Acral Lentiginous Melanoma  (ALM)

What is this Melanoma?

By Trish Nicholls, Bio Sculpture NZ Ltd

Acral Lentiginous Melanoma  under the fingernail

Acral Lentiginous Melanoma  on the base of the big toe

Acral Lentiginous Melanoma  on the fingernail bed

Acral Lentiginous Melanoma  on the sole of the foot

A while ago I was reading an international beauty magazine and came across a very small article about subungual melanoma.
I was intrigued. 
At Beauty College we are taught to recognise and understand many different types of Melanomas, which are mainly on the face and body. What about melanomas on the palms, fingers, fingernails, the soles of feet and toenails?
Who checks between their toes for pigmentation?
There I began my research....

Why should need to know about these melanomas?
We are a multi cultural nation and different types of melanomas may appear more prevalent in different ethic communities.  Professional awareness as Beauty Therapists or Nail Technicians is to be well informed.   We have a discerning clientele who enjoy nail enhancements, manicures and pedicures. 

What is this Melanoma?
Acral Lentiginous Melanoma  (ALM)
Location:
Palms, soles, fingers, toes & nails.
Lesions appear as deep nodules
Deeply Pigmented
Hutchinson's sign (Brown discolouration of the cuticle) 

There are four types of malignant melanomas,and this is the least common of the four. However, it is believed to be the most common malignant melanoma in Afro-Americans and Asians and maybe found in the elderly.  The diagnosis of this form of melanoma Acral Lentiginous Melanoma  (ALM) is often delayed, which is unfortunate since a late diagnosis can be fatal. 

ACRAL-LENTIGINOUS MELANOMA is the most troubling lesion on both the hands and feet is acral-lentiginous melanoma (ALM). Melanoma is rare in dark-skinned persons. However, when it does occur, it tends to do so on the hands and feet. ALM is the least common subtype of melanoma. 
These lesions occur most often in blacks and Asians. They are uncommon in white people. They appear on areas that do not bear hair, such as the palms, soles, and periungual and subungual skin. Similar lesions may occur around the mouth, anus, and vagina. 

ALM has a tendency toward early metastasis. A hallmark for ALM is pigment that spreads to the proximal or lateral nail folds (Hutchinson's sign).

Palms and soles are the workhorses of the body: The hands rub, scratch, use tools, turn steering wheels, and shake hands with other hands; the feet walk, run, kick. The stratum corneum is thickest in these locations, and the epidermis thickens further with use, as indicated by the formation of calluses and corns.
As a result of their thick stratum corneum, the palms and soles are less likely to develop contact dermatitis than are the dorsal hands and feet. The hands and feet are subject to benign and malignant lesions, lacerations, foreign body reactions, and viral infections (warts), and they serve as portals of entry or means of transmission for infectious materials.
Sun Exposure the dorsal hands almost always faces the sun, have a much thinner stratum corneum than the palms. Compared with the palms, the dorsal hands tend to have more reactions to the noxious environmental stimuli, like contactants and solar radiation.
Feet are protected from contactants and from sun in shoe-wearing cultures. Nails shield dorsal surfaces of the hands and feet distally.  The dorsal hands receive lifelong exposure to solar radiation.
The cumulative effects of sun damage are often apparent in the elderly, especially the fair-skinned. They may exhibit solar lentigines (liver spots), solar keratoses, and squamous cell carcinomas. Warts, protected from contactants and the sun in shoe-wearing cultures.  
The palmar and dorsal, are the most common benign lesions of the hands and soles (plantar warts); children are particularly affected. Seborrheic keratoses tend to be very small when they appear on the dorsal hands. Curiously, basal cell carcinomas are rarely seen here. 

The first signs or Acral Lentiginous Melanoma may appear darker in the nail; sometimes appearing with a brown discoloured cuticle (Hutchinson's sign) not all darker streaks in the nail are the result of malignant lesions.  As the lesion develops it produces variations in colour (brown, black, pink or blue) and it grows, occasionally becoming a nodule, which may ulcerate. 

Malignant melanoma is the most dangerous type of skin cancer. Melanomas beneath the fingernail appear as black or blue in discolouration.  This type of malignancy metastasizes easily (spreads). Periungual melanoma may be regarded as a variant of acra-lentiginous melanoma. Its clinical importance is that it is often misdiagnosed. Brown pigmentation on the nail fold is suggestive of melanoma - Hutchinson's sign. Periungual warts or plantar warts are uncommon in patients over 40 years of age.

What can I do to find skin cancer early?
As a Beauty professional, it is important when caring for a client thorough consultation for any hand or foot service and a detail visual consultation is recorded. (Often lacked in this industry)

We do check for contra indications such as fungal infections but many of us don't check for melanomas.
By being familiar with moles, freckles and beauty marks on your cleints skin and reminding them about self-examinations perhaps mention the value of Mole mapping.

Encourage the client to do self-examinations remembering to also check their fingers, fingertips, soles of feet, in-between toes, toes and toenails.  Through self-examination or thorough consultation by the Beauty professional skin cancer maybe detected early and if detected early it can easily be treated.

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