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DERMATOLOGY
LIST OF DERMATOLOGISTS IN THE AREA THAT WE USE
- 57 Bedford Street, Lexington : Lisa Arbesfeld, Stuart Arbesfeld, Jill Slater-Freedberg, Marion Buchsbaum : 781-862-2322
- 625 Mt Auburn Street, Cambridge : Derm Assoc of Concord : 617-354-5658
- 355 Waverley Oaks Road, Waltham : Derm Assoc of Concord : 617-354-5658
- 290 Baker Avenue, Concord : Derm Assoc of Concord : 978-369-9023
- 22 Mill Street, Suite 310, Arlington : Barry Paul and Kendra Martin : 781-643-0500
- 777 Concord Avenue, Cambridge : Dermcare physicians : Helen Raynham (Fridays)
- 22 Mill Street, Suite 304, Arlington : Dermcare physicians : 781-641-4900
- 1244 Boylston St, Chestnut Hill : SkinCare Physicians : Kay Kane : 617-731-1600
Want to know more about a particular skin problem?
Click on this link.
Skin Cancer :
Know the warning signs
Skin cancer — the abnormal growth of skin cells — most often develops on skin exposed to the sun. But this common form of cancer can also occur on areas of your skin not ordinarily exposed to sunlight.
There are three major types of skin cancer
Skin cancer develops primarily on areas of sun-exposed skin, including the scalp, face, lips, ears, neck, chest, arms and hands, and on the legs in women. But it can also form on areas that rarely see the light of day — your palms, beneath your fingernails, the spaces between your toes or under your toenails, and your genital area.
Skin cancer affects people of all skin tones, including those with darker complexions. When melanoma occurs in those with dark skin tones, it's more likely to occur in areas not normally considered to be sun-exposed.
A cancerous skin lesion can appear suddenly or develop slowly. Its appearance depends on the type of cancer.
Basal cell carcinoma
This is the most common skin cancer. It's also the most easily treated and the least likely to spread. Basal cell carcinoma usually appears as one of the following:
Squamous cell carcinoma is easily treated if detected early, but it's slightly more apt to spread than is basal cell carcinoma. Most often, squamous cell carcinoma appears as one of the following:
This is the most serious form of skin cancer and the one responsible for most skin cancer deaths. Melanoma can develop anywhere on your body, in otherwise normal skin or in an existing mole that turns malignant. Melanoma most often appears on the trunk, head or neck of affected men. In women, this type of cancer most often develops on the arms or legs.
Warning signs of melanoma include:
Not all skin changes are cancerous. The only way to know for sure is to have your skin examined by your doctor or dermatologist.
Skin cancer begins in your skin's top layer — the epidermis. The epidermis is as thin as a pencil line, and it provides a protective layer of skin cells that your body continually sheds. The epidermis contains three main types of cells:
The role of UV light
Much of the damage to DNA in skin cells results from ultraviolet (UV) radiation found in sunlight and in commercial tanning lamps and tanning beds. UV light is divided into three wavelength bands — ultraviolet A (UVA), ultraviolet B (UVB) and ultraviolet C (UVC). Only UVA and UVB rays reach the earth. UVC radiation is completely absorbed by atmospheric ozone.
At one time scientists believed that only UVB rays played a role in the formation of skin cancer. And UVB light does cause harmful changes in skin cell DNA, including the activation of oncogenes — a type of gene that, when turned on, can turn a normal cell into a malignant one. UVB rays are responsible for sunburn and for many basal cell and squamous cell cancers.
But UVA also contributes to skin cancer. It penetrates the skin more deeply than UVB does, even through window glass, weakens the skin's immune system and increases the risk of cancer, especially melanoma. Tanning beds deliver high doses of UVA, which makes them especially dangerous.
Other factors that may contribute to skin cancer
Sun exposure doesn't explain melanomas or other skin cancers that develop on skin not ordinarily exposed to sunlight. Heredity may play a role. Skin cancer can also develop from exposure to toxic chemicals or as a result of radiation treatments.
These factors may increase your risk of skin cancer:
When to seek medical advice
If you notice any suspicious change in your skin, consult your doctor right away. As with most cancers, early detection increases the chances of successful treatment. Don't wait for the area to start hurting — skin cancer seldom causes pain.
See your doctor if you notice a new skin growth, a bothersome change in your skin, a change in the appearance or texture of a mole, or a sore that doesn't heal in two weeks. Your doctor may suspect cancer by simply looking at your skin. But to properly diagnose skin cancer, your doctor or dermatologist will need to take a small sample of your skin (biopsy) for analysis in a lab. A biopsy can usually be done in a doctor's office using a local anesthetic.
