We are in the month of May so there’s still time for a plug for Skin Cancer Awareness Month.
Skin cancer is common.
More than 5 million cases of skin cancer are diagnosed in the U.S. every year.
As a dermatologist, I diagnose many of these skin cancers in my clinic every week. Today, I’m going to highlight a few statements that I have heard from various patients who were ultimately diagnosed with melanoma.
“This mole was changing but I wasn’t too worried because it wasn’t painful or causing any symptoms.”
A changing mole is a reason to see your dermatologist. About 50% of melanomas (a potentially deadly form of skin cancer) arise de novo — meaning not from an existing growth. That leaves the other ~50% of melanomas having arisen from pre-existing moles. If a mole is changing, please please bring it to the attention of your dermatologist. When you call the office, be clear that you have a changing mole. If you can’t get into see your dermatologist, see your primary care physician. These days, many insurance plans may require you to see your primary care physician first in order to get a referral (hopefully expedited) to your dermatologist. Melanoma is most often neither itchy nor painful. I often counsel my patients that it’s not your job to play doctor; let us evaluate your growth for you.
“I have a flaky spot on my face. I pick off or scrub off the flake and my skin seems to go back to normal but the flaking keeps coming back.”
This is often the history I get for a potentially pre-cancerous spot called an actinic keratosis. Left alone, it can progress to a type of skin cancer called a squamous cell carcinoma. If you have these spots, see your dermatologist! It’s a good marker of prior sun exposure that you’ve had. You are also more at risk for developing skin cancer. Actinic keratoses are easy for your dermatologist to treat.
“I had this growth I was concerned about for some time but I really don’t want a scar from any procedures so I didn’t come in until now. My [family member, spouse] finally made me come in.”
Yes, taking a skin biopsy can leave a scar. Yes, taking out a skin cancer can leave a scar. And yes, taking a skin cancer out can also save your life. Especially if you get it out early.
Find a dermatologist who you can communicate with so you can have a discussion about what your growth might be and what the steps for diagnosing and treating the growth are. We are not looking to biopsy and cut things out willy-nilly.
For more resources about skin cancer:
Too frequently, I meet new patients who come in noting they’ve had a skin growth they’ve been concerned about for months, a year, or even years. Some have had growths that have continued to grow in size, bleed, break open and even take over the face — growing into the eye, ear, or lip. Not surprisingly, these were skin cancer.
Why this wait before seeking care?
Is it because it takes so long to get in to see doctor? Certainly, access to a physician, and specifically a dermatologist, can be difficult and healthcare systems need to work on this problem, but wait times will rarely be over a year! Many practices also triage their calls to get patients who may have skin cancers in earlier.
In several of my interactions, people have been reluctant and even scared to seek care. Reasons I’ve heard include: 1) the growth wasn’t bothering them that much, 2) they didn’t think it would be anything serious, and 3) they were scared about what would happen if they did have a skin cancer.
Interestingly, I think back to why people do seek care for a new or changing growth. Oftentimes, it is a spot that the patient has picked up him/herself, but often, it’s someone else — most commonly a spouse — who has encouraged the patient to seek care. I’ve also had a handful of patients whose hairdressers kept pressing the patient to seek care. And guess what? Turned out that they did have skin cancer.
Have you waited before seeking care for a new or changing growth? If so, why?
Is there enough awareness about getting skin checks from your doctor, doing your own self skin checks, or when to seek care?
If you do have a new or changing growth on your skin, don’t wait. Pick up the phone and call a/your dermatologist or your primary physician to get it checked out. Explain your concerns about having skin cancer. When skin cancers are caught early, they can be very curable. However, there are many types of skin cancers, and some unfortunately are aggressive and not easy to cure once they have progressed or traveled to other parts of the body.
Yesterday, actor Hugh Jackman tweeted out a photo of his nose all bandaged with the following note: “Deb said to get the mark on my nose checked. Boy, was she right! I had a (basal) cell carcinoma. Please don’t be foolish like me. Get yourself checked. And USE sunscreen!!!” (Deb is Hugh Jackman’s wife)
As a dermatologist, I’m really happy that his public service announcement will reach thousands of people (and now maybe even more since it’s been covered by major news outlets). I’m hoping that some of those folks who read his message will use sunscreen and get their skin checked, including young folks who may feel immune to the effects of ultraviolet radiation.
If Wolverine tells you to wear sunscreen, you should wear sunscreen!
Basal cell carcinomas (BCCs) are the most common form of skin cancer and UV predisposes you to this skin cancer. I can’t tell you how many folks I see who are diagnosed with this skin cancer who tell me that they got plenty of sun in their younger years. Indeed, those in the older generation rarely used sunscreen. In fact, some people thought that the UV rays were good for the skin!
For those of you young and old, it’s not too late to practice good sun protection. Do it now and save yourself a large bandage later!
What is ultraviolet (UV) light? Ultraviolet light is made of up light waves of a certain wavelength. What does that mean? Well, I think back to grade school where we learned about different wavelengths of light. Certain wavelengths would form certain colors of light. e.g. in a rainbow, each color reflects a different wavelength of light (recall the mnemonic of ROYGBIV for the colors of the rainbow? red, orange, yellow, green, blue, indigo, and violet). However, these colors of light were part of visible light. This is light that we can see with our eyes.
However, there’s light that we can’t see as well. We can’t see ultraviolet light.
So what does ultraviolet light have to do with the skin? (After all, DermBytes is a blog about all things skin.) Well, ultraviolet light can cause damage to the DNA of our cells and can also make our immune system less effective. UV light can lead to sunburns, cause darkening or tanning of the skin, and lead to increased risk of skin cancer. In some people, UV light can also lead to various rashes. In others, patients may find that the light helps their skin rash (e.g. psoriasis).
