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Skin Cancer
Approximately 1 in 5 Americans will develop skin cancer in their lifetime. The principal risk for skin cancer is life long over exposure to the sun. Regular skin examination by a board-certified dermatologist allows recognition of skin cancers when they are small and easily cured by a minor surgical excision.
Actinic Keratosis (AKs): The most common precursor of skin cancer is the actinic keratosis. These premalignant lesions are red, scaly areas on the face, hands, and arms as a result of sun damage early in life. They are easily treated with liquid nitrogen (freezing) or with topical chemotherapy creams. Occasionally patients may have too many AKs for adequate control with freezing. The next level of therapy includes topical treatment with 5-fluorouracil, imiquimod, or “Blue Light” therapy. (see FAQ for details) The regular treatment of AKs reduces one’s lifetime risk for developing basal cell and squamous cell skin cancer.
Basal Cell Carcinoma (BCCs): The most common skin malignancy is basal cell carcinoma. One million new cases are diagnosed annually. These tumors often have a pearly opalescent appearance with overlying dilated blood vessels while others are crusted, non-healing “sores”. Rarely BCCs can present as a subtle ivory-colored or a scar-like area which expands by destroying the normal pores on the surface of the skin. These slow growing tumors do not metastasize, i.e. spread to internal organs, but they can cause major tissue destruction. BCCs are most often found on the face, scalp, back, and chest. In most patients these cancers and be cured with a simple surgical excision or a local destruction technique known as curettage and electrodessication. Occasionally patients require referral for Mohs surgery for very large tumors, tumors showing infiltrative and aggressive histology, recurrent tumors, or large tumors in sensitive anatomic areas such as the nose. For more information regarding Mohs surgery see “Do I need a referral for Mohs surgery?” under FAQ.
Squamous Cell Carcinoma (SCCs): Squamous cell carcinoma affects 200,000 Americans annually. SCCs are usually exhibit a thick surface scale although they can be ulcerated or even present with a “volcano-like” appearance. These tumors can show rapid growth, occasionally metastasize, and very rarely can be fatal. SCCs are most commonly seen on the face (especially lips and ears), scalp, hands, and arms. If diagnosed early a simple surgical excision is usually curative. SCCs can be very aggressive in organ transplant patients and others who take immunosuppressive medication.
Malignant Melanoma (MM): Although the worldwide incidence of melanoma is increasing, MM remains one of the the rarest skin malignancies. 50,000 cases per year are diagnosed in the United States. Melanomas are recognizable as “ugly ducklings” (moles which look different or stand out). They usually have no symptoms and present as brown or black (or rarely reddish) FLAT lesions which have the “ABCDEs”.
The ABCDE's of Melanoma
Skin cancer can develop anywhere on the skin. Ask someone for help when checking your skin, especially in hard to see places. If you notice a mole that is different from others, or that changes, itches or bleeds (even if it is small), you should see a dermatologist.
| A: |
Asymmetry…the two halves of the lesion are not mirror images. |
| B: |
Border irregularity…the edges are blurred, jagged, or notched. |
| C: |
Color Variation…the pigment is not uniform. The lesion has shades of tan, brown, or black. Red, white, or blue colors are especially worrisome. |
| D: |
Diameter…lesions are bigger than a pencil eraser or 6mm. |
| E: |
Evolution or change….lesions show centrifugal growth. |
Almost all melanomas are curable with a simple surgical excision if detected early, but thick, chronic lesions can fatally metastasize from the skin to internal organs. Sentinel node biopsy is appropriate for melanomas equal to or greater than 1mm in thickness. Radiation therapy is not effective in treating melanoma and chemotherapy is appropriate only for metastatic tumors.
Very rarely a gene increases the risk of melanoma in family members, but the main genetic risk for melanoma is fair skin and blue eyes. We recommend regular dermatology exams for patients over age 40 with the highest risk for developing a melanoma, such as blue-eyed redheads with freckles who burn easily and have little ability to tan. A monthly self-examination of all skin surfaces is also recommended for patients at high risk.
