Skin Cancer

Skin Cancer is the most common cancer. More than 2 million Americans are diagnosed with skin cancer each year.

With early detection and treatment, skin cancer is highly curable. The most common warning signs of skin cancer include changes in size, shape, or color of a mole or other skin lesion or the appearance of a new growth on the skin.

Skin Cancer Affects Everyone
No matter your skin color, you can get skin cancer. Some people have a higher risk of developing skin cancer than others. Age is a key risk factor, but there are many other risk factors.
People with a higher risk for skin cancer have:

• Light colored skin
• Skin that burns or freckles rather than tans
• Blonde or red hair
• Blue or green eyes
• More than 50 moles
• Irregularly-shaped or darker moles (nevi) called “atypical” or “dysplastic”
• Used (or used) indoor tanning devices such ad tanning beds and sunlamps

Your medical history also can increase your risk of getting skin cancer. You have a much greater risk of developing skin cancer if you have:

• History of sunburns, especially blistering sunburns
• Received an organ transplant
• Had skin cancer (or a blood relative has/had skin cancer)
• A weakened immune system
• Received a long term x-ray therapy, such as x-ray treatment for acne
• Been exposed to cancer-causing compounds such as arsenic or coal
• An area of skin that has badly burned, either in an accident or by the sun

ACTINIC KERATOSIS

Actinic keratosis (AK) is a skin condition caused by sun damage. It causes scaly, rough spots on the skin. These spots remain on the skin even if the scale is picked off. These are not skin cancers, they are pre-cancers. AKs can turn into a form of skin cancer called “squamous cell carcinoma” therefore we recommend they be treated while still in the precancerous stage.

TREATMENT: Treatment of actinic keratoses requires destruction of the defective skin cells. New skin then forms from the deeper undamaged skin cells. A common way of destroying actinic keratoses is by freezing them with liquid nitrogen. Temporarily freezing the skin causes blistering and shedding of the sun-damaged skin. In some instances when we are unable to tell clinically what is causing the abnormal skin changes, a skin biopsy will be performed. Healing after a biopsy usually takes 2-4 weeks, depending on the size and location of the keratosis. There is a risk of permanent scarring from a biopsy or freezing.

When there are many keratoses, we may suggest “field” therapy to treat broad areas. This can include chemotherapeutic creams or light sources. The creams are rubbed on the affected areas to destroy sun-damaged skin cells. Depending on the cream, you will apply it for 2-14 days. Another form of field therapy uses a light source and is known as “photodynamic therapy.” It involves applying a photosensitizing medicine to your skin and then exposing your skin to a special light source. If we select this therapy, we will review more details with you.

PREVENTION: Sun damage is permanent. Once sun damage has progressed to the point where actinic keratoses develop, new keratoses may appear even without further sun exposure. To prevent further damage you should avoid excessive sun exposure, but do not go overboard and deprive yourself from the pleasure of being outdoors. Reasonable sun protection should be your goal. Generally this involves seeking shade during times of intense sun exposure, wear long sleeved shirts and wide brimmed hats, and regularly apply a broad spectrum UVA & UVB sunscreen with an SPF of 30 or greater every two hours. Regular skin examinations with your dermatologist will enable early diagnosis and treatment. Please call the office if you note any new, changing, or non-healing lesions.

Types of Skin Cancer
The most common types of skin cancer are:

Basal Cell Carcinoma (BCC)
BCC is the most common type of skin cancer. BCC appears on the skin in many shapes and sizes. You may a dome-shaped growth with visible blood vessels; a shiny, pinkish patch; or a sore that heals, and then returns. BCC usually develops on skin that receives lots of sun, such as the scalp, nose, neck and hands. BCC rarely spread to other areas of the body, but it can grow deep into tissue and bone.

Squamous Cell Carcinoma (SCC)
SCC is the second most common type of skin cancer. SCC appears on the skin in many shapes. You may see a crusted or rough bump; a red, rough flat patch; a dome-shaped bump that grows and bleeds; or a sore that does not heal, or heals and returns. SCC commonly develops on skin that is exposed to sun, such as the face, ears, lips, back of the hands, arms and legs.
SCC also can develop on areas of the body that are not exposed to sun, such as inside the mouth or on the genitals. Smoking or chewing tobacco may increase the risk of getting SCC in the mouth or throat. Left untreated, SCC can spread to other parts of the body, making treatment difficult.

Melanoma
This is the deadliest form of skin cancer. Melanoma may develop on normal skin or in an existing mole. A change to the shape, color, or diameter (size) of a mole can be a sign of melanoma. Other changes to watch for include a mole that becomes painful or begins to bleed or itch.
Some melanomas develop on normal skin. A new growth, particularly one that does not match your other moles, could be melanoma.
Melanoma also can develop under fingernails or toenails. This will look like a brown or black streak underneath the nail.
Although melanoma is more common in those with light colored skin, people with skin of color also get melanoma. In skin of color, melanoma usually appears on palms of the hands, soles of the feet, under a nail, in the mouth, or on the genitals.

DYSPLASTIC NEVI A pigmented lesion (mole) which is neither entirely benign nor malignant (cancerous). This is because some dysplastic nevi are felt to have a higher risk of becoming malignant than ordinary, benign moles. In certain circumstances, dysplastic nevi serve to mark patients who, in general, are at a higher risk of developing a malignant melanoma, whether at the site of a dysplastic nevus or another site.

RECOGNITION: It is not easy to recognize these lesions and be absolutely certain of the diagnosis. In general, however, dysplastic nevi have many of the same features that may be seen in malignant melanomas such as:

1. Typically larger than ordinary, benign moles.

2. Can have a variety of colors within them (usually different shades of brown).

3. Can have irregular “scalloped” appearing borders.

4. May contain raised as well as flat areas of pigmentation within the same lesion.

DIAGNOSIS: When dysplastic nevi are noticed during a clinical visit, one or more of the suspicious lesions may be removed so that a pathologist can render a microscopic diagnosis to confirm the physician’s clinical impression.

