Skin Care

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Last Updated: February 24, 2002

Author(s): Michael S Lehrer, MD, Clinical Assistant Professor, Dermatologic Surgery, Hospital of the University of Pennsylvania, Private Practice in Mohs Micrographic Surgery for Skin Cancer

Co-author(s): Stuart Lessin, MD, Director, Department of Cutaneous Oncology, Fox Chase Cancer Center; Chief, Professor, Department of Medicine, Division of Dermatology, Temple University Hospital, Temple University School of Medicine

Michael S Lehrer, MD, is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Sigma Xi

Editor(s): Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; J Stephen Huff, MD, Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health System; Jonathan Adler, MD, Instructor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School; and Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Medical Director, Saint Barnabas Hospital

INTRODUCTION

Skin cancer is the most common of all human cancers. More than a million people are diagnosed yearly. The majority of these cases are basal cell carcinoma or squamous cell carcinoma, which may be locally disfiguring but unlikely to spread to other parts of the body.

A small but important number of skin cancers, however, are malignant melanomas. Malignant melanoma is a highly aggressive form that may be fatal if not treated early. Recent studies demonstrate that the number of skin cancer cases in the US is growing at an alarming rate. Fortunately, increased awareness on the part of Americans and their doctors has resulted in earlier diagnosis and improved outcomes.

CAUSES

Ultraviolet light exposure, most commonly from sunlight, is the overwhelming cause of skin cancer.

  • Other important causes of skin cancer include the following:
    • Tanning booths
    • Immunosuppression (when the body system that protects the body from foreign substances, such as germs or substances that cause an allergic reaction, is inhibited)
    • Exposure to unusually high levels of x-rays
    • Contact with certain chemicals (miners, sheep shearers, and farmers are exposed to arsenic; hydrocarbon exposure in tar, oils, and soot may raise rates of squamous cell carcinoma)
  • Who is most at risk?
    • People with fair skin, light hair, and blue eyes
    • Those with certain genetic disorders (some examples are people who have low levels of skin pigment with albinism and xeroderma pigmentosum)
    • Someone who has already been treated for skin cancer
    • People with numerous moles, unusual moles, large moles that were present at birth — [See Mole Removal for further information]
    • People with close family members who have developed melanoma

SIGNS AND SYMPTOMS

  • Basal cell carcinoma (BCC) usually looks like a raised, smooth, pearly bump on the sun-exposed skin of the head, neck, or shoulders. Small blood vessels may be visible within the tumor. A central depression with crusting and bleeding frequently develops. It is often mistaken for a sore that does not heal.
  • Squamous cell carcinoma (SCC) is commonly a well-defined, red, scaling, thickened patch on sun-exposed skin. Similar to BCC, ulceration and bleeding may occur. Left untreated, SCC may develop into a large mass.
  • The majority of malignant melanomas are brown- to black-pigmented lesions. Warning signs include change in size, shape, color, or elevation of a mole. The appearance of a new mole during adulthood, or new pain, itching, ulceration, or bleeding of an existing mole should be checked.
  • The easy-to-remember guideline “ABCD” is useful for identifying malignant melanoma:
    • A – Asymmetry: One side does not look like the other
    • B – Border irregularity: Margins may be notched or irregular
    • C – Color: Often a mixture of blacks, tan, brown, blue, red, or white
    • D – Diameter: Usually greater than 6 mm (about the size of a pencil eraser) but note any change in size

HOME CARE

Do not attempt home treatment but be active in preventing and detecting skin cancer on yourself and others. Perform regular self-examinations of your skin and note any changes.

WHEN TO CALL THE DOCTOR

Have your regular doctor or a skin specialist (dermatologist) check any suspicious moles or spots. Promptly make an appointment with your doctor to check your skin if you notice any changes in the size, shape, color, or texture of pigmented areas (such as darker areas of skin or moles).

WHEN TO GO TO THE HOSPITAL

In most cases, skin cancer can be diagnosed and treated entirely within the dermatologist’s office.

PHYSICIAN DIAGNOSIS

The dermatologist will examine any moles in question and, in many cases, the entire skin surface. Any lesions that are difficult to identify or are suspected to be skin cancer may then be checked. A sample of skin (biopsy) will be taken so that the suspicious area of skin can be examined under a microscope.

PHYSICIAN TREATMENT

Surgical removal is the mainstay of therapy for both BCC and SCC.