Skin cancer is generally divided into two stages:
Treatments and drugs
Treatment for skin cancer and the precancerous skin lesions known as actinic keratoses varies, depending on the size, type, depth and location of the lesions. Often the abnormal cells are surgically removed or destroyed with topical medications. Most skin cancer treatments require only a local anesthetic and can be done in an outpatient setting. Sometimes no treatment is necessary beyond an initial biopsy that removes the entire growth.
If additional treatment is needed, options may include:
Treatments for skin cancer under study include:
Most skin cancers are preventable. To protect yourself, follow these skin cancer prevention tips:
Self-examination: A guide
To detect melanomas or other skin cancers, use the A-B-C-D-E skin self-examination guide, adapted from the American Academy of Dermatology:
June 3, 2008
© 1998-2010 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only.
There are three major types of skin cancer
- basal cell carcinoma,
- squamous cell carcinoma
- melanoma, which is the most serious of skin cancer.
Skin cancer develops primarily on areas of sun-exposed skin, including the scalp, face, lips, ears, neck, chest, arms and hands, and on the legs in women. But it can also form on areas that rarely see the light of day — your palms, beneath your fingernails, the spaces between your toes or under your toenails, and your genital area.
Skin cancer affects people of all skin tones, including those with darker complexions. When melanoma occurs in those with dark skin tones, it's more likely to occur in areas not normally considered to be sun-exposed.
A cancerous skin lesion can appear suddenly or develop slowly. Its appearance depends on the type of cancer.
Basal cell carcinoma
This is the most common skin cancer. It's also the most easily treated and the least likely to spread. Basal cell carcinoma usually appears as one of the following:
- A pearly or waxy bump on your face, ears or neck
- A flat, flesh-colored or brown scar-like lesion on your chest or back
Squamous cell carcinoma is easily treated if detected early, but it's slightly more apt to spread than is basal cell carcinoma. Most often, squamous cell carcinoma appears as one of the following:
- A firm, red nodule on your face, lips, ears, neck, hands or arms
- A flat lesion with a scaly, crusted surface on your face, ears, neck, hands or arms
This is the most serious form of skin cancer and the one responsible for most skin cancer deaths. Melanoma can develop anywhere on your body, in otherwise normal skin or in an existing mole that turns malignant. Melanoma most often appears on the trunk, head or neck of affected men. In women, this type of cancer most often develops on the arms or legs.
Warning signs of melanoma include:
- A large brownish spot with darker speckles located anywhere on your body
- A simple mole located anywhere on your body that changes in color, size or feel or that bleeds
- A small lesion with an irregular border and red, white, blue or blue-black spots on your trunk or limbs
- Shiny, firm, dome-shaped bumps located anywhere on your body
- Dark lesions on your palms, soles, fingertips and toes, or on mucous membranes lining your mouth, nose, vagina and anus
Not all skin changes are cancerous. The only way to know for sure is to have your skin examined by your doctor or dermatologist.
Skin cancer begins in your skin's top layer — the epidermis. The epidermis is as thin as a pencil line, and it provides a protective layer of skin cells that your body continually sheds. The epidermis contains three main types of cells:
- Squamous cells lie just below the outer surface and function as the skin's inner lining.
- Basal cells, which produce new skin cells, sit beneath the squamous cells.
- Melanocytes — which produce melanin, the pigment that gives skin its normal color — are located in the lower part of your epidermis. Melanocytes produce more melanin when you're in the sun to help protect the deeper layers of your skin. Extra melanin produces the darker color of tanned skin.
The role of UV light
Much of the damage to DNA in skin cells results from ultraviolet (UV) radiation found in sunlight and in commercial tanning lamps and tanning beds. UV light is divided into three wavelength bands — ultraviolet A (UVA), ultraviolet B (UVB) and ultraviolet C (UVC). Only UVA and UVB rays reach the earth. UVC radiation is completely absorbed by atmospheric ozone.
At one time scientists believed that only UVB rays played a role in the formation of skin cancer. And UVB light does cause harmful changes in skin cell DNA, including the activation of oncogenes — a type of gene that, when turned on, can turn a normal cell into a malignant one. UVB rays are responsible for sunburn and for many basal cell and squamous cell cancers.
But UVA also contributes to skin cancer. It penetrates the skin more deeply than UVB does, even through window glass, weakens the skin's immune system and increases the risk of cancer, especially melanoma. Tanning beds deliver high doses of UVA, which makes them especially dangerous.
Other factors that may contribute to skin cancer
Sun exposure doesn't explain melanomas or other skin cancers that develop on skin not ordinarily exposed to sunlight. Heredity may play a role. Skin cancer can also develop from exposure to toxic chemicals or as a result of radiation treatments.
