MD Dermatology · 25+ yrs international practice
Dermatologist's quick take
- Melanoma in dark skin most often appears on soles, palms, nails, and mucous membranes
- Survival is lower than in light skin — primarily due to late diagnosis, not biology
- Bob Marley died of acral lentiginous melanoma under his toenail at age 36
- ABCDE rule still applies, but the search pattern is different
- AI screening trained on diverse skin tones is critical for equitable detection
I'm Dr. Urhekar, Section Head of Dermatology at M.P. Shah Hospital in Nairobi. After 25 years practising across Africa, the Middle East, and Asia, I've seen too many late-stage melanomas in patients of colour — almost always preventable, almost always missed because they didn't fit the "fair-skin sunburn" narrative most patients (and many doctors) were taught.
This article exists to fix that. If you have Fitzpatrick V or VI skin, the rules are different — not the underlying biology, but where to look. Read it once, then use ScanSkinAI's AI mole check (validated across all skin tones) for ongoing monitoring.
The mortality gap is real
Melanoma occurs in roughly 1 in 1,000 Black Americans, vs 1 in 38 white Americans. But once diagnosed, the 5-year survival rate is 67% for Black patients vs 92% for white patients. That gap is not biological — it is diagnostic. Late stage at presentation is the single biggest driver, and most of those late presentations come down to where doctors and patients aren't looking.
Where to actually look
Soles of feet
The single most common melanoma site in Black patients. Check between toes and heels monthly.
Palms of hands
Look for new pigmented spots, especially asymmetric or irregular ones.
Under nails
Dark longitudinal streaks (subungual melanoma) — especially if widening or pigment extends to cuticle.
Mucous membranes
Inside mouth, gums, nostrils, genital area, anal region. Mucosal melanoma is rare but aggressive.
Sun-exposed areas
Still possible — face, neck, hands. Don't skip these just because the rate is lower.
Old scars and pressure points
Areas of chronic friction or scarring (heels, fingertips, surgical scars) deserve regular checks.
Acral lentiginous melanoma — the dominant subtype
In Fitzpatrick V–VI skin, acral lentiginous melanoma (ALM) accounts for 50–70% of cases. ALM appears on hairless skin — palms, soles, under nails — and progresses through a long "horizontal growth" phase that's easy to dismiss as a bruise, callus, or fungal nail. The signature features are:
- Asymmetric pigmented patch on a palm or sole that grows over months
- Brown or black streak under a nail, often wider at the base than the tip
- Hutchinson's sign — pigment extending into the cuticle or surrounding skin
- A "bruise" that doesn't fade in 4–6 weeks
The ABCDE rule still works — with adjustments
The ABCDE rule applies, but for ALM the diameter cutoff is more useful at ≥7 mm, and any pigmented lesion on palms, soles, or nails warrants lower threshold for biopsy. Some clinicians add a CUBED rule for nail/foot lesions: Coloured, Uncertain diagnosis, Bleeding, Enlargement, Delay in healing.
Monthly self-check protocol for skin of colour
- Sit in good light. Examine each sole, between toes, both palms
- Check fingernails and toenails — look for new dark streaks or widening
- Use a hand mirror for the back of legs, buttocks, and back
- Open your mouth wide; check gums, inside cheeks, and tongue
- Photograph any new or changing spot, with date and ruler for size
- Annual professional check from age 30 (earlier with family history)
Sun protection still matters
Melanin offers partial UV protection, but UVA penetrates deeply and contributes to hyperpigmentation, photoageing, and (less commonly) cutaneous melanoma. Use SPF 30+ daily on the face, neck, and hands. For routines tuned to deeper skin tones, see skincare for dark skin tones.
See a dermatologist within 2 weeks for any of these:
- A new pigmented spot on palm, sole, or under a nail
- A nail streak that is widening, has multiple colours, or extends to cuticle
- A non-healing ulcer or "bruise" on the foot or hand lasting 4+ weeks
- Any pigmented lesion in the mouth or genital area
- A previous skin cancer or strong family history
How AI screening helps close the gap
Most early dermatology AI was trained primarily on light skin — meaning detection sensitivity dropped sharply on Fitzpatrick V–VI. ScanSkinAI was deliberately trained on diverse datasets and validated across all six Fitzpatrick types. Use the free AI mole check monthly for any concerning lesion — it stores dated photos so you and your dermatologist can track change objectively.
AI screening trained on all skin tones
Free 60-second mole check validated across Fitzpatrick I–VI skin types.
Frequently Asked Questions
Dr. Anand S. Urhekar
VerifiedMD Dermatology · 25+ yrs · Section Head, M.P. Shah Hospital Nairobi · Former UN Dermatologist
Dr. Urhekar is a board-certified dermatologist with over 25 years of practice across Africa, the Middle East and Asia. As Section Head of Dermatology at M.P. Shah Hospital Nairobi and a former UN dermatologist, he specialises in tropical skin disease, Fitzpatrick IV–VI skin care and global health.