Isolated limb perfusion (ILP) for limb melanoma remains controversial despite its frequent use for over 35 years. To determine whether it has proven benefits, reported results have been reviewed. The value of adjuvant ILP cannot be determined from the multitude of retrospective studies on this subject. Preliminary results of the large European Organization for Research and Treatment of Cancer–World Health Organization–North American Perfusion Group trial suggest that patients with melanomas of 1·5–3·0 mm in thickness who do not undergo elective lymph node dissection may have a locoregional control benefit from ILP. However, as long as a definite survival advantage for ILP has not been demonstrated, such treatment does not seem justified for these patients. The value of prophylactic ILP after resection of recurrent limb melanoma is also scientifically unproven. The potential prevention of further limb recurrence for only a limited period of time, as demonstrated in a rather small Swedish trial, probably does not justify routine use of ILP in these patients; a large international trial will be needed to assess whether ILP provides a survival advantage. For those with locally inoperable limb melanoma, ILP appears to be the treatment of choice since it results in complete disappearance of all macroscopic disease in a substantial proportion of patients, removing the need for amputation and providing palliation of symptoms. However, high limb recurrence rates and short duration of response need improvement. Results of alternative treatments should be compared prospectively with those of ILP in this clinical situation.