Skin cancer is the most common of cancers, affecting an estimated 1.3 million Americans each year. With rates of newly diagnosed cases rising at a rate of 4 to 5 percent annually, skin cancer continues to be is a veritable epidemic. Three cancers of the skin comprise this category of sun-induced cancer: the basal cell (BCC), the squamous cell (SCC) carcinoma, and of course malignant melanoma.

Ultraviolet exposure and sun damage is the leading factor to developing skin cancer. Damaging rays create cellular DNA damage and ultimately skin cancer. Under normal circumstances, skin has a repair system that literally cuts out damaged DNA and replaces it with new, healthy code. Genetics play a role in one's ability to repair the damage. But too much ultraviolet damage may simply overwhelm the system.

Obviously lighter skin is more prone to becoming sun burned. Red heads and fair blondes with blue eyes are notorious for developing skin cancer. A lifelong history of sun exposure places one at higher risk. Take for instance those raised on farms, veterans of WWII who were stationed in the South Pacific, construction workers and basically anyone who spent a lot of time outdoors. In addition, patients who are immunosuppressed, especially transplant patients, are quite likely to see rapid and early development of skin cancer (particularly squamous cell carcinoma). Regardless of race, anyone can develop skin cancer.

Basal Cell Carcinoma

The most common skin cancer, newly diagnosed cases of BCC will affect an estimated 800,000 Americans this year. That said, most have never heard of this form of skin cancer. Basal cell carcinomas earn their name from the location deep within the epidermis in which they form, the basal (or basement) layer. Basal cell carcinomas are traditionally slowly growing tumors of the skin. While they can grow quite large and invade spaces to which they're adjacent, they rarely metastasize to other areas of the body.

BCCs often look pearly. Pink or flesh-toned bumps (papules) slowly rise above the skin's surface. It's the pearlescent quality that gives them away. Given enough time, a basal cell carcinoma may go on to form a central ulceration (sore). Early basal cell carcinomas (superficial spreading basal cell aka SSBCC) resemble reddish dry skin patches that simply won't heal over months or even longer. They may also develop a pearly quality.

It's not unusual for patients claiming a longstanding "acne" bump that's been present for months, or years to find out it's really a BCC. Acne resolves spontaneously, skin cancer does not.

Diagnosis of a BCC involves a skin biopsy. Whether performed as a simple shave biopsy or a deeper punch, the basal cell carcinoma has easy diagnostic features. There is no concern about the spread of a BCC if cut through during the biopsy, unlike melanoma.

Treatment of a basal cell carcinoma is relatively straightforward.

• Simple Excision

  The skin is numbed with a local anesthetic and the visible area of skin cancer with a small margin of normal skin is excised and sutured closed. This allows the pathologist to determine if the entire skin cancer was removed.

• ED&C x 3

  An abbreviation for electrodessication and curettage, the affected area is cauterized and scraped 3 times after being numbed with a local anesthetic. A quick, simple method, ED& C x 3 is ideal for larger skin cancers on the torso (less excised skin), and for handling skin cancer on elderly or infirm patients unlikely to be able to care adequately for a large sutured area. The downfall is that no pathological confirmation certifying 100% eradication of the skin cancer exists. Typically ED&C x 3 has a 75-80% rate of successfully eliminating the BCC. Given the slow growth rate and the tendency for BCCs to remain localized, ED&C x 3 is an excellent option under the proper conditions.

• Mohs Micrographic Surgery

  Named for namesake and creator Dr. Frederick Mohs, this form of excision combines surgical excision with immediate surgical confirmation that the tumor has been fully removed. Under local anesthetic, the visible cancer is removed, processed for surgical path and microscopically accessed, all at the same time in the specialist's office. Should any remnant skin cancer remain, the edges are gradually removed, evaluated, etc. These steps are repeated as necessary to assure complete removal of the skin cancer and to preserve healthy uninvolved tissue. Mohs surgeons are typically dermatologists who have undergone an additional 1-2 years of training in this area. Mohs is particularly ideal for skin cancer involving the central face where protecting cosmetically important areas such as the nose is vital and is now the standard of care.

