Melanoma in Special Patient Populations

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In this interview, Jane Margaret Grant-Kels, MD, FAAD, discusses unique screening challenges, the importance of early detection, and strategies for reducing disparities in melanoma outcomes.

The Dermatologist: Military personnel, firefighters, and patients living in rural areas face unique environmental and occupational risks for melanoma. What key factors should dermatologists consider when screening and educating these high-risk populations?

Dr Grant-Kels: I think that people who are at high risk need to be seen by their dermatologist at least once a year. And for people who have risks like firefighters from breathing in carcinogens, dermatologists should make sure to also examine the mucosa, such as the mouth, nose, genitalia, and anal perianal area, as well as the external skin. All patients who are at high risk need to wear sun protective clothing, hats, sunglasses, and sunscreen. For fire-fighters, they need to wear protective clothing, so the soot and chemicals do not get on their skin, as well as masks so they do not breathe it in.

The Dermatologist: How does pregnancy influence melanoma prognosis and management, and what adjustments should dermatologists make when treating melanoma in patients who are pregnant?

Dr Grant-Kels: There is a misconception that women who are pregnant have a higher risk of melanoma or of getting melanoma, but studies on women who are pregnant show that their prognosis is the same as if they were not pregnant. If a patient develops a superficial melanoma, you can cut it out because it is considered relatively safe to use local anesthesia in the skin during pregnancy. But if they have a deep melanoma and they need a sentinel lymph node biopsy, general anesthesia, or magnetic resonance imaging, then you must try to avoid the first trimester. Some people suggest waiting until after the birth to do a sentinel lymph node biopsy, if possible, although it has been done quite safely in patients who are pregnant. You must take the risk to the child and mother into consideration. If a patient who is pregnant has stage 4 melanoma, which is metastatic melanoma, the newer targeted treatments are teratogenic and cross the breast milk barrier. A woman who is pregnant cannot take those medications, and a woman who is breastfeeding should not take those medications. If a patient who is pregnant previously had a melanoma, there is a strong family history of melanoma, or they have a lot of nevi or atypical nevi, I tend to see them every trimester because I worry they are not being checked with so much going on with their body and I would want to pick up a melanoma as early as I can.

The Dermatologist: Melanoma in patients with skin of color is often diagnosed at later stages. What are the biggest gaps in early detection, and what strategies can dermatologists use to improve outcomes in this population?

Dr Grant-Kels: People with skin of color can get melanoma on sun-exposed areas, but they most commonly get melanoma in areas that practitioners may not examine, such as the hands, feet, nails, and mucosa. Examining those areas clinically and with your dermatoscope is very important. Some patients are not aware that they are at risk, and even some physicians are not aware and by the time those sites are examined, the lesion is quite thick or ulcerated, and so the prognosis is poor. There is a health care disparity because some of these patients live in rural areas, may not have good insurance, or may not have access to a dermatologist who would be aware of their risks and examine them appropriately.

The Dermatologist: With health care disruptions caused by the COVID-19 pandemic, have you observed long-term impacts on melanoma diagnosis and treatment delays? How should dermatologists address these challenges moving forward?

Dr Grant-Kels: Yes, the pandemic kept people at home, and they were afraid to go to the doctor for a period. After physician offices opened back up, there was a spike in deeper melanomas post pandemic that were diagnosed. I think that things are back to normal, but the major problem is that, unfortunately, there are still not enough dermatologists, and a lot of primary care providers just do not have the time or knowledge to examine the skin as thoroughly as they should. Patients at high risk who have a family history or personal history of melanoma really do need to get themselves in to see a dermatologist, particularly someone who is a pigmented lesion specialist and skilled in using the dermatoscope.

The Dermatologist: Given the diverse risk factors and barriers to care in these special populations, what are the most critical steps dermatologists can take to enhance melanoma prevention and early detection in their practice?

Dr Grant-Kels: Educating the population is so important. People think that if they get a tan, they are safe to go out in the sun, with some people going to tanning salons to get a tan before the summer. Any time you get a tan, you are damaging your skin, but we can control the amount of sunlight that hits our skin. There is another misnomer that you need some amount of sunlight to make vitamin D, but you can get vitamin D through supplements and diet, and you do not need a lot of the vitamin. We know that ultraviolet light is unequivocally a carcinogen, so we need to keep educating people and ask them to protect their skin from the environment.

The Dermatologist: Is there anything else you would like to share with your colleagues regarding melanoma in special populations?

Dr Grant-Kels: Never use the word never. I have heard pediatricians say that a child can never get a melanoma. It is rare, but I have diagnosed it in children, even preadolescent children. If somebody comes in to a physician with a changing pigmented lesion that the provider finds worrisome, they need to make sure the patient gets seen by an expert or dermatologist to evaluate the lesion. I would especially say to pediatricians and primary care providers, listen to the chest with the back of the patient’s shirt up. Look at the back and if you see anything that is an outlier, call your local dermatologist and get the patient in to be evaluated.