Self Examination
Above illustrations and images courtesy AAD.org
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Moles or Nevi
Most human beings have 50-100 Harmless Moles. These are harmless tumors of melanocytes (or pigment producing cells) which first appear in childhood. Benign or harmless moles are smaller than a pencil eraser, show uniform pigment distribution, are raised, and change very slowly. Moles increase in number throughout teen and early adult years, but NEW moles after age 40 are unusual and may be dangerous, i.e. melanoma precursors. Moles can be removed for cosmetic reasons, if they are irritated by clothing or shaving, or if they have a worrisome appearance or behavior.
Congenital Nevi: Congenital moles (brown or black “birthmarks”) are very common and are always larger than a pencil eraser. Most small congenital nevi (smaller than a quarter) require removal only if they show worrisome changes since the lifetime risk of transformation into melanoma is very small.
Dysplastic Nevi: The most common abnormal mole is the dysplastic nevus (DN). Most DN exhibit the “ABCDEs” and more than 50% of adults develop these harmless nevi. It is normal to develop DN throughout life. Since a TINY percent of DN patients develop a malignant melanoma, we consider these moles to be “atypical”. The DN patients at greatest risk for developing melanoma have numerous large (eg. bigger than a dime) moles which are changing. For such patients mole mapping (photographs plus measurment) may be recommended. Multiple DN in family members also increases the lifetime risk for developing a melanoma. 25% of new melanomas in DN patients develop in a pre-existent mole while 75% develop in normal skin.
In general we recommend monthly self exam of all DN, preferably in comparison with mole map photos to detect new DN or change in a pre-existent DN. We recommend an annual comprehensive dermatology exam for patients with multiple large DN. We biopsy or completely excise DN which are new or changing and have a worrisome appearance.
Seborrheic Keratosis: Patients often consult their dermatologist regarding changing brown growths. The majority of these lesions are seborrheic keratoses (SKs) which are harmless pigmented (light tan, brown, or even black) warty growths which may exhibit the "ABCDEs" of melanoma. They are not caused by sun damage and have no chance to become cancer. An experienced dermatologist can easily make an accurate visual diagnosis (i.e. no biopsy needed) of these benign growths. SKs are hereditary and increase in number and size with advancing age. Removal of SKs is "medically necessary" if they are irritated or symptomatic, although some patients desire removal for cosmetic concerns. Cryotherapy or freezing is the most popular way to destroy these growths, but very thick lesions are most reliably removed by a minor surgical procedure.
Lentigo: One of the most common pigmented lesions on the face, hands, and arms is the lentigo, aka "age spot" or "liver spot". "Liver spot" refers only to the brown color. Lentigos have no relationship to the liver or liver disease. These are flat, brown lesions which are age-related and caused by sun exposure. They have no potential to become malignant, but occasionally a lentigo maligna (LM) or melanoma in situ can be mistaken for a harmless lentigo. LM is a slow growing lesion which usually has shades of black and brown. Lentigos can be removed for cosmetic reasons by freezing (cryotherapy) or with our Sciton Laser.
For further information visit: www.aad.org.
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Eczema or Dermatitis
Atopic Dermatitis: Atopic Dermatitis usually occurs in individuals who have a personal or family history of Atopy or Atopic Diseases, such as hay fever, asthma, eczema, hives, bee sting allergy, latex sensitivity, food allergy, multiple medication allergy, etc. In infancy atopic dermatitis may be precipitated by food allergy and can affect generalized areas of the face, torso, and extremities. Later in childhood the eczema may be localized to the face or flexor creases of the arms and legs. Some patients “outgrow” their eczema while in others it is a lifelong, incurable, but usually controllable condition.
Contact Dermatitis usually results from a chemical irritant, eg. excess exposure to soap and water, or a substance which produces a true allergic reaction, such as the nickel in earrings or fragrances. Poison ivy grows along many Montana rivers and is a common cause of severe allergic contact dermatitis in the summer. Occasionally patch testing is performed to identify the source of allergic contact dermatitis.
Dyshidrotic eczema often presents as intensely itchy blisters between the fingers or toes. In many patients stress is a precipitating factor.
Neurodermatitis is caused by an itch-scratch-cycle involving localized areas of the skin, such as the nape of the neck, arms, or legs.