These factors may increase your risk of skin cancer:
- Fair skin. Having less pigment (melanin) in your skin provides less protection from damaging UV radiation. If you have blond or red hair, light-colored eyes, and you freckle or sunburn easily, you're much more likely to develop skin cancer than is a person with darker features.
- A history of sunburns. Every time you get sunburned, you damage your skin cells and increase your risk of developing skin cancer. After a sunburn, your body works to repair the damage. Having multiple blistering sunburns as a child or teenager increases your risk of developing skin cancer as an adult. Sunburns in adulthood also are a risk factor.
- Excessive sun exposure. Anyone who spends considerable time in the sun may develop skin cancer, especially if your skin isn't protected by sunscreen or clothing. Tanning also puts you at risk. A tan is your skin's injury response to excessive UV radiation.
- Sunny or high-altitude climates. People who live in sunny, warm climates are exposed to more sunlight than are people who live in colder climates. Living at higher elevations, where the sunlight is strongest, also exposes you to more radiation.
- Moles. People who have many moles or abnormal moles called dysplastic nevi are at increased risk of skin cancer. These abnormal moles — which look irregular and are generally larger than normal moles — are more likely than others to become cancerous. If you have a history of abnormal moles, watch them regularly for changes.
- Precancerous skin lesions. Having skin lesions known as actinic keratoses can increase your risk of developing skin cancer. These precancerous skin growths typically appear as rough, scaly patches that range in color from brown to dark pink. They're most common on the face, lower arms and hands of fair-skinned people whose skin has been sun damaged.
- A family history of skin cancer. If one of your parents or a sibling has had skin cancer, you may be at increased risk of the disease. Some families are affected by a condition called familial atypical mole-malignant melanoma (FAMMM) syndrome. The hallmarks of FAMMM include a history of melanoma in one or more close relatives and having more than 50 moles — some of which are atypical. Because people with this syndrome have an extremely high risk of developing melanoma, frequent screening for signs of skin cancer is crucial.
- A personal history of skin cancer. If you developed skin cancer once, you're at risk of developing it again. Even basal cell and squamous cell carcinomas that have been successfully removed can recur in the same spot, often within two to three years.
- A weakened immune system. People with weakened immune systems are at greater risk of developing skin cancer. This includes people living with HIV/AIDS or leukemia and those taking immunosuppressant drugs after an organ transplant.
- Fragile skin. Skin that has been burned, injured or weakened by treatments for other skin conditions is more susceptible to sun damage and skin cancer. Certain psoriasis treatments and eczema creams might increase your risk of skin cancer.
- Exposure to environmental hazards. Exposure to environmental chemicals, including some herbicides, increases your risk of skin cancer.
- Age. The risk of developing skin cancer increases with age, primarily because many skin cancers develop slowly. The damage that occurs during childhood or adolescence may not become apparent until middle age. Still, skin cancer isn't limited to older people. Basal cell and squamous cell carcinomas are increasing fastest among women younger than 40.
When to seek medical advice
If you notice any suspicious change in your skin, consult your doctor right away. As with most cancers, early detection increases the chances of successful treatment. Don't wait for the area to start hurting — skin cancer seldom causes pain.
See your doctor if you notice a new skin growth, a bothersome change in your skin, a change in the appearance or texture of a mole, or a sore that doesn't heal in two weeks. Your doctor may suspect cancer by simply looking at your skin. But to properly diagnose skin cancer, your doctor or dermatologist will need to take a small sample of your skin (biopsy) for analysis in a lab. A biopsy can usually be done in a doctor's office using a local anesthetic.
Skin cancer is generally divided into two stages:
- Local. In this stage, cancer affects only the skin.
- Metastatic. At this point, cancer has spread beyond the skin.
Treatments and drugs
Treatment for skin cancer and the precancerous skin lesions known as actinic keratoses varies, depending on the size, type, depth and location of the lesions. Often the abnormal cells are surgically removed or destroyed with topical medications. Most skin cancer treatments require only a local anesthetic and can be done in an outpatient setting. Sometimes no treatment is necessary beyond an initial biopsy that removes the entire growth.
If additional treatment is needed, options may include:
- Freezing. Your doctor may destroy actinic keratoses and some small, early skin cancers by freezing them with liquid nitrogen (cryosurgery). The dead tissue sloughs off when it thaws. The treatment may leave a small, white scar. You may need a repeat treatment to remove the growth completely.