• Aldara

  A topical immune response modifier originally used to treat genital warts. The drug's ability to provoke local tissue production of tumor-fighting interferons and tumor necrosis factor-alpha has taken this medication to the forefront of basal cell carcinoma treatment. Multiple studies show the ability of topical imiquimod to resolve early SBCCs and more advanced basal cell carcinomas, and in 2004 the drug was approved to treat actinic keratoses (AKs), potential precursors of squamous cell carcinoma. Patients who are unable to undergo surgery and have very small BCCs may be potential candidates for this therapy.

Less commonly used treatment options include laser destruction, cryosurgery, radiation therapy, topical chemotherapy with 5-fluouracil, and photodynamic therapy (Levulan Kerastick for early BCCs). And there are ongoing clinical trials involving biologic agents similar to Aldara, PEPOO5 (which affects an enzyme that plays a role in cell development), and Celecoxib, a Cox-2 inhibitor.

Patients who have had a basal cell carcinoma should undergo a follow-up skin exam at least every 6 months for the first 5 years out from the time of treatment. I often revisit every 3 months for a few visits to keep my eye on ED& C sites to monitor for recurrence. It is during this time frame that the BCC would be most likely to recur. But it's important to realize that skin in the same region is more at risk for developing an entirely new skin cancer. A complete skin examination is recommended, not just a spot check of the surgery site.

Squamous Cell Carcinoma

Affecting about 200,000 in the U.S. per year, squamous cell carcinoma (SCC) is a more dangerous form of skin cancer as it's associated with a small risk (less than 1%) of spreading to other areas of the body. This results annually in approximately 2000 deaths.

Squamous cell carcinoma arises on sun-exposed, sun damaged skin. The more sun exposure, even cumulative sun acquired from routine "tanning" is associated with a higher risk of developing SCC. Squamous cell carcinoma may also form on areas exposed to chemicals, thermal burns, radiation, and occasionally within vaccination scars. Arsenic exposure is an uncommon though important risk factor. Arsenic was found in "old fashioned" cough and cold treatments predominantly in the Southeastern U.S. More recently, arsenic exposure is typically associated with pesticide use.

Typically looking like a hard, sometimes scaly or crusty red bump or nodule, squamous cell carcinoma continues to grow in height and diameter until removed. Ulceration, itching and bleeding may develop. Squamous cell carcinomas may arise from precancerous skin changes known as actinic keratoses that resemble chronic reddish brown scaly patches on sun-exposed skin.

Due to the somewhat higher risk of squamous cell carcinoma of the skin to metastasize (spread to other areas of the body), the best option for treatment is one that guarantees complete removal. Straightforward excision or Mohs micrographic surgery would both be appropriate options. Here again, in patients who may be unable for some reason to undergo a full excision, other options may be appropriate in certain cases. These include laser destruction, ED&C x 3, radiation therapy, cryosurgery and treatment with 5-fluoruracil. Clinical trials are ongoing with the use of biologic therapies alone and with retinoids as well.

Follow-up again mirrors that of basal cell carcinoma patients. Because of the low potential for metastasis, quarterly skin checks are best. It's important to remember that if one form of skin cancer develops, the level of sun damage has been reached that patients are at higher risk to develop any or all of them. Vigilance is the best bet for early detection and intervention.

Melanoma

By far the most lethal of these 3 skin cancers, melanoma is responsible for 7400 deaths a year in the U.S. Arising from pigment producing cells known as melanocytes, melanoma is associated with moles (medically termed nevi). The vast majority of moles are visible on the skin, and brown in color. Rarely, moles may be pink or red, (amelanotic) and there are even moles which can be hidden internally, such as at the back of the eye.

Fortunately, moles don't change into Melanoma overnight. Gradually moles will go through a series of changes (some faster than others) known as dysplasia. The greater the degree of dysplasia, the more likely the mole may turn into melanoma.

Early detection is key since melanoma is almost 100 percent curable if discovered early. Famous people who have survived melanoma include Troy Aikman, Sam Donaldson and Senator John McCain.

While easy to detect, many symptomatic moles go ignored. According to The Melanoma Research Foundation, every hour of every day of the year an American dies of malignant melanoma.

