Nodular melanoma ++ Nodular melanomas account for 20% of melanomas, are aggressive and invasive, and have no radial growth phase. They are typically found on the trunk and limbs of young to middle-aged individuals (see FIG. 125.8). It may have a ‘blueberry’-like nodule. Prognosis is determined by thickness at the time of excision. Dermatoscopy is usually less useful. ++ FIGURE 125.8 Nodular melanoma on the back. It has no radial growth phase and because it grows vertically can be readily misdiagnosed. The ABCD rule often does not apply but this lesion shows variable colours and an irregular border. Photo courtesy Robin Marks Graphic Jump LocationView Full Size| Favorite Figure|Download Slide (.ppt) ++ The early nodular melanoma problem4,5 ++ Nodular melanoma can present a diagnostic dilemma since the ABCD rule (see later in this chapter) often does not apply. The mnemonic EFG, standing for ‘Elevated’, ‘Firm’ and ‘Growing for more than 1 month’, is more appropriate. Early melanomas tend to be symmetrical, non-pigmented, even in colour, of small diameter and to grow vertically. ++ They are often mistaken for a haemangioma or a pyogenic granuloma. If one is suspicious, refer early to a specialist/specialist clinic. ++ Acral lentiginous melanoma ++ These typically occur on palms, soles and distal phalanges (see FIG. 125.9). They have a poorer prognosis than other types. They occur mainly in people with dark skin. ++ FIGURE 125.9 Acral lentiginous melanoma. A 30-year-old man presented with a ‘mole’ on his toe that had become ‘lumpier’. This type of melanoma, which occurs on the distal areas of the limbs, begins as a spreading pigmented, macule before developing into a nodule surrounded by a pigmented halo (as shown). Photo courtesy Robin Marks Graphic Jump LocationView Full Size| Favorite Figure|Download Slide (.ppt) ++ Desmoplastic melanoma4 ++ This is a rare and aggressive subtype of melanoma. They are often subtle