- Excisional surgery. This type of treatment may be appropriate for any type of skin cancer. Your doctor cuts out (excises) the cancerous tissue and a surrounding margin of healthy skin. A wide excision — removing extra normal skin around the tumor — may be recommended in some cases. To minimize or avoid scarring, especially on your face, you may need to consult a doctor skilled in skin reconstruction.
- Laser therapy. A precise, intense beam of light vaporizes growths, generally with little damage to surrounding tissue and with minimal bleeding, swelling and scarring. A doctor may use this therapy to treat superficial skin cancers or precancerous growths on lips.
- Mohs surgery. This procedure is for larger, recurring or difficult-to-treat skin cancers, which may include both basal and squamous cell carcinomas. Your doctor removes the skin growth layer by layer, examining each layer under the microscope, until no abnormal cells remain. This procedure allows cancerous cells to be removed without taking an excessive amount of surrounding healthy skin. Because it requires special skill, the surgery should be done only by specially trained doctors.
- Curettage and electrodesiccation. After removing most of a growth, your doctor scrapes away layers of cancer cells using a circular blade (curet). An electric needle destroys any remaining cancer cells. This simple, quick procedure is common in treating small or thin basal cell cancers. It leaves a small, flat, white scar.
- Radiation therapy. Radiation may be used to destroy basal and squamous cell carcinomas if surgery isn't an option.
- Chemotherapy. In chemotherapy, drugs are used to kill cancer cells. For cancers limited to the top layer of skin, creams or lotions containing anti-cancer agents may be applied directly to the skin. Topical drugs can cause severe inflammation and leave scars. Systemic chemotherapy can be used to treat skin cancers that have spread to other parts of the body.
Treatments for skin cancer under study include:
- Photodynamic therapy (PDT). This treatment destroys skin cancer cells with a combination of laser light and drugs that makes cancer cells sensitive to light. Photodynamic therapy for precancerous skin lesions is currently available by prescription. If you have PDT, you will need to avoid direct sunlight for at least six weeks after treatment.
- Biological therapy (also called immunotherapy). Immunotherapy medications such as interferon and interleukin-2 are under study to treat melanoma and nonmelanoma skin cancers. These types of drugs stimulate your immune system to fight cancer. Other medications applied to your skin, such as imiquimod (Aldara), enhance your immune reaction to skin cancer.
Most skin cancers are preventable. To protect yourself, follow these skin cancer prevention tips:
- Avoid the sun between 10 a.m. and 4 p.m. Because the sun's rays are strongest during this period, try to schedule outdoor activities for other times of the day, even in winter or when the sky is cloudy. You absorb UV radiation year-round, and clouds offer little protection from damaging rays. Remember, sunburns and suntans cause skin damage that can increase your risk of developing skin cancer. Sun exposure accumulated over time also may cause skin cancer.
- Wear sunscreen year-round. Sunscreens don't filter out all harmful UV radiation, especially the radiation that can lead to melanoma. But they play a major role in an overall sun protection program. Sunscreens that contain ingredients such as titanium dioxide and mexoryl do a better job at blocking UVA rays. Choose a broad-spectrum sunscreen that has a sun protection factor (SPF) of at least 15. Use a generous amount of sunscreen on all exposed skin, including your lips, the tips of your ears, and the backs of your hands and neck.
For the most protection, apply sunscreen 20 to 30 minutes before sun exposure and reapply it every two hours throughout the day, as well as after swimming or exercising. Apply sunscreen to young children before they go outdoors, and teach older children and teens how to use sunscreen to protect themselves. Keep sunscreen in your car as well as with your gardening tools, and sports and camping gear.
- Wear protective clothing. Sunscreens don't provide complete protection from UV rays. That's why it's a good idea to also wear dark, tightly woven clothing that covers your arms and legs, and a broad-brimmed hat, which provides more protection than a baseball cap or visor does. Some companies also sell photoprotective clothing. A dermatologist can recommend an appropriate brand. Don't forget sunglasses. Look for those that block both UVA and UVB rays.
- Avoid tanning beds and tan-accelerating agents. Tanning beds emit UVA rays, which may be as dangerous as UVB rays — especially since UVA light penetrates deeper into your skin and causes precancerous skin lesions.
- Be aware of sun-sensitizing medications. Some common prescription and over-the-counter drugs — including antibiotics; certain cholesterol, high blood pressure and diabetes medications; birth control pills; nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin, others); and the acne medicine isotretinoin (Accutane) — can make your skin more sensitive to sunlight. Ask your doctor or pharmacist about the side effects of any medications you take. If they increase your sensitivity to sunlight, be sure to take extra precautions.