PROGNOSTIC FACTORS: Many factors that are considered risk factors for skin cancer have been identified. They include:

1. Personal history of excessive sun exposure or

artificial tanning.

2. Personal history of severe sunburns.

3. Personal history of medical problems that directly or indirectly lead to a weakening of the immune system.

4. Personal history of malignant melanoma.

5. Family history of malignant melanoma.

6. Family history of dysplastic nevi (microscopically proven).

The more variables that apply to a patient, the higher the general risk of developing melanoma. Compared with the general, unaffected population, a patient with dyplastic nevi, for whom none of these variables apply, may have only a slightly higher risk of developing a malignant melanoma. The more risk factors a person has, the higher their overall risk of developing malignant melanoma. It must be stressed that the whole process of assigning risk to patients with dysplastic nevi in such situations is not an exact science.

LESION REMOVAL: The factors mentioned above and their application to the individual patient largely determines whether dyplastic nevi are removed. In general, the diagnosis of a dyplastic nevus determined both clinically and microscopically, is not an absolute indication for its removal. Often, these lesions are carefully watched for any changes in their size, shape, or color. Such changes would be an indication for removal, as would dysplastic-appearing nevi located in difficult to follow areas (i.e. the scalp).

PATIENT RESPONSIBILITIES AT HOME BETWEEN OFFICE VISITS

1. Total body self examination, done monthly, is an excellent habit to develop. Use a full-length and a hand-held mirror, or seek the aid of a family member, so that all skin can be carefully examined.

2. Examine yourself regularly to become familiar with your moles so you will notice if they undergo any changes.

3. As much sun avoidance and sun protection (sunscreens, hats, shirts, etc.) as possible are absolutely essential. Sun tanning salons are clearly harmful. Ultraviolet rays, whether they are acquired in many small doses or in fewer, larger doses, are damaging to the skin. Specifically, ultraviolet light exposure only adds to the injury that is already present in the form of the abnormal cells from which dysplastic nevi are derived.

OTHER POINTS: The frequency of office visits for patients with dysplastic nevi can vary from every 4 months to every year, depending again on the risk category that a given patient falls into. In some cases, a patient who has only a few dysplastic nevi, all of which have been removed at the initial visit with no other suspicious lesions and none of the high risk factors that were listed above, can be seen on an “as needed” basis as long as the practices of routine self-examination and sun protection are rigorously adhered to at home.

We hope that this handout has helped to clarify some of the very vague issues that surround this difficult condition. Please call us if you have any questions or problems. For more information, contact either of the following:

Melanoma Education Foundation P.O. Box 2023 Peabody, MA 01960

The Skin Cancer Foundation 149 Madison Avenue Suite 901 New York, New York 10016

ABCD’s of Melanoma Detection
When melanoma is caught early and treated, the cure rate is nearly 100%. Performing skin self-examinations can help you find skin changes that could be an early melanoma. When looking at your skin for signs of melanoma, it helps to keep in mind the ABCD’s of Melanoma:

A stands for Asymmetry; one half does not look like the other half.
B stands for Border; irregular, scalloped or poorly defined border.
C stands for Color; varied from one spot to another; shades of tan and brown, black; sometimes white, red, or blue.
D stands for Diameter; meaning if a mole changes, grows, itches, bleeds, changes colors, or is different than the rest of your moles, it should be checked.
E stands for Evolving; a mole or skin lesion that looks different from the rest or is changing in size, shape, or color.

NICOTINAMIDE (NIACINAMIDE) DOSEGE

Nicotinamide, also known as Niacinamide, is a form of Vitamin B3. Studies have shown that consistently taking Nicotinamide or Niacinamide, can help reduce some non-melanoma skin cancers by as much as 23%, in patients with a history of Basal Cell carcinoma or Squamous Cell carcinoma. This supplement has also been shown to help reduce the risk of developing Actinic Keratoses, which is a common type of precancer of the skin. This is an over the counter supplement which is widely available and is not covered by insurance. The recommended dosage is Nicotinamide/Niacinamide (NOT Niacin) 500mg taken twice daily; you will need to continue consistent dosing for full benefit and should not take more than the recommended dosage. This supplement appears to be well tolerated without any significant side effects but should be avoided if you are currently taking anticonvulsants, such as carbamazepine.

Before your procedure, there are certain instructions that we would like you to review and understand.

First, when possible, avoid medications that could increase bleeding. These include over the counter medications such as vitamins and pain medications such as Aspirin, St. John’s Wort, Vitamin E, Fish Oil, Garlic and Gingko Biloba. These medications should not be taken for 2 weeks before the surgery. Medications known as NSAIDS or anti-inflammatory drugs (Ibuprofen, Naproxen, Motrin or Aleve) need to be avoided 3 days prior to surgery.

If you are on any prescription blood thinning agents, we generally recommend staying on these before and after procedure but ask that you inform us prior to the day of surgery so we can plan appropriately. Some prescription blood thinners include Heparin, Plavix, Coumadin, Eliquis, Pradaxa and Xarelto.

If you do have minor aches and pains in the days leading up to your surgery, you may use Tylenol as it does not increase your bleeding risk. During your procedure you will receive a local anesthesia known as lidocaine. If you have a history of an allergy to this type of medication, please let us know so an alternate medication can be used. Generally, patients can drive after the procedure. If you have a high amount of anxiety over the procedure, we can give you a mild sedative (like Valium) but you will need a driver. Following these instructions should help ensure that you have a safe and successful surgery. If you have any questions or concerns, please do not hesitate to contact our office.