Treatment options for melanoma patients, both young and old, were extremely limited until recently. Elderly patients faced a particular challenge due to less aggressive surgical management, poor tolerance of available therapies, aggressive biologic behaviors, and rapid tumor progression. Over the past several years, however, a number of remarkably active immune and targeted agents have been developed. These agents are generally well tolerated and present numerous effective therapeutic options for elderly patients with advanced melanoma. In this manuscript, we discuss the distinct clinical and genetic aspects of melanoma in elderly patients. Furthermore, we review treatment options for older patients with local and regional melanoma and disseminated disease.