- Check your skin regularly and report changes to your doctor. Examine your skin often for new skin growths or changes in existing moles, freckles, bumps and birthmarks. With the help of mirrors, check your face, neck, ears and scalp. Examine your chest and trunk, and the tops and undersides of your arms and hands. Examine both the front and back of your legs, and your feet, including the soles and the spaces between your toes. Also check your genital area, and between your buttocks.
- Have regular skin exams. Consult your doctor for a complete skin exam every year if you're older than 40, or more often if you're at high risk of developing skin cancer.
Self-examination: A guide
To detect melanomas or other skin cancers, use the A-B-C-D-E skin self-examination guide, adapted from the American Academy of Dermatology:
- A is for asymmetrical shape. Look for moles with irregular shapes, such as two very different-looking halves.
- B is for irregular border. Look for moles with irregular, notched or scalloped borders — the characteristics of melanomas.
- C is for changes in color. Look for growths that have many colors or an uneven distribution of color.
- D is for diameter. Look for growths that are larger than about 1/4 inch (about 6 millimeters).
- E is for evolving. Look for changes over time, such as a mole that grows in size or that changes color or shape. Moles may also evolve to develop new signs and symptoms, such as new itchiness or bleeding.
June 3, 2008
© 1998-2010 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only.
Skin-Cancer Groups Push for More Checkups
Melanoma is on the rise, particularly in people younger than age 30.
Laura Landro : WSJ : September 2, 2013
With current estimates that 1 in 5 Americans will develop skin cancer in their lifetime, dermatologists and cancer groups are stepping up efforts to screen patients at least once a year and teach them to perform their own self-exams as often as monthly.
Doctors are creating photographic "mole maps" to track changes over time, and some dermatologists are turning to a new, noninvasive device that helps determine which moles should be biopsied for melanoma, the deadliest form of skin cancer.
What to Look For Skin Cancer Warning Signs
Unexpected Spots
Skin cancer can occur even in spots usually not exposed to sunlight. Some areas of the body people may fail to check:
Skin cancer accounts for nearly half of all cancers in the U.S., with an estimated 3.5 million non-melanoma types diagnosed each year, according to federal data analyzed for a 2010 study in the journal in the journal JAMA Dermatology. Melanoma is rarer, with an estimated 137,900 new cases predicted for this year, nearly 78,000 of them invasive. But its incidence is rapidly increasing, especially in people younger than 30.
While skin cancers such as basal and squamous cell cancers can be disfiguring, they are highly curable. Melanoma is curable if caught early and surgically removed, but can quickly thicken, spread elsewhere in the body and turn lethal. Recurrence of melanoma 10 or more years after treatment is more common than previously thought, occurring in more than 1 in 20 patients, according to a study in July in the Journal of the American College of Surgeons.
While melanoma can occur in any skin color and in areas such as the soles of the feet where there is little or no sun exposure, all skin cancers are strongly linked to ultraviolet radiation from the sun and increasingly, from tanning beds.
One blistering sunburn at a young age can more than double the chances of melanoma later in life. Pediatric melanomas, though still unusual, are steadily rising. A study in April in the journal Pediatrics found that childhood and adolescent melanoma increased 2% a year from 1973 to 2009, driven by 15- to-19 year-olds, with 18 cases per million.
Dirk Elston, president of the American Academy of Dermatology, says there is increasing evidence that self-exams and physician examinations may lead to a reduction in melanoma thickness at time of diagnosis and improved survival rates.
The issue of how widely to screen patients is a subject of debate. The U.S. Preventive Services Task Force, an advisory body, concluded in 2009 that evidence isn't sufficient to assess the balance of benefits and harms of whole-body skin exams or self exams for the general population. It cites risks from misdiagnosis, over-diagnosis and harms from unnecessary biopsies and overtreatment.
The task force says doctors should remain alert for unusual skin lesions in physical exams performed for other purposes and consider risk factors such as fair skin, number of moles and family history. (Generally, a family history appears to increase risk of melanoma by about twofold, according to the National Cancer Institute. In recent years, researchers have found gene mutations that seem to play a part in some cases.)
The task force is expected to review new evidence next year, which includes a 2012 study from Germany, where more than 360,000 patients in one state were offered skin-cancer checks. The screening detected earlier-stage tumors and significantly reduced mortality rates compared with other parts of the country without the screening programs.
While widespread screening for melanoma in children isn't necessary, says Lynn Cornelius, chief of dermatology at Washington University in St. Louis, kids should be checked individually. She tells parents, "know your kids' moles, and when something is persistent, changing or bleeding, or it is unusual looking and new, bring it to your pediatrician's attention."
