scholar 

  15. 15.

    Soong SJ, Shaw HM, Balch CM, McCarthy WH, Urist MM, Lee JY: Predicting survival and recurrence in localized melanoma: a multivariate approach. World J Surg. 1992, 16: 191-195. 10.1007/BF02071520.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Dwyer PK, Mackie RM, Watt DC, Aitchison TC: Plantar malignant melanoma in a white Caucasian population. Br J Dermatol. 1993, 128: 115-120. 10.1111/j.1365-2133.1993.tb15138.x.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Hsueh E, Lucci A, Qi K, Morton D: Survival of patients with mealnoma of the lower extremity decreases with distance from the trunk. Cancer Causes Control. 1998, 85: 383-388.

    Google Scholar 

  18. 18.

    Day CL, Sober AJ, Kopf AW, Lew RA, Mihm MC, Golomb FM, Hennessey P, Harris MN, Gumport SL, Raker JW, et al: A prognostic model for clinical stage I melanoma of the lower extremity. Location on foot as independent risk factor for recurrent disease. Surgery. 1981, 89: 599-603.

    PubMed  Google Scholar 

  19. 19.

    Talley LI, Soong S-j, Harrison RA, McCarthy WH, Urist MM, Balch CM: Clinical Outcomes of Localized Melanoma of the Foot: A Case-Control Study. J Clin Epidemiol. 1998, 51: 853-857. 10.1016/S0895-4356(98)00071-7.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Barnes B, Seigler H, Saxby T, Kocher M, Harrelson J: Melanoma of the foot. J Bone Joint Surg Am. 1994, 76: 892-898.

    CAS  PubMed  Google Scholar 

  21. 21.

    Dawber RP, Colver GB: The spectrum of malignant melanoma of the nail apparatus. Semin Dermatol. 1991, 10: 82-87.

    CAS  PubMed  Google Scholar 

  22. 22.

    Franke W, Neumann NJ, Ruzicka T, Schulte K: Plantar malignant melanoma - a challenge for early recognition. Melanoma Res. 2000, 10: 571-576. 10.1097/00008390-200012000-00009.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Hemo Y, Gutman M, Klausner JM: Anatomic site of primary melanoma is associated with depth of invasion. Arch Surg. 1999, 134: 148-150. 10.1001/archsurg.134.2.148.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Nagore E, Oliver V, Moreno-Picot S, Fortea JM: Primary cutaneous melanoma in hidden sites is associated with thicker tumours - a study of 829 patients. Eur J Cancer. 2001, 37: 79-82. 10.1016/S0959-8049(00)00370-1.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Bristow I, Acland K: Acral lentiginous melanoma of the foot: a review of 27 cases. J Foot Ankle Res. 2008, 1: 11-10.1186/1757-1146-1-11.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Dainichi T, Kobayashi C, Fujita S, Shiramizu K, Ishiko T, Kiryu H, Urabe K, Tsuneyoshi M, Furue M: Interdigital amelanotic spindle-cell melanoma mimicking an inflammatory process due to dermatophytosis. J Dermatol. 2007, 34: 716-719. 10.1111/j.1346-8138.2007.00367.x.

    Article  PubMed  Google Scholar 

  27. 27.

    Dunkley MP, Morris AM: Cutaneous malignant melanoma: audit of the diagnostic process. Ann R Coll Surg Engl. 1991, 73: 248-252.

    CAS  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Serarslan G, Akcaly C, Atik E: Acral lentiginous melanoma misdiagnosed as tinea pedis: a case report. Int J Dermatol. 2004, 43: 37-38. 10.1111/j.1365-4632.2004.02085.x.

    Article  PubMed  Google Scholar 

  29. 29.

    Waddington AM, Hogg L: The surgical management of a subungual acral malignant melanoma:a case presentation and review of the literature. Brit J Pod. 2007, 10: 166-170.

    Google Scholar 

  30. 30.

    De Giorgi V, Sestini S, Massi D, Panelos J, Papi F, Dini M, Lotti T: Subungual melanoma: a particularly invasive "onychomycosis". J Am Geriatr Soc. 2007, 55: 2094-2096. 10.1111/j.1532-5415.2007.01438.x.

    Article  PubMed  Google Scholar 

  31. 31.

    Arroyo MP, Chu DH, Mobini N, Park HS: Verrucous plaque on the foot. J Cutan Pathol. 2004, 31: 271-273. 10.1111/j.0303-6987.2003.00185.x.

    Article  PubMed  Google Scholar 

  32. 32.

    De Giorgi V, Massi D: Images in clinical medicine. Plantar melanoma--a false vegetant wart. N Engl J Med. 2006, 355: e13-10.1056/NEJMicm055674.

    Article  PubMed  Google Scholar 

  33. 33.

