May is Skin Cancer Awareness Month in this two part series, Dr. Long explores how to spot skin cancer, the need for self-skin exams, and how to protect yourself (and your family) from harmful ultraviolet rays from the sun.
ONE in FIVE Americans will be diagnosed with skin cancer in their lifetime. During a mole check, I am often asked how can the patient learn to distinguish good spots from bad spots like I can. After 16 years as a student of dermatology, it is still no easier to explain just “what” I see. Pattern recognition from years of observation and reviewing biopsy results affect my interpretation. If you want to learn to recognize skin cancer, you must learn what normal is. For the layperson, this means a monthly self-skin exam can help teach you “your” normal, so that you can learn to detect abnormal (and potentially cancerous lesions). Remember ANYONE can develop skin cancer.
What is skin cancer?
Skin cancer is the most common type of cancer in the US. While there are multiple types of cancers of the skin and its appendages, there are three main types:
- Basal Cell Carcinoma (BCC)
BCC is the most common type of skin cancer with over 4 MILLION new cases diagnosed each year in the US. While they are not considered life-threatening, these tumors can be sneaky and grow with finger-like projections. Over time, they can lead to significant disfigurement and have been referred to as “rodent ulcers”.
- Squamous Cell Carcinoma (SCC)
SCC is the second most common type of skin cancer (> 1 MILLION cases in the US per year). A small percentage of these tumors can metastasize (move to distant body sites) and be life threatening. There are roughly 15,000 deaths from SCC of the skin each year in the US.
- Malignant Melanoma (MM)
Melanoma is the third most common type of skin cancer, but it is the deadliest of the three. Melanoma kills 1 person every hour. If it is detected early, however, cure rates are high. Most melanomas arise de novo (as a new spot on the skin) and not from pre-existing moles.
Other less common types of skin cancers include merkel cell carcinoma, Kaposi’s sarcoma, cutaneous lymphomas, skin adnexal tumors (cancers of hair follicles or sweat glands), as well as various sarcomas.
While skin cancer may be more common in people with lighter skin, ANYONE can develop skin cancer.
What are “pre-cancers”?
Actinic Keratoses (AKs) are the most common type of pre-cancer in the skin and affect over 58 MILLION Americans each year. They are found on chronically sun exposed skin (face, ears, neck, chest, arms, hands, and lower legs). They appear as reddish, rough, crusty growths that may sting or burn after shaving or washing the skin. Early lesions may not be visible, but may feel like sandpaper. They can come and go. Rarely, they may bleed.
What spots are suspicious? What does skin cancer “look” like?
Dermatology is a visual specialty that involves an enormous amount of pattern recognition that is often difficult to communicate well with the layperson. In general, a new spot that will not heal or an old spot that suddenly changes or starts to itch, bleed or become painful is cause for concern. Check out the American Cancer Society website for more pictures of skin cancer as studies show the more images of skin cancer you see, the better able you will be to recognize it.
What to look for: Basal Cell Carcinoma (BCC)
The classic medical description of a BCC is of the pearly telangiectatic papule with a central dell. To the layperson, BCC may appear as a smooth shiny raised growth with prominent blood vessels. With time, the center of the growth may become depressed and have an open crusted sore. They may also present as rough, red eczema looking patches that do not heal with eczema treatments. Some BCCs look scar-like and depressed. Early BCC can be very subtle and resemble the pimples of rosacea (clue: rosacea spots come and go, BCC would not go away) or benign growths such as sebaceous hyperplasia, intradermal moles, or fibrous papules (clue: these benign lesions do not bleed and grow very slowly if at all once first noticed).
What to look for: Squamous Cell Carcinoma (SCC)
SCC can present as rapidly growing tender bumps with a central core, or as rough warty bumps or as thick tender “horns”. Some SCC can resemble eczema. Patients often note a painful “tack-like” sensation with direct pressure on the growth.
What to look for: Melanoma
Below is an explanation of the public health ABCDE Campaign and its shortcomings – i.e., why you need to look AND be looked at. In fact, up to 50% of melanomas are self-detected!
A – ASYMMETRY: We are taught that nature likes symmetry. Symmetry in 2 axes is great, but 1 axis can be okay, too. But some melanomas can be symmetric 😬
B – BORDER: A border should look smooth and regular. A jagged, angular border may suggest a melanoma. In general, an angular (rectanglular or triangular) border on a smooth brown spot always gets my attention. 🤔
C – COLOR: An even color is best in any shade from tan to deep brown. The presence of multiple colors especially the presence of red, black, or white within a mole is ABNORMAL and should be evaluated by a dermatologist. But some melanomas can have an even color. 😔
D – DIAMETER: A diameter of > 6mm or the “size of a pencil eraser.
Here’s where it gets more complicated. Melanomas start somewhere: early on they may be symmetric and have a smooth border to the naked eye. And they may be tiny! Well less than the size of a pencil eraser. Also, nodular melanomas and amelanotic melanomas may be smooth and even colored but grow rapidly. What clues exist to detect EARLY melanomas (AKA: melanoma in situ)?
E – EVOLVING: Changes in moles include color, size, shape, or a new symptom such as itching, tenderness or bleeding. “New” moles deserve special consideration especially after age 30 when one’s potential to make new moles decreases. Roughly 70% of melanomas arise de novo as melanoma. Only 30% of melanomas arise within pre-existing nevi. Thus, any perceived “change” in a mole should be addressed.