At the beginning of the summer, Jennifer Phillips became concerned about changes in a mole on her 13-year-old daughter Maggie Foley-Phillips's back since birth. Ms. Phillips says she is vigilant about sunscreen, but the family lives in Rancho Palos Verdes, Calif., and is active outdoors. She asked Manhattan Beach dermatologist, Glynis Ablon, to take a look.
Dermatologists typically view moles with a magnifying lens known as a dermatascope that examines the skin's surface. Dr. Ablon used a device called MelaFind, approved by the Food and Drug Administration in 2011, which relies on computer light technology to examine moles as deep as 2.5 millimeters below the skin's surface. Dr. Ablon, also a consultant to the device's developerMela Sciences Inc., MELA -0.46% says the results indicated the mole was benign, and helped her determine a biopsy wasn't necessary.
Dermatologists pay about $10,000 for the machine and a fee per usage, then charge patients $25 to $40 per lesion or $150 to $175 per session for multiple lesions, which isn't covered by insurance. Ms. Phillips says her 16-year-old daughter, Mackenzie, had a skin biopsy several years ago that hurt and left a scar, so Maggie was apprehensive. Ms. Phillips was relieved not to put her through the same thing unnecessarily. "It was the best $150 I ever spent," she says.
Jennie Brach, owner of a Brooklyn, N.Y., furnishings and design company, saw Darrell Rigel, a professor of dermatology at New York University who consults for Mela Sciences, last year about an unusual patch of skin on her leg. "It had some changes and had spread out a little bit," she says. After MelaFind indicated it had irregular growth patterns under the surface, Dr. Rigel did a biopsy. The mole turned out to be an early stage melanoma, and was surgically removed. "It hit me like a bomb, and was very traumatic, but thank God it was only on the surface," Ms. Brach says.
MelaFind is in use in about 100 doctors offices and clinics in 29 states.
One concern, says Dr. Cornelius of Washington University, is that the device may lead doctors to become "complacent" and not do a thorough visual exam. "The jury is still out as to whether this is better than a trained eye with a dermatascope," she says. She creates mole maps using digital photos to track changes over time, but advises patients to be vigilant in monthly self exams, "because things can change so quickly."
Melanoma is on the rise, particularly in people younger than age 30.
Laura Landro : WSJ : September 2, 2013
With current estimates that 1 in 5 Americans will develop skin cancer in their lifetime, dermatologists and cancer groups are stepping up efforts to screen patients at least once a year and teach them to perform their own self-exams as often as monthly.
Doctors are creating photographic "mole maps" to track changes over time, and some dermatologists are turning to a new, noninvasive device that helps determine which moles should be biopsied for melanoma, the deadliest form of skin cancer.
What to Look For Skin Cancer Warning Signs
- A skin growth that increases in size and appears pearly, translucent, tan, brown, black, or multicolored
- A spot or sore that continues to itch, hurt, crust, scab, erode, or bleed
- An open sore that does not heal within three weeks
- A mole, birthmark, beauty mark, or any brown spot that: changes color; increases in size or thickness; changes in texture; is irregular in outline; is bigger than 6 mm or ¾ inch, the size of a pencil eraser; appears after age 21.
Unexpected Spots
Skin cancer can occur even in spots usually not exposed to sunlight. Some areas of the body people may fail to check:
- Scalp
- Soles of the feet
- Palms of the hands
- Fingernails, toenails
- Back of the legs
- Genital area
Skin cancer accounts for nearly half of all cancers in the U.S., with an estimated 3.5 million non-melanoma types diagnosed each year, according to federal data analyzed for a 2010 study in the journal in the journal JAMA Dermatology. Melanoma is rarer, with an estimated 137,900 new cases predicted for this year, nearly 78,000 of them invasive. But its incidence is rapidly increasing, especially in people younger than 30.
While skin cancers such as basal and squamous cell cancers can be disfiguring, they are highly curable. Melanoma is curable if caught early and surgically removed, but can quickly thicken, spread elsewhere in the body and turn lethal. Recurrence of melanoma 10 or more years after treatment is more common than previously thought, occurring in more than 1 in 20 patients, according to a study in July in the Journal of the American College of Surgeons.
While melanoma can occur in any skin color and in areas such as the soles of the feet where there is little or no sun exposure, all skin cancers are strongly linked to ultraviolet radiation from the sun and increasingly, from tanning beds.
One blistering sunburn at a young age can more than double the chances of melanoma later in life. Pediatric melanomas, though still unusual, are steadily rising. A study in April in the journal Pediatrics found that childhood and adolescent melanoma increased 2% a year from 1973 to 2009, driven by 15- to-19 year-olds, with 18 cases per million.