    Knedgen J, Colburn M, Cooke R, Silvani S: Digital occurrence of nodular malignant melanoma. J Am Podiatr Med Assoc. 1997, 87: 178-182.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    McBurney EI, Herron CB: Melanoma mimicking plantar wart. J Am Acad Dermatol. 1979, 1: 144-146. 10.1016/S0190-9622(79)70012-0.

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Rosen T: Acral lentigious melanoma misdiagnosed as verruca plantaris: a case report. Dermatol Online J. 2006, 12:

    Google Scholar 

  36. 36.

    Virgili A, Corazza M: Guess what! Metastatic malignant melanoma of the leg from a warty acral amelanotic malignant melanoma. Eur J Dermatol. 2001, 11: 591-592.

    CAS  PubMed  Google Scholar 

  37. 37.

    Fountain JA: Recognition of subungual hematoma as an imitator of subungual melanoma. J Am Acad Dermatol. 1990, 23: 773-774. 10.1016/S0190-9622(08)81099-7.

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    Hussain W, Desai S, Fitzgerald D: An (un)lucky blow to the nail?. Clin Exp Dermatol. 2009, 34: 446-447. 10.1111/j.1365-2230.2008.02889.x.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Yasuoka , Ueda , Ohgami , Hayashi , Ichihashi : Amelanotic acral lentiginous malignant melanoma. Br J Dermatol. 1999, 141: 370-372. 10.1046/j.1365-2133.1999.03009.x.

    CAS  Article  PubMed  Google Scholar 

  40. 40.

    Metzger S, Ellwanger U, Stroebel W, Schiebel U, Rassner G, Fierlbeck G: Extent and consequences of physician delay in the diagnosis of acral melanoma. Melanoma Res. 1998, 8: 181-186. 10.1097/00008390-199804000-00014.

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Lemont H, Brady J: Amelanotic Melanoma Masquerading as an Ingrown Toenail. J Am Podiatr Med Assoc. 2002, 92: 306-307.

    Article  PubMed  Google Scholar 

  42. 42.

    Soon SL, Solomon AR, Papadopoulos D, Murray DR, McAlpine B, Washington CV: Acral lentiginous melanoma mimicking benign disease: the Emory experience. J Am Acad Dermatol. 2003, 48: 183-188. 10.1067/mjd.2003.63.

    Article  PubMed  Google Scholar 

  43. 43.

    Winslet M, Tejan J: Subungual amelanotic melanoma: a diagnostic pitfall. Postgrad Med J. 1990, 66: 200-202. 10.1136/pgmj.66.773.200.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Lemon B, Burns R: Malignant melanoma: A literature review and case presentation. J Foot Ankle Surg. 1998, 37: 48-54. 10.1016/S1067-2516(98)80011-2.

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Elmets CA, Ceilley RI: Amelanotic melanoma presenting as a pyogenic granuloma. Cutis. 1980, 25: 164-166. 168

    CAS  PubMed  Google Scholar 

  46. 46.

    Thomson CE, Lang S: Clinical review of an atypical malignant melanoma. Brit J Pod Med. 1991, 46: 75-77.

    Google Scholar 

  47. 47.

    Bristow I, Metcalfe S: Case report. Acral lentiginous melanoma or diabetic foot ulcer?. Diabetic Foot Journal. 2008, 11: 28-31.

    Google Scholar 

  48. 48.

    Gregson CL, Allain TJ: Amelanotic malignant melanoma disguised as a diabetic foot ulcer. Diabet Med. 2004, 21: 924-927. 10.1111/j.1464-5491.2004.01338.x.

    CAS  Article  PubMed  Google Scholar 

  49. 49.

    Jude E, Dorman S, Kumar S, HBarnett AH: Malignant melanoma masquerading as a diabetic foot ulcer - a case report. Brit J Pod Med. 1997, 52: 35-36.

    Google Scholar 

  50. 50.

    Kong MF, Jogia R, Jackson S, Quinn M, McNally P, Davies M: Malignant melanoma presenting as a foot ulcer. Lancet. 2005, 366: 1750-10.1016/S0140-6736(05)67701-X.

    Article  PubMed  Google Scholar 

  51. 51.

    Longobardi JJ: A foot "ulcer" resistant to healing. Acral-lentiginous melanoma. Adv Wound Care. 1997, 10: 16-18

    CAS  PubMed  Google Scholar 

  52. 52.

    Rogers LC, Armstrong DG, Boulton AJ, Freemont AJ, Malik RA: Malignant melanoma misdiagnosed as a diabetic foot ulcer. Diabetes Care. 2007, 30: 444-445. 10.2337/dc06-2251.

    Article  PubMed  Google Scholar 

  53. 53.

    Perks AGB, Miller G, Watson JS: Acral lentignous malignant melanoma in a diabetic foot:a plea for better education. The Foot. 1993, 3: 83-85. 10.1016/0958-2592(93)90067-D.