Because of the potential deleterious effects of UV on the skin and its potential to lead to skin cancer, dermatologists recommend using sunscreen. Remember from our previous post that we should choose a sunscreen that protects against both UVA and UVB. UVA and UVB simply refers to different sets of wavelengths. (Specifically, UVA includes wavelengths of 315-400 nm and UVB includes wavelengths of 290-315 nm).
An exciting talk from this year’s American Academy of Dermatology Meeting (AAD 2013) in Miami was the annual Marion B. Sulzberger Memorial Award and Lectureship given by Dr. Hensin Tsao. Dr. Tsao talked about “Melanoma and Its Metaphors,” drawing parallels between the machinery behind melanoma to the machinery behind cars. While problems can arise with cars, so can the biological machinery that drives cells to go out of control and develop into melanoma. Dr. Tsao discussed tumor suppressor and proto-oncogenes. Likening them to faulty brake systems, Dr. Tsao discussed how tumor suppressor genes are like the brakes in cells, and when messed up, the cell keeps going, dividing out of control. On the other hand, if the accelerator of the car gets stuck in the down position, the car keeps going as well. Proto-oncogenes, or oncogenes, are accelerators of melanoma.
In the realm of melanoma therapy, we’ve made some great strides in directed therapy. Among these are the drugs that target a very specific mutation that 60% of melanomas have (the V600E mutation). These are drugs like vemurafenib and dabrafenib. Although some of the tumors then find ways around these drugs when given alone, researchers and physicians have then added an additional drug, tramatenib (a MEK inhibitor) to the cocktail. Two hits against the melanoma! And there’s even more exciting stuff to come.
In short, in these past few years, we have seen major advances in melanoma therapy and I hope that with the direction we’re going, we’ll be able to put a permanent halt to melanoma!
It’s a good idea to look over your skin about once a month. This allows you to get to know your skin and what your skin looks at baseline. Anything new or changing on top of your first exam would be of concern. Secondly, anything that looks suspicious, especially via the ABCDE criteria for melanoma, would be of concern as well.
Having a full-length mirror and handheld mirror can be helpful tools. First, look over the front of your body: your face, neck, chest, arms, belly, thighs and legs — including under the undergarment areas. Examining the back side of your body can be a little more difficult. Using a hand held mirror along with the full-length mirror can allow you to visualize the back of the neck, the back, buttocks, and back of the thighs and legs. Also look at the hands including the palms, and soles. Check behind the ears and through the scalp as well. If you don’t have a hand held mirror or find that you still don’t have good visualization of certain areas of your body, you might to have someone examine your skin for you (e.g. a partner or spouse). Your barber/hairdresser can also help you look through your scalp. If any of the spots on your skin are concerning to you, you should let your dermatologist know even before your regularly scheduled skin examination.
The American Academy of Dermatology (AAD) has a good webpage diagramming the steps to the self-skin exam.
One day after Tropical Storm/Hurricane Irene passed through town, the sun is back! Perfect time to learn about sunscreen.
A common question is: what is SPF? SPF stands for sunburn protection factor. (The FDA changed it from sun protection factor to sunburn protection factor as sunscreen does not completely protect you from the harmful UV of the sun.) The number is a measure of how many times more it takes for you to burn with the sunscreen on compared to not wearing the sunscreen. So for instance, if it takes a certain amount of UV rays for you to become red without sunscreen, it would take 15 times that amount of UV for you to become red when you wear SPF 15 sunscreen. The SPF label assumes that you correctly apply the sunscreen. You should use about 1 ounce to cover the surface of your body. Furthermore, you need to reapply the sunscreen as you sweat, or get wet. Additionally, the SPF value on bottles refers to harmful UVB (ultraviolet-B) rays, but not harmful UVA rays. When choosing a sunscreen, look for one that covers UVA and UVB (“broad spectrum” sunscreens).
B: Border irregularity
C: Color change or different colors
D: Diameter greater than 5 mm (the size of a pencil eraser)
E: Evolution. Watch for any change.
If you have any doubts at all, have your doctor check your skin!
Does the phrase “pigmented lesion” mean something to you? Or does is it sound strangely foreign? The online Merriam-Webster dictionary defines lesion as, “1. Injury, harm. 2. an abnormal change in structure of an organ orpart due to injury or disease; especially: one that is circumscribed and well defined.” So in the skin, a lesion is an area that presents with a change from the surrounding normal skin. Pigmented lesions account for a large proportion of referrals from primary care physicians. Many patients also self-refer after noticing a funny looking pigmented spot on their skin. The majority of these referred pigmented lesions do not turn out to be melanoma, but I still believe in better safe than sorry. Dermatologists are trained to distinguish a concerning pigmented lesion from a benign (safe) spot. We do this by looking at the spot and we might use a special lens to look at the spot (dermoscopy). If we’re concerned enough about the spot, we may biopsy it (cut out a small piece of it) or cut it out all together and send the skin to a pathologist. The pathologist is a doctor who looks at the cells of the tissue and tells us what the lesion is.
Pigmented lesions can be many things. Of course, we’re most concerned about catching a melanoma, which is a serious type of skin cancer that can spread to other parts of the body and cause all sorts of problems including death. Then there are atypical moles, which we call “dysplastic nevi.” We believe that some percentage of these can turn into melanomas. That’s why if the pathologist tells us that your mole is atypical with a certain degree of atypia (usually moderate atypia or worse), then we may suggest that you get your mole cut out. Keep in mind though that melanomas don’t have to evolve from moles. They can arise from a part of your skin that never had a mole before! This type of melanoma is said to arise de novo. A pigmented lesion can also be many other things. Again, better safe than sorry. When in doubt, find someone who is trained to distinguish the good, the bad, and the ugly pigmented lesions.