Melanoma of the scalp diagnosis
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Epidemiology and Risk Factors of Scalp Melanoma
Scalp melanoma is a particularly aggressive and high-risk form of skin cancer, accounting for a disproportionate number of melanoma cases relative to the scalp’s small surface area. It is more common in older adults and occurs much more frequently in men, likely due to factors such as androgenetic alopecia and increased ultraviolet exposure on the scalp. Scalp melanomas are associated with higher mortality rates and poorer prognosis compared to melanomas at other body sites, with a 10-year survival rate of around 60% 157.
Clinical Presentation and Diagnostic Challenges
Scalp melanomas can present in various histological subtypes, including lentiginous, desmoplastic, superficial spreading, and nodular melanoma. In both adults and children, these tumors often appear as pigmented lesions, nodules, or rapidly enlarging masses. Pediatric and congenital cases are rare but tend to have a poor prognosis, especially when associated with congenital melanocytic nevi or when presenting with ulceration or necrosis 346.
Diagnosis is often delayed because scalp lesions are less visible and may be mistaken for benign conditions or chronic wounds, especially in elderly patients. This delay contributes to the advanced stage at diagnosis and worse outcomes 59.
Diagnostic Tools and Techniques
Dermoscopy and Reflectance Confocal Microscopy
Dermoscopy is useful for evaluating scalp lesions. Thin melanomas may show an atypical network or pseudo-network and regression, while thick lesions often display a blue-white veil, irregular pigmented blotches, or an unspecific pattern. However, dermoscopy can be inadequate in giant or complex melanomas, making diagnosis challenging 110.
Reflectance confocal microscopy (RCM) can aid in the diagnosis, especially for complex or lentigo maligna subtypes, by revealing irregular meshwork, ringed, or disarranged patterns 12.
Biopsy Methods
All suspicious scalp lesions should be biopsied. Excisional biopsy with 2 mm margins is preferred for accurate diagnosis. In cases of large or giant melanomas, punch biopsies may be insufficient due to sampling errors, and larger incisional or excisional biopsies are recommended to avoid diagnostic delays 110.
Histopathological analysis, including immunohistochemistry and molecular profiling, is essential for confirming the diagnosis and identifying aggressive or rare subtypes, such as atypical fibroxanthoma-like melanoma, which may have a high risk of recurrence and metastasis .
Differential Diagnosis
Scalp melanoma must be distinguished from benign lesions such as solar lentigo, actinic keratoses, lichen planus-like keratosis, melanocytic nevi, and blue nevi. Accurate diagnosis relies on a combination of clinical examination, dermoscopy, RCM, and histopathology .
Importance of Early Detection
Routine scalp examination is crucial, especially in high-risk populations with chronic sun damage or pre-existing nevi. Early detection and diagnosis significantly improve outcomes, as early-stage melanomas respond well to treatment, while advanced cases are associated with high recurrence and mortality rates 579.
Conclusion
Scalp melanoma is a high-risk, aggressive cancer that is often diagnosed late due to its hidden location and challenging presentation. Early recognition, thorough scalp examination, and the use of advanced diagnostic tools such as dermoscopy and confocal microscopy are essential. Excisional biopsy remains the gold standard for diagnosis, and clinicians should maintain a high index of suspicion for any atypical scalp lesion to improve patient outcomes 1257910.
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