    Article  Google Scholar 

  54. 54.

    Yesil S, Demir T, Akinci B, Pabuccuoglu U, Ilknur T, Saklamaz A: Amelanotic melanoma misdiagnosed as a diabetic foot ulcer. J Diabetes Complications. 2007, 21: 335-337. 10.1016/j.jdiacomp.2006.05.004.

    Article  PubMed  Google Scholar 

  55. 55.

    Krige JE, Isaacs S, Hudson DA, King HS, Strover RM, Johnson CA: Delay in the diagnosis of cutaneous malignant melanoma. A prospective study in 250 patients. Cancer. 1991, 68: 2064-2068. 10.1002/1097-0142(19911101)68:9<2064::AID-CNCR2820680937>3.0.CO;2-3.

    CAS  Article  PubMed  Google Scholar 

  56. 56.

    Osborne JE, Bourke JF, Graham-Brown RAC, Hutchinson PE: False negative clinical diagnoses of malignant melanoma. Brit J Dermatol. 1999, 140: 902-908. 10.1046/j.1365-2133.1999.02823.x.

    CAS  Article  Google Scholar 

  57. 57.

    Department of Health: Cancer Reform Strategy. 2007, Book Cancer Reform Strategy (Editor ed.^eds.). City

    Google Scholar 

  58. 58.

    MacKie RM: Clinical recognition of early invasive malignant melanoma. BMJ. 1990, 301: 1005-1006. 10.1136/bmj.301.6759.1005.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  59. 59.

    National Institute for Health and Clinical Excellence: Referral guidelines for suspected cancer. Book Referral guidelines for suspected cancer (Editor ed.^eds.). 2005, City: Department of Health

    Google Scholar 

  60. 60.

    Bishop JAN, Corrie PG, Hall PN, Evans J, Gore ME, Kirkham N, Roberts DLL, Anstey AV, Barlow RJ, Cox NH: UK guidelines for the management of cutaneous melanoma. Br J Plast Surg. 2002, 55: 46-54. 10.1054/bjps.2001.3745.

    CAS  Article  PubMed  Google Scholar 

  61. 61.

    Roberts D, Anstey A, Barlow R, Cox N: UK guidelines on the management of cutaneous melanoma. Br J Dermatol. 2002, 146: 7-17. 10.1046/j.1365-2133.2001.04614.x.

    CAS  Article  PubMed  Google Scholar 

  62. 62.

    Australian Cancer Network Melanoma Guidelines Revision Working Party: Clinical Practice Guidelines for the management of melanoma in Australia and New Zealand. 2008, Wellington: Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group

    Google Scholar 

  63. 63.

    Albreski D, Sloan SB: Melanoma of the feet: misdiagnosed and misunderstood. Clin Dermatol. 2009, 27: 556-563. 10.1016/j.clindermatol.2008.09.014.

    Article  PubMed  Google Scholar 

  64. 64.

    Reviewing and grading the evidence. []

  65. 65.

    Vandenbroucke JP: In Defense of Case Reports and Case Series. Ann Intern Med. 2001, 134: 330-334.

    CAS  Article  PubMed  Google Scholar 

  66. 66.

    Levit EK, Kagen MH, Scher RK, Grossman M, Altman E: The ABC rule for clinical detection of subungual melanoma. J Am Acad Dermatol. 2000, 42: 269-274. 10.1016/S0190-9622(00)90137-3.

    CAS  Article  PubMed  Google Scholar 

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The melanoma working group consisted of:

Ivan Bristow, Lecturer, School of Health Sciences, University of Southampton, UK

David de Berker, Consultant Dermatologist, Bristol Royal Infirmary, Bristol, UK

Katharine Acland, Consultant Dermatologist, St John's Institute of Dermatology, St Thomas' Hospital London, UK

Richard Turner, Consultant Dermatologist, Churchill Hospital, Oxford Radcliffe Hospitals, Oxford, UK

Jonathan Bowling, Dermatologist, Churchill Hospital, Oxford Radcliffe Hospitals, Oxford, UK

The authors would like to thank colleagues who reviewed the drafts and for their detailed feedback including Laurie King and Alistair McInnes.

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Correspondence to Ivan R Bristow.

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The authors declare that they have no competing interests.

Authors' contributions

IB was responsible for the original drafting of this paper. Subsequent revisions and amendments were made jointly by DB and IB. Both authors have read and approved the final manuscript.

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Bristow, I.R., de Berker, D.A. Development of a practical guide for the early recognition for malignant melanoma of the foot and nail unit. J Foot Ankle Res 3, 22 (2010).

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  • Melanoma
  • Skin Cancer
  • Health Care Practitioner
  • Expert Assessment
  • Tinea Pedis