Nummular dermatitis literally means “coin-like” patches of rash in a generalized distribution. Although dry skin is a common cause, occasionally “internal diseases” can be associated with this type of eczema.
Seborrheic dermatitis: This is an itchy condition characterized by redness and scaling of the scalp, ear canals, central face skin, eye lashes, or chest. It probably represents a “sensitivity” to a normal yeast found on all human’s skin. It is made worse by stress or neurological conditions, such as Parkinson’s disease or stroke. Seborrhea is a chronic and incurable condition but it can be controlled with medicated shampoos, cortisone salves, or antifungal medications.
Stasis dermatitis occurs from poor circulation in the lower extremities. Red or brown scaly and itchy areas develop on the shins and ankles. In people with varicose veins chronic leg ulcers can develop.
Generally speaking the various types of eczema can be controlled with topical cortisone creams plus emollients. Rarely expensive immunomodulators such as Protopic or Elidel are needed to control difficult cases of eczema..
For more information visit: www.aad.org or www.nationaleczema.org.
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Psoriasis
Psoriasis causes red, scaly patches on the scalp, torso, and extremities in approximately 3% of the population. 30% of patients with psoriasis have a positive family history and 10-20% have co-existent psoriatic arthritis. Psoriasis is caused by a defect in the immune system which allows tumor necrosis factor to cause excessive skin turn over. Localized psoriasis is easily controlled with topical cortisone ointments, tar ointments, topical vitamin D-3, or UV light treatments. Widespread psoriasis is best controlled with systemic medication such as methotrexate or injections of “biologicals” such as Enbrel.
For more information visit: www.aad.org or www.psoriasis.org.
Urticaria or hives: 20% of the population develops urticaria (itchy welts or hives) or angioedema (itchy red swelling of the face, hands, or feet) at some point in life. Red itchy welts affect widespread areas of the body and usually fade after a few hours, but appear in new areas in cyclic patterns. This is an “internal allergy” caused by a circulating complex molecule, e.g. penicillin, peanut protein, or a viral particle, which causes the blood vessels in the skin to dilate and leak serum into the skin or deeper tissues. Most cases of acute urticaria are caused by a new food, medication, or a viral infection. This type of hives clears within 4-6 weeks. Chronic urticaria by definition lasts more than 8 weeks and rarely may last for years. Most cases of chronic urticaria have no specific cause despite any amount of laboratory testing. In some patients stress is the cause of this type of hives. Other patients have physical urticaria such as dermatographism (hives produced by skin stroking or writing). Other people have physical urticaria produced by vibration, pressure, exertion, or exposure to cold. Topical medications have no effect on hives. Oral antihistamines, cortisone, and other oral medictions are needed to “break the cycle” of hives.
For more information visit: www.aad.org
Lupus Erythematosis: This is an autoimmune disease caused by defective regulation of the immune system allowing self- or auto-antibodies to attack normal tissues such as the skin, joints, or internal organs. Discoid lupus is the most common category of lupus seen in dermatology. Red, scaly, burning or scarring lesions develop on the scalp, face, or arms as a result of sun exposure. Topical cortisone creams and an antimalarial drug, Plaquenil, provide effective control. Systemic lupus is less common, more serious, and can affect internal organs such as the brain, heart, or joints.
For more information visit: www.aad.org
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Rosacea
Rosacea occurs in adults and starts as “easy blushing” or persistent facial redness. As the disease progresses, pimples develop over the nose and central face. In severe untreated case disfiguring nasal enlargement, the so-called W.C. Field’s nose or rhinophyma, can develop. Trigger factors for rosacea include alcohol, hot beverages, spicy foods, and sun light.
For more information visit: www.aad.org or www.rosacea.org.
Acne
Acne usually starts in the early teens with plugged pores on the central face. As the condition progresses pimples and larger cystic nodules can develop over the face, back and chest. Mild acne can be controlled with topical products. More advanced, potentially scarring acne requires treatment with oral antibiotics, hormone manipulation in women, and in extreme cases oral Accutane.
For more information visit: www.aad.org.
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