  • Small tumors may be removed through a variety of techniques including simple excision (cutting it away), electrodesiccation and curettage (burning the tissue with an electric needle), and cryosurgery (freezing the area with liquid nitrogen).
  • Larger tumors, lesions in high-risk locations, recurrent tumors, and lesions in cosmetically sensitive areas are removed by Mohs micrographic surgery. The surgeon carefully removes tissue, layer by layer, until cancer-free tissue is reached.
  • People who are poor surgical candidates may be treated by external radiation therapy.
  • Malignant melanoma is treated more aggressively than just surgical removal. To ensure the complete removal of this dangerous malignancy, 1-3 cm of normal-appearing skin surrounding the tumor is also removed.
    • Depending on the thickness of the melanoma, some doctors may take samples of lymph nodes, perform blood work, or order chest x-rays.
    • In advanced cases, trials of immune therapies, vaccines, or chemotherapy may be used. Because of the complexity of these decisions, people with malignant melanoma may benefit from the combined expertise of the dermatologist, a cancer surgeon, and a medical oncologist (cancer specialist).

PROGNOSIS

Although the number of skin cancers in the US continues to rise, medical consumers and their doctors are catching skin cancer earlier when it is easier to treat. Thus, illness and death rates have decreased.

  • When treated properly, the cure rate for both BCC and SCC approaches 95%. Those that do recur most often do so locally and cause significant tissue destruction. Less than 1% of SCC will eventually spread elsewhere in the body and turn into dangerous cancer.
  • The outcome of malignant melanoma depends in most cases on the thickness of the tumor.
    • Early, thin lesions are almost always cured by simple surgery alone.
    • If detected later, thicker tumors may spread to other organs and result in death.
  • Of 40,300 people with malignant melanomas who were diagnosed in the US in 1997, the vast majority were cured. Yet, 7,300 deaths due to melanoma were reported.

PREVENTION

  • Limit sun exposure. Attempt to avoid the sun’s intense rays between 10 am and 2 pm.
  • Frequently apply sunscreens with sun protection factor (SPF) of at least 15 both before and during sun exposure. Select products that block both UVA and UVB light. The label will tell you.
  • If you are likely to sunburn, wear long sleeves and a wide-brimmed hat.
  • Avoid artificial tanning booths.
  • Conduct periodic self-examinations. With the help of mirrors and significant others, become comfortable with the appearance of your skin. Monthly self-examination will help you recognize any new or changing areas.

FOLLOW-UP

Most skin cancer is cured surgically in the doctor’s office. Those skin cancers that do recur, however, most often do so within 3 years. So follow up with a dermatologist (skin specialist) as often as your doctor suggests. Make an appointment immediately if you suspect a problem.

In the case of advanced malignant melanoma, the doctor may want to see you every few months. These visits may include total body skin examinations, regional lymph node checks, and periodic chest x-rays. Over time, follow-up appointments may be moved to once a year.

PICTURES

Malignant melanoma
skncncr_basalcell Basal cell carcinoma
skncncr_spreadmelan Superficial spreading melanoma, left breast.
(Photo courtesy of Susan M Swetter, MD, Director of Pigmented Lesion and Cutaneous Melanoma Clinic, Assistant Professor, Department of Dermatology, Stanford University Medical Center, Veterans Affairs Palo Alto Health Care System)
skncncr_footmelan Melanoma on the sole of the foot. Diagnostic punch biopsy site located at the top.
(Photo courtesy of Susan M Swetter, MD, Director of Pigmented Lesion and Cutaneous Melanoma Clinic, Assistant Professor, Department of Dermatology, Stanford University Medical Center, Veterans Affairs Palo Alto Health Care System)
skncncr_cheekmelan Melanoma, right lower cheek.
(Photo courtesy of Susan M Swetter, MD, Director of Pigmented Lesion and Cutaneous Melanoma Clinic, Assistant Professor, Department of Dermatology, Stanford University Medical Center, Veterans Affairs Palo Alto Health Care System)
skncncr_squamouscell Large sun-induced squamous cell carcinoma (skin cancer) on the forehead/temple
(Image courtesy of Dr. Glenn Goldman)

BIBLIOGRAPHY

  • Brown TJ, Nelson BR: Malignant melanoma: a clinical review. Cutis 1999 May; 63(5): 275-8, 281-4[Medline]
  • Lang PG: Malignant melanoma. Med Clin North Am 1998 Nov; 82(6): 1325-58[Medline].
  • Martinez JC, Otley CC: The management of melanoma and nonmelanoma skin cancer: a review for the primary care physician. Mayo Clin Proc 2001 Dec; 76(12): 1253-65[Medline].
  • Miller DL, Weinstock MA: Nonmelanoma skin cancer in the United States: incidence. J Am Acad Dermatol 1994 May; 30(5 Pt 1): 774-8[Medline].
  • Parker SL, Tong T, Bolden S, Wingo PA: Cancer statistics, 1997. CA Cancer J Clin 1997 Jan-Feb; 47(1): 5-27[Medline].
  • Skidmore RA, Flowers FP: Nonmelanoma skin cancer. Med Clin North Am 1998 Nov; 82(6): 1309-23, vi[Medline].

NOTE:

Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert.

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