Melanomas of the scalp: is hair coverage preventing early diagnosis?

Abstract

Background Scalp melanomas are usually thicker and show worse prognosis than other sites and other head and neck melanomas. One hypothesis to explain this aggressive behavior could be diagnosis delay attributed to hair concealment of lesions. Methods Primary melanomas of the scalp diagnosed over two decades at four reference centers in Australia and Italy were included. Hair coverage and visibility of the lesions were assessed on preoperative photographic documentation by two investigators and correlated with some prognostic factors (Breslow thickness, mitotic rate, and ulceration). Patients records and pathology reports provided clinical and histological data. Results The majority of 113 melanomas included were located on easily visible areas of the scalp – hairless scalp (49%) or hairline (15%). The remaining ones (36%), considered to be hair‐covered, showed more frequently thinning of hair (63%) than a dense hair coverage (37%). Melanomas of “hairy scalps” were more frequently invasive (81%) and had higher median Breslow (0.8 ± 1.3 mm) than those arising on bald scalps or areas with thinning of hair (43%; 0 ± 0.6 mm), P = 0.004. However, when considering only the invasive cases (n = 55), Breslow thickness and mitotic rate were not statistically different between concealed and easily visible areas. Melanomas detected by a doctor were thinner than those first noticed by the patient, relatives, or a hairdresser (P < 0.001). Conclusions Most scalp melanomas arose on easily visible areas, which are more prone to ultraviolet damage. Hair‐covered ones, despite rare, could be overlooked during examination. Proactive screening of the scalp area should be encouraged.

Complex melanoma of the scalp: Diagnosis and management aided by confocal microscopy

“…They usually coexist with benign and premalignant lesions, such as AKs, SLs and seborrheic keratoses (SKs), which can obscure the malignancy and contribute to delayed diagnosis. 8 One particular challenge of lentiginous melanomas of sun-damaged skin is their slow-growing nature, which often results in a large dimension upon detection. 5 An excisional biopsy is frequently not feasible or could cause significant morbidity and cosmetic disfigurement.…”

“…Most scalp melanomas arise on the bald and sun‐damaged scalp of elderly males, similarly to the case presented herein. They usually coexist with benign and premalignant lesions, such as AKs, SLs and seborrheic keratoses (SKs), which can obscure the malignancy and contribute to delayed diagnosis 8 …”

Diagnosis and Management of Melanoma of the Scalp: A Review of the Literature

“…However, they added, when considering only the invasive cases, Breslow thickness was not different among different categories of hair coverage. Considering these results, Pereira et al 14 concluded that there are two different scenarios: Lentigo Maligna (LM) and non-LM subtype of SM. Elderly patients with androgenic alopecia and photodamage tend to develop LM type of melanoma, the melanomas are detected before becoming invasive because they appear on visible areas and are of a slow growing subtype.…”

A cross-sectional study of clinical, dermoscopic, histopathological, and molecular patterns of scalp melanoma in patients with or without androgenetic alopecia

“…SM is associated with a greater risk of disease progression and death than melanoma in other sites [5][6][7][8][9][10] , likely due to hair coverage resulting in later diagnosis (Fig. 1) [11][12][13] , the high proportion of melanomas with rapid vertical growth 4,9 , the presence of melanomas in an area of higher blood and lymph supply 14,15 , and inadequate surgical margins (Fig. 2) 16 .…”