Skin Cancer

Skin Cancer

Skin cancer is the most common form of cancer in the United States. More than 4 million new cases of skin cancer are diagnosed each year. One in five people will develop a skin cancer in their lifetime. Approximately 40-50% of Americans who live to 65 will have a basal or squamous cell skin cancer. The incidence of skin cancer has increased partly due to a thinner ozone layer leading to greater ultraviolet light exposure. Tanning bed use also increases the risk of skin cancer.

Skin cancer is the abnormal growth of skin cells. They most often develop on skin exposed to the sun. Skin cancer can also occur on areas of your skin not exposed to sunlight.

What are the types of skin cancer?

There are three major types of skin cancer:

Basal cell carcinoma and squamous cell carcinoma are classified as Non-Melanoma Skin Cancers.

Where do skin cancers develop?

Ninety percent of skin cancers develop on areas of sun-exposed skin. This includes the scalp, face, lips, ears, neck, chest, hands, arms and legs. They can also form on areas that rarely see the light of day, including your palms, beneath your fingernails or toenails, and in your genital area.

Skin cancer affects people of all skin tones, including those with darker complexions. When melanoma occurs in people with dark skin tones, it’s more likely to occur in areas not normally exposed to the sun, such as on the palms of the hands and soles of the feet.

What Causes Skin Cancer?

Ultraviolet radiation (UVA and UVB) in sunlight and in the lights used in tanning beds damages the DNA in skin cells. But sun exposure doesn’t explain skin cancers that develop on skin not ordinarily exposed to sunlight. This indicates that other factors may contribute to your risk of skin cancer. Exposure to toxic substances or having a condition that weakens your immune system can lead to the formation of a skin cancer.

Skin cancer occurs when errors or mutations occur in the DNA of skin cells. The mutations cause the cells to grow out of control and form a mass of cancer cells.

Skin cancer begins in your skin’s top layer: the epidermis. The epidermis is a thin layer that provides a protective coverSkin Cancer Cell Layers of skin cells that your body continually sheds. The epidermis contains three main types of cells:

  • Squamous cells: These cells lie just below the outer surface and function as the skin’s inner lining.
  • Basal cells: These cells sit beneath the squamous cells and produce new skin cells. As these cells move upward, they become flattened squamous cells.
  • Melanocytes: Melanocytes produce melanin. This is the pigment that gives skin its normal color. They are located in the lower part of your epidermis. Melanocytes produce more melanin when you are in the sun to help protect the deeper layers of your skin.

Who gets skin cancer?

Factors that may increase your risk of skin cancer include:

Fair skin. Anyone, regardless of skin color, can get skin cancer. However, having less pigment (melanin) in your skin provides less protection from damaging UV radiation. If you have blond or red hair and light-colored eyes, and you freckle or sunburn easily, you’re much more likely to develop skin cancer than is a person with darker skin.

A history of sunburns. Having had one or more 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 the skin isn’t protected by sunscreen or clothing. Tanning, including exposure to tanning lamps and beds, 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, head and hands of fair-skinned people whose skin has been sun damaged.

Family history of skin cancer. If one of your parents or a sibling has had skin cancer, you may have an increased risk of the disease.

Personal history of skin cancer. If you developed skin cancer once, you’re at increased risk of developing it again.

Weak immune system. People with weakened immune systems have a greater risk of developing skin cancer. This includes people living with HIV/AIDS and those taking immunosuppressant drugs after an organ transplant.
Exposure to radiation. People who received radiation treatment for skin conditions such as eczema and acne may have an increased risk of skin cancer, particularly basal cell carcinoma.

Exposure to certain substances. Exposure to certain substances, such as arsenic, may increase your risk of skin cancer.

What do skin cancers look like?

Basal Cell Skin Cancer

Basal Cell Skin Cancer

Basal cell carcinoma may appear as:

  • A pearly or waxy bump
  • A flat, flesh-colored or brown scar-like lesion
  • A pimple which does not go away in 6 weeks

Sometimes small blood vessels, called telangiectasias, can be seen within the tumor. Crusting and bleeding in the center of the tumor frequently develops. It is often mistaken for a sore that does not heal.

Squamous Cell Skin Cancer

Squamous Cell Skin Cancer

Squamous cell carcinoma may appear as:

  • A firm, red nodule
  • A flat lesion with a scaly, crusted surface

Melanoma may appear as:

Melanoma Skin Cancer

Melanoma

  • A large brownish spot with darker speckles
  • A mole that changes in color, size or feel or that bleeds
  • A small lesion with an irregular border and portions that appear red, white, blue or blue-black
  • Dark lesions on your palms, soles, fingertips or toes, or on mucous membranes lining your mouth, nose, vagina or anus

Also, melanomas may not have any pigment present and appear as an irregular white lesion.  These skin cancers are called amelanotic melanomas.