Dirk Elston, president of the American Academy of Dermatology, says there is increasing evidence that self-exams and physician examinations may lead to a reduction in melanoma thickness at time of diagnosis and improved survival rates.
The issue of how widely to screen patients is a subject of debate. The U.S. Preventive Services Task Force, an advisory body, concluded in 2009 that evidence isn't sufficient to assess the balance of benefits and harms of whole-body skin exams or self exams for the general population. It cites risks from misdiagnosis, over-diagnosis and harms from unnecessary biopsies and overtreatment.
The task force says doctors should remain alert for unusual skin lesions in physical exams performed for other purposes and consider risk factors such as fair skin, number of moles and family history. (Generally, a family history appears to increase risk of melanoma by about twofold, according to the National Cancer Institute. In recent years, researchers have found gene mutations that seem to play a part in some cases.)
The task force is expected to review new evidence next year, which includes a 2012 study from Germany, where more than 360,000 patients in one state were offered skin-cancer checks. The screening detected earlier-stage tumors and significantly reduced mortality rates compared with other parts of the country without the screening programs.
While widespread screening for melanoma in children isn't necessary, says Lynn Cornelius, chief of dermatology at Washington University in St. Louis, kids should be checked individually. She tells parents, "know your kids' moles, and when something is persistent, changing or bleeding, or it is unusual looking and new, bring it to your pediatrician's attention."
At the beginning of the summer, Jennifer Phillips became concerned about changes in a mole on her 13-year-old daughter Maggie Foley-Phillips's back since birth. Ms. Phillips says she is vigilant about sunscreen, but the family lives in Rancho Palos Verdes, Calif., and is active outdoors. She asked Manhattan Beach dermatologist, Glynis Ablon, to take a look.
Dermatologists typically view moles with a magnifying lens known as a dermatascope that examines the skin's surface. Dr. Ablon used a device called MelaFind, approved by the Food and Drug Administration in 2011, which relies on computer light technology to examine moles as deep as 2.5 millimeters below the skin's surface. Dr. Ablon, also a consultant to the device's developerMela Sciences Inc., MELA -0.46% says the results indicated the mole was benign, and helped her determine a biopsy wasn't necessary.
Dermatologists pay about $10,000 for the machine and a fee per usage, then charge patients $25 to $40 per lesion or $150 to $175 per session for multiple lesions, which isn't covered by insurance. Ms. Phillips says her 16-year-old daughter, Mackenzie, had a skin biopsy several years ago that hurt and left a scar, so Maggie was apprehensive. Ms. Phillips was relieved not to put her through the same thing unnecessarily. "It was the best $150 I ever spent," she says.
Jennie Brach, owner of a Brooklyn, N.Y., furnishings and design company, saw Darrell Rigel, a professor of dermatology at New York University who consults for Mela Sciences, last year about an unusual patch of skin on her leg. "It had some changes and had spread out a little bit," she says. After MelaFind indicated it had irregular growth patterns under the surface, Dr. Rigel did a biopsy. The mole turned out to be an early stage melanoma, and was surgically removed. "It hit me like a bomb, and was very traumatic, but thank God it was only on the surface," Ms. Brach says.
MelaFind is in use in about 100 doctors offices and clinics in 29 states.
One concern, says Dr. Cornelius of Washington University, is that the device may lead doctors to become "complacent" and not do a thorough visual exam. "The jury is still out as to whether this is better than a trained eye with a dermatascope," she says. She creates mole maps using digital photos to track changes over time, but advises patients to be vigilant in monthly self exams, "because things can change so quickly."
Explaining Sunscreen and the New Rules
By Jane E. Brody : NY Times : June 20, 2011
Attention, sun lovers (and yes, that includes all who think they are adequately protected against the sun’s damaging rays): Nearly four years after announcing its intention to improve the labeling of sunscreens, the Food and Drug Administration has finally issued new rules that should help reduce the confusion that currently prevails when consumers confront the aisle-long array of products in most pharmacies.
But these rules will not take effect for another year (and for small manufacturers, two years). Meanwhile, everyone needs to know what to do now about preventing painful sunburns, disfiguring and deadly skin cancers and premature skin aging.
How high an SPF should one choose? Is SPF 60 really that much better than SPF 30? What does “broad spectrum” mean? Are all sunscreen ingredients equally effective? And equally safe?
And perhaps the most frightening question: Why has the incidence of melanoma, the deadliest of skin cancers, doubled since sunscreens (as opposed to tanning lotions) became popular?
No better time to get the answers to these questions than now, the week of the summer solstice. Even if it is not sunny where you are, the ultraviolet rays hitting your skin will be their most intense.
