Is It Skin Cancer?

As a family practice physician, a task I routinely perform is a skin evaluation on each of my patients at least annually. I live and practice in Florida, so this is pretty important, but people everywhere can and do get skin cancers.

The best thing to do is, of course, to limit exposure to the sun, and when in the sun, wear gobs of the highest SPF sunblock you can find. Also, wear hats and sleeves. The amount of sun exposure in a lifetime DEFINITELY plays a role in your likelihood of having skin cancer. It also makes a noticeable difference in how the skin ages. If you have body parts with sagging, wrinkly skin, those parts are usually on sun-exposed areas, while the parts of you that don’t normally see the sun remain relatively youthful and elastic. (Why anyone would want to be a nudist is beyond me!)

There are three main types of skin cancers. There are others, but they are not common, and I can not cover them in this article. The ones I will emphasize are: Basal Cell Carcinoma, Squamous Cell Carcinoma, and Melanoma.

Melanoma is the worst of the bunch, in my opinion. It is the most likely to kill you. I hope that none of you ever have one, but statistically, it is becoming more and more commonplace, but no less lethal. The depletion of the ozone layer thanks to man’s propensity to manufacture large quantities of chlorofluorocarbons, is probably the greatest contributor to that trend.

A melanoma is usually a darkly pigmented, often black mole. It can be smooth and flat, or elevated and nodular. Usually, it is oddly-shaped, and asymmetrical. It doesn’t usually have a clean edge, but may be serrated, or feathered at the edges as opposed to having a sharp line of demarcation with the normal skin around it. There is even a melanoma that doesn’t have any of the color findings above. It can be red, or even flesh-colored. But the melanoma I have diagnosed most often has an appearance of an ink-stain. It literally looks like someone has dropped black ink in a splotch on their skin.

Melanoma is curable if caught very early. This is where you need to arm yourself with a bit of knowledge. I use and teach an old, probably outdated system of identifying melanomas, but it still works well, and it is reasonably easy to remember:

The ABCD system of diagnosing melanomas:

A = asymmetry (one half does not look like the other)

B = border irregularity (not straight and smooth, but jagged or spiculated like a star, or feathered, or blending)

C = color variation (black and white, or black and tan, or black and brown, or any variation with or without the black)

D = Diameter of 7 mm or more. 7mm is approximately the size of a pencil eraser. So, if you can take a No.2 pencil and cover your lesion entirely with the eraser tip, then it is less than 7mm (which is a favorable finding).

In addition to the above, any skin lesion that is changing visibly in size, shape, or color needs to be evaluated by a professional.

If you have a mole or a mark and ANY of the above apply, then you should have it evaluated by a physician – preferably a dermatologist, but a Family Practice Doctor or an Internist who has skin training can usually advise you appropriately. If caught early – which should be done with an excisional, full-thickness biopsy, these are curable with wide excision. That is, if the biopsy is positive for melanoma and if the biopsy didn’t leave any of the cancer behind, then the area is re-excised taking at least a full centimeter of tissue in all directions – no matter what that tissue is. Even if it is on a face. Of course, this should be done by a plastic or maxillofacial surgeon in most cases. Then, you will need frequent follow-ups for a couple of years afterward. A lymph node exam is also mandatory to look for early spread of the cancer to lymph nodes. If caught too late, melanoma spreads all over the body, and is incurable, and doesn’t respond well to chemotherapy. Other notes about melanoma: it can be elusive. It can look like just about anything else, including normal skin. For this reason, the only way to be sure you don’t have a melanoma is to biopsy the lesion. Also, melanoma, while made more likely with excessive sun exposure, can occur in people who don’t even get much sun, and it can occur in parts of the body where there is little sun exposure anyway – like under a toenail or fingernail. I think that everyone should have an annual skin inspection, head to toe just for the purpose of catching potential melanomas. Melanoma is an adversary worthy of more respect than the general public tends to give it.

The good news is that the other two skin cancers are not as vicious as melanoma. Squamous Cell and Basal Cell cancers are more common than melanomas, and they tend to look different. Rather than being darkly pigmented, they usually are red, and ulcerated or scaly. Most of the time, they just look like a sore or a scab that either won’t go away, or keeps coming back in the same place over and over again. They definitely favor sun-exposed areas like faces, foreheads, lips, noses and ears, forearms hands and backs of necks. If you look closely at a Squamous cell or Basal Cell cancer, it often has red or purple tiny blood vessels growing into it that are big enough to be seen with the eye. This is because cancers actually make a hormone that stimulates blood vessels to grow into them. Cancers tend to grow faster than normal tissue and thus need added blood to feed their hungry cells.

Basal Cell and Squamous Cell cancers are much less likely to metastasize (spread) to other parts of the body, but if negleted for years and allowed to grow very large, they can spread or grow into neighboring body parts. Otherwise, they are curable if they can be cut out entirely with an excisional biopsy. If they are small, then they can be treated with cryosurgery (freezing) or even topical chemotherapy (Efudex or 5-fluorouracil). The good news is that Basal Cell and Squamous Cell cancers are relatively easy to treat and cure. The bad news is that once you have one, you are at much higher risk to develop others.

Although not a skin cancer, there is an exceedingly common type of skin lesion that bears mention because it is Pre-cancerous. Actinic Keratosis is a small, sandpapery lesion, that most often occurs on forearms and faces, as well as the tops of the ears. They are often too small or subtle to see with the naked eye, but they can be felt to the touch. These, if you have them should be frozen by your doctor because they will probably one day turn into skin cancers.

Some final thoughts. Because our bodies manufacture Vitamin D in the skin in the presence of sunlight, it is highly likely that a significant proportion of adult humans will be deficient in Vitamin-D. The good news is that it is easy to take Vitamin-D3 as a supplement tablet, and most of us should probably be taking in at least 1,000mg daily. Unfortunately, Vitamin-D is fat soluble, which means that it can accumulate and become toxic if you get too much, so at some point in time, I recommend that everyone have a Vitamin D blood test done. Still, because lack of Vitamin D can cause serious diseases like rickets, osteoporosis, and even diabetes, it is probably safe for most adults to take the supplement if you know that you are not getting any significant sun exposure. It is said that the average adult can manufacture enough vitamin D with a daily dose of 15 minutes of direct sun exposure. I think that 15 minutes is way too much and that doing this daily would cause an unacceptable skin cancer risk. I do not know this for certain, but I think that if you apply sunblock as I have advised, you will prevent much of that Vitamin D from being made. What to do? Take the supplement, when you are able to, get your blood tested at least once in a lifetime.

Keep babies out of the sun, and slather children with SPF 45 or higher sunblock, repeating applications every hour or two. As we age, our skins develop some protective pigmentation, but children do not have that yet. As a result a great many of the skin cancers people develop as adults actually stem from sunburns they received when they were children. This problem is only going to get worse as the ozone is further depleted.

Finally, everyone should have a skin check from head to toe once a year, preferably by a doctor, but if that isn’t possible, have someone you trust look you over and comment on anything out of the ordinary. I have found several melanomas on people’s backs when they had no clue that there was anything there at all. Use the ABCD scoring system. It is designed for melanomas, but it does a pretty good job of picking up most of the other cancers too. Wear hats. Lots of the more disfiguring skin cancers occur on the face, and their repairs can be expensive and require multiple procedures. Also, for men, a bald scalp is like a baby’s skin in that it never developed the protective defenses that other areas do.

Good Health to all