Malignant melanoma of the hand and foot: diagnosis and management.

Forty-six patients with melanoma of the hand (5) and foot (41) studied prospectively between 1972-84 have been reviewed to determine guidelines for diagnosis and management. The clinical appearance is varied and the lesions are often misdiagnosed as warts or fungal infections. Clinical assessment of tumour thickness on the sole is difficult because of the nature of the plantar skin. Incision rather than excision biopsy is indicated because of the functional consequences of large excisions on the hand and foot. Melanoma of the toe was treated by local metatarsophalangeal amputation. Plantar melanomas were excised with a 3 cm margin. Dorsum melanomas were treated by a selective policy of 1, 2 or 3 cm margins according to clinical assessment of tumour thickness. These policies have resulted in only one case of local recurrence. An in situ Silastic foam mould facilitates immediate application of split skin grafts to irregular areas. The functional results of split skin grafts on sole and heel have been satisfactory. Toe lesions were thickest, dorsum thinnest, sole and heel intermediate. The prognosis related to these groupings of tumour thickness. Simultaneous clinical nodal involvement carried a hopeless prognosis, and most patients developing nodes within 2 years die--unless treated by prophylactic dissection. The role of prophylactic dissection is still not defined, but it is likely that it will be used more frequently in the future. Early diagnosis offers most hope of improving the outlook. Many elderly patients with nodular lesions have had moles for many years. Younger patients are now being seen with thin lesions, even on the toe.