Purpose Data on treatment approaches in geriatric melanoma patients are scant. Efficacy of oncologic treatments across age groups, with special focus on immunotherapy, and the impact of comorbidities were analyzed. Methods A retrospective multicenter cohort study of the ADOREG registry included patients with cutaneous melanoma, who received oncological drugs at German skin cancer centers between 2013 and 2023. Outcomes were objective response rate (ORR), progression-free survival (PFS), melanoma-specific survival (MSS), toxicities and reasons for treatment discontinuation. Age groups were prespecified as < 75 vs ≥ 75 years (geriatric), comorbidities were summarized by Charlson-Comorbidity-Index (CCI). Comparisons across groups were conducted with X²-test, survival outcomes were compared via log-rank tests. Results Of 14,356 melanoma patients, 8213 met the inclusion criteria, 6063 and 2150 were < 75 and ≥ 75 years old, respectively. Among the 3646 patients with metastatic disease, older patients received fewer treatment lines and were less likely to undergo surgery, radiotherapy and systemic therapy. However, efficacy of any first-line treatment did not differ between both age groups (p = 0.306). Immunotherapy selection at any line was similar in both groups (p = 0.109), but geriatrics were treated mainly with first-line anti-PD1 monotherapy, whereas combination ICIs was preferred in younger patients. Efficacy was not impaired (PFS and MSS: p > 0.05), while toxicity rates were lower. This pattern persisted across CCI categories. Conclusion Age influenced treatment selection in melanoma patients. However, in geriatric patients, efficacy was not impaired, and a balanced toxicity profile was noticed, particularly for immunotherapy. Future studies considering biological age and impairment by comorbidities seems important to assess individualized treatment approaches.