While the American Academy of Dermatology doesn't expect the general public to be home dermatologists, there are 4 signs to know that can save your life. These are the ABCD [and now Es] of melanoma.

A: Asymmetry. The mole is not completely even in appearance.
B: Border. The margins should be even and smooth, without ratty or projecting edges.
C: Circumference. The mole should be nice and round, without jagged or sharp edges
D: Diameter. The size of the mole should not be more than 6mm measured across the mole. This is the size of a pencil eraser.
E: Evolving (changes) - Any changes over time in size, shape, symptoms (itching, tenderness), surface (bleeding, scaling, inflammation), and shades of color.

Other signs to pay close attention to include rapid mole growth, formation of a sore, and itching or bleeding within the mole.

The above signs and symptoms do not automatically mean the mole is malignant or even dysplastic. But, these are definitely a reason to seek out a dermatology evaluation.

Biopsy of a suspicious mole should consist of a full excision around the area unless the mole is so large that this is impossible for some unusual reason. The excision would be performed under a local anesthetic and the area closed with stitches. If melanoma were diagnosed, unless the margins were significantly clear (a minimum of a 5mm border), then a reexcision would be performed.

The prognosis for melanoma is based upon the depth of the mole (how deeply it has grown). Further work-up and treatment are based upon this very important measurement. That is why simply shaving through a suspicious mole or lasering it off without a path report is inappropriate.

As for follow-up, for "routine" simple excision took care of it melanoma patients, certainly a complete skin examination (CSE) performed every 3 months, ultimately extending to no longer than once a year is appropriate for melanoma patients. I also include an ophthalmology appointment (looking for hidden moles at the back of the eyes), chest x-ray, blood work and sometimes a CT scan (patient history dependent).

Melanoma tends to have some genetic predisposition. For anyone with a primary family history of melanoma (parents and sibs), a complete skin examination and eye exam once a year is a starting point. Those who have large number of moles or dysplastic nevus syndrome (multiple changing moles) would be screened more often.

When it comes to prevention, by now everyone is more than familiar with these tips. Let me just recap those steps we simply can't do without:

• Sun Avoidance Try to avoid being outdoors during the hours of 11-3 when sun is at its strongest.
• Sunscreen Use Only use broad-spectrum screens or blocks that protect against UVA and UVB rays. An SPF 15 should be considered entry level minimum protection, so skip those products with an SPF of less than 15. Try DERMAdoctor Body Guard Exquisitely Light SPF 30 For Face & Body or Total Block Clear SPF 65 (the latter is ideal for anyone with a prior history of skin cancer or AKs).
• Tanning Bed Avoidance The smoking ban of the new millennium? Skip the tanning beds; they're far more dangerous than an unprotected day at the beach.
• UV Treated Sunglasses Protecting the eyes makes sense; helps prevent ultraviolet damage against melanoma as well as helps save your sight.
• SPF Treated Clothing It's so easy to do. Throw in a packet of Sun Guard Laundry Treatment UV Protectant in with your laundry and give your clothing an SPF 30 (over a mundane SPF 4).
• Don't Forget The Lips - The darkest shade of lipstick has only an SPF of 5, leaving lips vulnerable at best. Actinic damage followed by BCCs or SCCs may result. Apply a separate sunscreen made specially for the lips. Consider trying B. Kamins Lip Balm SPF 20.
• Complete Skin Examination Don't have access to a dermatologist? Take advantage of any number of free skin cancer screenings performed across the U.S. every May during Skin Cancer Awareness Month.
• Awareness Being aware is half the battle. Don't ignore symptoms.

Rapid growth of a mole, itching, bleeding, crusting, or sore formation within ANY skin lesion should be checked. The good news is that when most patients follow up on these signs, either the lesion isn't melanoma/skin cancer or they get their condition diagnosed in the early stages when it's curable. It's easier than you think to help save your life.

Thank you for taking the time to read through this important information. I hope you have found this article informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

www.dermadoctor.com
Copyright 2000-2012, DERMAdoctor, Inc., All rights reserved.

Click here for permission to use this copyrighted content.