Rating Sunscreens
First, some facts about sun and current sunscreen labels. There are two kinds of solar rays: short ones called UVB that cause burning and skin cancer and long ones called UVA that cause skin cancer and wrinkling. SPF ratings — the letters stand for sun protection factor — reflect only the extent of protection against UVB. The higher the rating, the longer one can stay in the sun before burning.
But there are two important caveats. First, SPF ratings are based on a rather thick application of sunscreen, not the amount consumers normally use, which is most often a quarter to a half the amount applied in manufacturers’ tests. An adult in a bathing suit should apply about three tablespoons of lotion every two hours, experts say.
Second, above an SPF of 30, which can block 97 percent of UVB (if used in testing amounts), effectiveness increases by only 1 or 2 percent. In the way that sunscreens are used in the real world, then, a product with an SPF of 30 actually provides the protection of SPF 2.3 to 5.5, and one rated SPF 50 provides the protection of SPF 2.7 to 7.1, according to a report published this month in Drug and Therapeutics Bulletin.
UVA, which represents more than 95 percent of solar radiation reaching the earth, does not figure in SPF ratings. The phrase “broad spectrum” is meant to indicate protection against UVA, but there is no numerical rating for product effectiveness. Under the new rules, products labeled “broad spectrum” will have to provide equal protection against UVB and UVA, and only products with an SPF of 15 or higher will be allowed to claim protection against skin cancer and premature skin aging.
Meanwhile, dermatologists suggest choosing only products that are labeled “broad spectrum” and have an SPF rating of 30 to 50. There is no evidence that anything higher than 50 is any better. Apply the sunscreen just before exposure, and reapply it two hours later — it loses effectiveness over time. And even if the label claims the sunscreen is water resistant, be sure to reapply it after swimming or sweating heavily.
The rise in melanoma has led to fears that sunscreens may actually cause this deadly cancer. But other explanations are more likely. By allowing people to stay in the sun longer, sunscreens have greatly increased exposure to UVA radiation. And many, if not most, victims of melanoma were damaged long before sunscreens became popular. A history of sunburn is a major risk factor for this cancer; five sunburns per decade raise the risk by about threefold.
Another reason for the increase in diagnoses: skin cancer screening and detection have improved greatly in recent decades.
With regard to ingredients, many dermatologists recommend products with micronized titanium or zinc oxide as the most effective sun blockers that leave no white residue on the skin. There is some concern, based on animal studies, that the most popular ingredient in sunscreens, oxybenzone, may disrupt natural hormones, but the scientific evidence is scant.
Another chemical, retinyl palmitate, sometimes listed among the inactive ingredients, has been linked to skin cancers in animal studies. Because it is converted into a compound that can cause birth defects, it should be avoided by women who are pregnant or likely to become pregnant.
However, although more studies of these possible risks should be done, Consumer Reports concluded that “the proven benefits of sunscreen outweigh any potential risks.”
Finally, don’t be fooled by price. In tests of 22 sunscreens, Consumer Reports found nine to be effective against UVB and UVA and ranked three as “Best Buys”: Up & Up Sport SPF spray (88 cents an ounce) at Target; No-Ad With Aloe and Vitamin E SPF 45 lotion (59 cents); and Equate Baby SPF 50 lotion (63 cents). The organization said La Roche-Posay Anthelios SPF 40 cream, at $18.82 an ounce, scored well below these three in effectiveness.
Although it may be tempting to try to kill two birds at once with a combination sunscreen and insect repellent, the Centers for Disease Control and Prevention does not recommend this. Multiple applications could result in an overdose of the repellent.
Seek Other Protection
The best advice to prevent UV damage is to stay out of the midday sun altogether and to cover up with clothing, a hat and umbrella during the rest of the day even if it is cloudy. Clouds do not block damaging rays.
Keep in mind that ultraviolet radiation is reflected off sand and water, intensifying exposure even if you are protected by an umbrella from above.
Ordinary clothing provides a good sun shield when dry (the tighter the weave, the better) but little or no protection when wet. Special sun-protective clothing is costly but works well wet or dry; it is a wise investment for children who tend to stay in or around water for hours. Caps with a neck flap are especially helpful for sports enthusiasts. And no matter how well covered up you are, don’t forget to apply sunscreen to your face, ears, neck and hands.
Also, keep in mind that some sun exposure is necessary to maintain a healthful level of vitamin D. Dermatologists suggest, for light-skinned people, that exposing one’s hands, arms, face or back to nonburning doses of sunlight for 15 minutes two or three times a week from April to September should result in adequate vitamin D synthesis. Dark-skinned people need longer exposure.