Treatment of Lentigo Maligna Melanoma

Diagnosis and Initial Assessment

The British Journal of Dermatology recommends that any patient with a suspicious pigmented lesion should be referred urgently to a dermatologist or surgeon with expertise in pigmented lesions 3
Specialists should ensure patients with suspicious lesions are seen within 2 weeks of referral, as recommended by the British Journal of Dermatology 3
A full skin examination should be performed, documenting the site and size of the pigmented lesion, according to the British Journal of Dermatology 3
Clinical photographs may be helpful for documentation, as suggested by the British Journal of Dermatology 3
Examination should include checking for lymphadenopathy and hepatomegaly, as recommended by the British Journal of Dermatology 3

The British Journal of Dermatology recommends that for suspected melanoma, an excisional biopsy should be performed as a full-thickness skin biopsy that includes the entire lesion with a 2-5 mm clinical margin and a cuff of subdermal fat 3, 1
Shave and punch biopsies are not recommended as they make pathological staging impossible, according to the British Journal of Dermatology 1
Incisional biopsy is occasionally acceptable for facial lentigo maligna to establish diagnosis, but should only be performed by specialists within the skin cancer multidisciplinary team, as recommended by the British Journal of Dermatology 1, 2

The standard treatment for lentigo maligna is surgical excision with a margin of 0.5 cm, as recommended by the British Journal of Cancer 4, 5, 6
Complete excision with clear histological margins is the goal as lentigo maligna has no potential for metastatic spread, according to the British Journal of Dermatology 2
For elderly patients or when complete excision is impossible or contraindicated, alternative options include radiotherapy, CO2 laser, and cryotherapy, as suggested by the British Journal of Cancer 4, 5

Surgical margins depend on the Breslow thickness: for melanomas <1 mm in depth, a 1 cm margin is safe and appropriate, as recommended by the British Journal of Dermatology 2
For melanomas 1-2 mm in depth, a minimum 1 cm margin, with 2 cm preferred where functionally and cosmetically sensible, is recommended by the British Journal of Dermatology 2
For melanomas 2-4 mm in depth, 2 cm margins are recommended, according to the British Journal of Dermatology 2

Lentigo maligna on the face has a higher risk of recurrence compared to other in situ melanomas, often due to a "field effect" where atypical melanocytes extend laterally but are not clinically detectable, as reported by the British Journal of Dermatology 2

After complete excision with adequate margins, the risk of local recurrence for melanoma in situ is negligible, according to the British Journal of Cancer 4, 6
Patients should be followed annually throughout life to detect potential second melanomas, as recommended by the British Journal of Cancer 4, 6
Self-surveillance should be encouraged with appropriate patient education, as suggested by the British Journal of Cancer 4

Partial removal of melanocytic lesions can result in pseudomelanoma, causing needless anxiety and diagnostic confusion, as reported by the British Journal of Dermatology 1
Prophylactic excision of pigmented lesions without suspicious features is not recommended, according to the British Journal of Dermatology 3
Incisional biopsies should not be performed in primary care settings, as recommended by the British Journal of Dermatology 3, 1
Underestimating the extent of lentigo maligna, particularly on the face, can lead to incomplete excision and recurrence, as reported by the British Journal of Dermatology 2