F – FUNNY LOOKING (AKA “The Ugly Duckling Sign”): The mole that stands out deserves attention. Most people with a lot of nevi (or moles) have signature features to their moles (= “signature nevi”). Examples of signature moles include:
- “Solid brown nevi” = smooth brown, symmetric moles of varying size that can be raised or flat
- “Solid pink nevi” = pink raised or flat moles that lack pigment
- “Fried egg nevi” = a dark brown slightly raised center (the yolk) with a lighter flat rim (the egg white)
- “Eclipse nevi” = a dark rimmed border with a lighter center. As the mole ages, the dark rim disappears and the central portion becomes raised.
- “Nevus en cockade/cockarde” = target like moles that resemble the tricolor cockades worn by supporters of the French Revolution
- “Halo nevi” = a mole surrounded by a light or white rim or “halo” of hypo- or depigmentation
- “Nevi with perifollicular hypopigmentation” = lighter colors surround the hair follicles within some moles and can give a speckled appearance
- “Non-pigmented melanocytic nevus” = “white” moles
- “Lentiginous nevi” = small deeply pigmented flat brown moles when numerous and mixed with other types of sunspots is called the “Cheetah Phenotype”
For more images of melanoma, check out the Melanoma Research Foundation melanoma photo gallery.
In short, it takes a bit of practice to recognize good and bad features in moles. It also takes comparing the various moles on your body and not just looking at ONE spot. Also, moles age with us and can change. Some types of moles will lose their color over time and become raised “tag moles” and that can be okay. Early detection of skin cancer, requires both the patient AND the dermatologist.
What happens during a “Mole Check” at RRD?
Mole checks are total skin exams. When you are checked into an exam room, you will be asked to disrobe. You will be given a “one size fits most” gown. Sadly, after 13 years in private practice, I have yet to find a satisfactory exam gown. (Any creatives with sewing skills would be appreciated – contact me here.) I prefer to start my exam at the top with an examination of the scalp and the face and then move caudally towards the back, buttocks, arms, hands, chest, abdomen, groin, legs and feet. I use a dermatoscope to closely examine any moles or suspicious growths. I then review with the patient any spots that he or she has noticed.
Any growths that appear abnormal by history (new or changing) or by look (ABCDEF or “ugly duckling” or intuition) or by dermoscopic features are biopsied (removed and sent for evaluation by a pathologist to determine if cancerous) or photographed to be serially monitored.
What is NOT a “mole”?
Moles are the layperson term for melanocytic nevi. Growths that are not made of melanocytes (the pigment making cells) are not “moles”. Follow the links below to other growths that are often concerning to patient but are not “moles”.
CHERRY ANGIOMA= a benign growth of blood vessels. These begin as tiny red specks and over time can grow into dark red or purple bumps that bleed with minor trauma. See pictures here.
SEBORRHEIC KERATOSIS = benign growth of the epidermis (squamous cells). They are generally rough and greasy and can flake off. They are not caused by ultraviolet light, but rather by genetics and are extremely COMMON. Click here to see images.
DERMATOFIBROMA = a firm scar-like growth that can be brown or flash-colored often with a rim of darker pigmentation. They are most common on the legs of women and result from minor trauma such as bug bites and shaving injuries. View more information and pictures.
What are the risk factors for skin cancer?
- Over 90% of NMSC are caused by ultraviolet (UV) light from the sun. If you spend a lot of the time unprotected outside for work or for leisure – you are at increased risk for skin cancer.
- Ultraviolet light from indoor tanning beds is a known carcinogen. If you have EVER used a tanning bed, you are increased risk for skin cancer.
- If you have fair hair, light eyes, or fair skin prone to freckles. See the skin type chart below to determine your risk.
- If you have a personal or family history of skin cancer, you have an increased risk of skin cancer.
- If you smoke, you have an increased risk of skin cancer (especially for SCC).
- If you have greater than 50 moles or a history of dysplastic moles, you have an increased risk of developing melanoma.
- If you have a history of blistering sunburns, you are at increased risk of developing skin cancer.
- If you have a history of an organ transplant, you have an increased risk of developing skin cancer (particularly SCC).
How are pre-cancers and skin cancers treated?
- Topical creams such as 5-fluorouracil or imiquimod or ingenol mebutate
- Chemical peels
- Local destructions with heat (electrodessication + curettage) or cold (cryotherapy).
- PDT (Photodynamic Therapy)
- Standard excisional surgery
- Mohs Micrographic Surgery
Treatments are selected based upon the type and location of a skin cancer. A biopsy is required to determine the type of cancer and how invasive or aggressive it may be. Follow this LINK to the Skin Cancer Foundation to explore a glossary of medical and procedural treatments.
Is skin cancer preventable?
Yes! Minimize your ultraviolet light exposure through REGULAR sun protection. AVOID tanning beds. QUIT smoking. GET CHECKED by a board-certified dermatologist and CHECK YOURSELF monthly. When caught early, skin cancer is CURABLE.
Download this Mini Skin Cancer Guide from the Skin Cancer Foundation and share with your loved ones.
Want More Facts About Skin Cancer:
- An Australian Handbook on Understanding Skin Cancer
- Skin Cancer Facts from the Skin Cancer Foundation
- American Academy of Dermatology Spot Skin Cancer site
Do you have one or more risk factors for skin cancer? Do you have a suspicious growth that is new or changing or causes pain or will not heal? Do you have a personal or family history of skin cancer?
Contact us at Red River Dermatology at 318-442-9395 to schedule a skin check to look for skin cancer and to discuss prevention and treatment strategies.