How do I prevent skin cancers from forming?

Most skin cancers are preventable. To protect yourself, follow these skin cancer prevention tips:

Avoid the sun during the middle of the day. For many people in North America, the sun’s rays are strongest between 10 a.m. and 4 p.m. 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. Avoiding the sun at its strongest helps you avoid the sunburns and suntans that cause skin damage and increase your risk of developing skin cancer. Sun exposure accumulated over time causes skin cancer.

Wear sunscreen year-round. Sunscreens don’t filter out all harmful UV radiation, especially the radiation that can lead to melanoma. They do play a major role in an overall sun protection program.

Use a broad-spectrum sunscreen with an SPF of at least 15. Apply sunscreen generously, and reapply every two hours. Apply more often if you are swimming or perspiring. Use a generous amount of sunscreen on all exposed skin, including your lips, your ears, and the backs of your hands and neck.

Wear protective clothing. Sunscreens do not provide complete protection from UV rays. So cover your skin with dark, tightly woven clothing that covers your arms and legs Wear a broad-brimmed hat, which provides more protection than a baseball cap or visor.

Wear sunglasses to protect the eye and the eyelids.

Avoid tanning beds. Lights used in tanning beds emit UV rays and will increase your risk of skin cancer.

Be aware of sun-sensitizing medications. Some common prescription and over-the-counter drugs, including antibiotics, can make your skin more sensitive to sunlight.

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.

How are skin cancers diagnosed?

Your doctor will perform the following to determine if you have a skin cancer:

  • Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Skin exam: An exam of the skin for bumps or spots that look abnormal in color, size, shape, or texture. A dermatoscope or Wood’s lamp may be used.
  • Skin biopsy : All or part of the abnormal-looking growth is cut from the skin and viewed under a microscope by a pathologist to look for signs of cancer.

There are four main types of skin biopsies:

  • Shave biopsy : A sterile razor blade is used to “shave-off” the abnormal-looking growth.
  • Punch biopsy : A special instrument called a punch or a trephine is used to remove a circle of tissue from the abnormal-looking growth.
  • Incisional biopsy : A scalpel is used to remove part of a growth.
  • Excisional biopsy : A scalpel is used to remove the entire growth.

What additional tests may I need?

If you have skin cancer, you may have additional tests to determine the extent or stage of the skin cancer.
Because superficial skin cancers such as basal cell carcinoma rarely spread, a biopsy which removes the entire growth often is the only test needed to determine the skin cancer stage. But if you have a large squamous cell carcinoma, Merkel cell carcinoma or melanoma, you may require further tests to determine the extent of the cancer.

Additional tests may include:

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the head, neck, and chest, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

Chest x-ray : An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. Sometimes a PET scan and CT scan are done at the same time.

Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues, such as lymph nodes, or organs and make echoes. The echoes make a picture of body tissues called a sonogram. The picture can be printed to be looked at later. An ultrasound exam of the regional lymph nodes may be done for basal cell carcinoma and squamous cell carcinoma of the skin.

Eye exam with dilated pupil : An exam of the eye in which the pupil is dilated (opened wider) with medicated eye drops to allow the doctor to look through the lens and pupil to the retina and optic nerve. The inside of the eye, including the retina and the optic nerve, is examined with a light.

Lymph node biopsy : The lymph nodes may be removed and checked to see if cancer has spread to them.

What are the treatment options for skin cancer?

The treatment options for skin cancer and the precancerous skin lesions known as actinic keratoses will vary, depending on the type, size, depth and location of the lesions. Small skin cancers limited to the surface of the skin may not require treatment beyond an initial skin biopsy that removes the entire growth.

If additional treatment is needed, options 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.

Laser. The laser beam destroys the cancer cells.

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.

Mohs surgery. This procedure is for larger, recurring or difficult-to-treat skin cancers, which may include both basal and squamous cell carcinomas. It’s often used in areas where it’s necessary to conserve as much skin as possible, such as on the nose. During Mohs surgery, 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.

Curettage and electrodesiccation or cryotherapy. After removing most of a growth, your doctor scrapes away layers of cancer cells using a device with a circular blade (curet). An electric needle destroys any remaining cancer cells. In a variation of this procedure, liquid nitrogen can be used to freeze the base and edges of the treated area.

These simple, quick procedures may be used to treat basal cell cancers or thin squamous cell cancers:

Radiation therapy. Radiation therapy uses high-powered energy beams, such as X-rays, to kill cancer cells. This may be an option when cancer can’t be completely removed during surgery.

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. Systemic chemotherapy can be used to treat skin cancers that have spread to other parts of the body.

Photodynamic therapy. This treatment destroys skin cancer cells with a combination of laser light and drugs that makes cancer cells sensitive to light.

Biological therapy. Biological therapy uses your body’s immune system to kill cancer cells.

If I have surgery to remove the skin cancer, will I need reconstruction?

Currently, surgical excision is the most common form of treatment for skin cancers. The goal of reconstructive surgery is restoration of normal appearance and function. The choice of technique in reconstruction is dictated by the size and location of the defect. Excision and reconstruction of facial skin cancers is generally more challenging due to presence of highly visible and functional anatomic structures in the face.

When skin defects are small in size, most can be repaired with simple repair where skin edges are approximated and closed with sutures. This will result in a linear scar. If the repair is made along a natural skin fold or wrinkle line, the scar will be hardly visible. Larger defects may require repair with a skin graft, local skin flap, a pedicle skin flap, or a microvascular free flap. Skin grafts and local skin flaps are by far more common than the other listed choices.

Skin grafting is patching of a defect with skin that is removed from another site in the body. The skin graft is sutured to the edges of the defect, and a bolster dressing is placed atop the graft for seven to ten days, to immobilize the graft as it heals in place. There are two forms of skin grafting: split thickness and full thickness. In a split thickness skin graft, a shaver is used to shave a layer of skin from the abdomen or thigh. The donor site regenerates skin and heals over a period of two weeks. In a full thickness skin graft, a segment of skin is totally removed and the donor site needs to be sutured closed.
Split thickness grafts can be used to repair larger defects, but the grafts are inferior in their cosmetic appearance. Full thickness skin grafts are more acceptable cosmetically. However, full thickness grafts can only be used for small or moderate sized defects.

Local skin flaps are a method of closing defects with tissue that closely matches the defect in color and quality. Skin from the periphery of the defect site is mobilized and repositioned to fill the deficit. Various forms of local flaps can be designed to minimize disruption to surrounding tissues and maximize cosmetic outcome of the reconstruction. Pedicled skin flaps are a method of transferring skin with an intact blood supply from a nearby region of the body. An example of such reconstruction is a pedicle forehead flap for repair of a large nasal skin defect. Once the flap develops a source of blood supply form its new bed, the vascular pedicle can be detached.

What is my prognosis?

The mortality rate of basal-cell and squamous-cell carcinoma is around 0.3%, causing 2000 deaths per year in the US. In comparison, the mortality rate of melanoma is 15–20% and it causes 6500 deaths per year. Even though it is much less common, malignant melanoma is responsible for 75% of all skin cancer related deaths.

The survival rate for people with melanoma depends upon when they start treatment. The cure rate is very high when melanoma is detected in early stages, when it can easily be removed surgically. The prognosis is less favorable if the melanoma is deep or has spread to other parts of the body.

Australia and New Zealand exhibit one of the highest rates of skin cancer incidence in the world, almost four times the rates registered in the United States, the UK and Canada. Around 434,000 people receive treatment for non-melanoma skin cancers and 10,300 receive treatment for melanoma. Melanoma is the most common type of cancer in people between 15–44 years in both countries. The incidence of skin cancer has been increasing. The incidence of melanoma among Auckland residents of European descent in 1995 was 77.7 cases per 100,000 people per year, and was predicted to increase in the 21st century because of “the effect of local stratospheric ozone depletion and the time lag from sun exposure to melanoma development.

Dr. DeConti received extensive training in the diagnosis, removal and reconstruction of skin cancers at the Ochsner Cancer Center and from the University of Virginia Department of Dermatolgy and the University of Virginia Department of Plastic Surgery.  He has treated and reconstructed over 25,000 skin cancers in his career.  Dr. DeConti has special expertise in Mohs, Slow Mohs, and CCPDMA excision.  He also can combine excision with radiation and laser treatments to achieve the most complete removal with the least cosmetic deformity and scarring possible.

If you think you may have a skin cancer or would like to learn more about skin cancer, call DeConti Plastic Surgery at 804 673-8000 and schedule a skin evaluation today.

For more information:
The American Society of Plastic Surgeons
The Skin Cancer Foundation

CareCredit Richmond Virginia DeConti Plastic Surgery
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