PRECANCERS AND THE DANGERS THEY PRESENT

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Actinic keratosis (AK) is the most common type of precancerous skin lesion. The more time individuals spend in the sun over the years, the greater their odds of developing one or more AKs. That is why these lesions are more common in older people and those who work outdoors. People with fair skin, freckles, blonde or red hair, and blue, green, or gray eyes are at greatest risk because they are more susceptible to sun damage. However, anyone can develop skin precancers and cancers.

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If one AK develops, others may have developed as well, and the individual is at greater risk of developing invasive skin cancer. The more AKs that are untreated, and the older the lesions are, the greater the chance that one or more may develop into invasive squamous cell carcinoma (SCC), the second most common form of skin cancer. Some individuals may also develop basal cell carcinoma (BCC), the most common form of skin cancer. 

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AKs typically occur on the face, lips, ears, scalp, back of the hands, and forearms - the parts of the body most exposed to sun. Ranging in size from 1 mm to 1 inch, AKs usually appear as small crusty or scaly bumps or "horns". The base can be dark or light skin-colored and may have additional colors such as tan, pink, or red (see pictures below). 

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Early on, AKs may come and go. In addition, patients may have many more subclinical (invisible) lesions than those appearing on the skin surface. Sometimes they are more easily detected by feel than by sight. They are dry and rough to the touch and may be raw, sensitive, and painful. Occasionally, AKs itch and cause a pricking or burning sensation. They can also be inflamed and surrounded by redness. In rare instances, they may bleed or ulcerate, signs usually associated with skin cancer formation. 

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BASAL CELL CARCINOMA

 

Basal cell carcinoma (BCC) is the most frequently occurring form of skin cancer, with approximately 2.8 million cases diagnosed each year. These cancers are abnormal, uncontrolled growths or lesions that arise in the skin's basal cells, which line the deepest layer of the epidermis (the outermost layer of the skin). BCCs often look like open sores that bleeds, oozes, or crusts and remains open for three or more weeks; red patches or irritated areas that may sometimes itch or hurt; pink growths with a slightly elevated border and a crusted indentation; a shiny bump or nodule, or scar-like area that is white, yellow or waxy, and often has poorly defined borders (see pictures below). Usually caused by a combination of cumulative UV exposure and intense, occasional UV exposure. BCC can be highly disfiguring if allowed to grow, but almost never spreads (metastasizes) beyond the original tumor site. Only in exceedingly rare cases can BCC spread to other parts of the body and become life-threatening. 

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THE MAJOR CAUSE OF BASAL CELL CARCINOMA

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Both long term sun exposure over your lifetime and occasional extended, intense exposure (typically leading to a sunburn) combine to cause sun damage that can lead to BCC; almost all BCCs occur on parts on the body excessively exposed to the sun - especially the face, ears, neck, scalp, shoulders, and back. On rare occasions, however, tumors develop on unexposed areas. In a few cases, contact with arsenic, exposure to radiation, open sores that resist healing, chronic inflammatory skin conditions, and complications from burns, scars, infections, vaccinations, or even tattoos are contributing factors. 

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WHO IS AT RISK OF BASAL CALL CARCINOMA?

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Anyone with a history of sun exposure can develop BCC. However, people who are at highest risk have fair skin, blonde or red hair, and blue, green, or grey eyes. The most often affected are older people, but as the number of new cases has increased each year in the last few decades, the average age of patients at onset has steadily become lower. The disease is rarely seen in children, but occasionally a teenager is affected. Dermatologists report that more and more people in their twenties and thirties are being treated for this type of skin cancer. Men with BCC have outnumbered women this this disease, but more women are getting BCC than in the past. The number of women under age 40 diagnosed with BCC has more than doubled in the last 35 years. Workers in occupations that require long hours outdoors and people who spend their leisure time in the sun are particularly susceptible. 

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NOT TO BE IGNORED

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BCCs are easily treated in their early stages, with cure rates close to 100%. The larger the tumor has grown, however, the more extensive the treatment needed. Although the skin cancer seldom spreads, or metastasizes, to vital organs, it can damage surrounding tissue, sometimes causing considerable destruction and disfigurement. Some extremely rare, aggressive forms can become dangerous if not treated. 

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After small skin cancers are removed and the wounds are allowed to heal naturally, the scars are usually cosmetically acceptable. If the tumors are sizable, or in certain critical areas, a simple closure, skin graft, or flap may be used to repair the wound to achieve the best cosmetic result and enhance healing. 

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RISK OF RECURRENCE

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People who have had one BCC are at increased risk for developing others over the years, either in the same area or elsewhere on the body. They are also at higher risk for other types of skin cancer. Therefore, regular visits to a skin specialist should be routine so that not only the site(s) previously treated, but the entire skin surface can be examined. 

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BCCs on the scalp and nose are especially troublesome, with recurrences typically taking place within the first two years following surgery.

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Should a cancer recur, the physician might recommend a different type of treatment from the one used initially. Some methods, such as Mohs surgery, may be highly effective for recurrences. 

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SQUAMOUS CELL CARCINOMA

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Squamous cell carcinoma (SCC) is the second most common type of skin cancer, after basal cell carcinoma. The incidence of SCC has increased up to 200% in the past three decades in the US. About 1.5% of SCC patients - between 3,900 and 8,800 people a year - die from the disease in the US. This type of skin cancer is an uncontrolled growth of abnormal cells arising in the squamous cells that make up most of the skin's outermost layer, the epidermis. SCC may occur on any areas of the body including the mucus membranes and genitals, but is most common in areas frequently exposed to the sun, such as the rim of the ear, lower lip, face, balding scalp, neck, hands, arms, and legs. Daily year-round exposure to the sun's ultraviolet light, as well as intense exposure in the summer months, all add to the cumulative damage that can lead to SCC. Often the skin in these areas reveals telltale signs of sun damage, including wrinkles, pigment changes, freckles, "age spots," loss of elasticity, and broken blood vessels. 

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An SCC typically appears as a persistent thick, rough, scaly patch that can bleed if traumatized (e.g., scratched or scraped). It often looks like a wart and sometimes appears as an open sore with a raised border and a crusted surface (see pictures below). Additionally, any changes in a preexisting skin growth, such as an open sore that fails to heal, or the development of a new growth, should prompt an immediate visit to a physician. 

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WHO DEVELOPS SQUAMOUS CELL CARCINOMA

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People who have fair skin, light hair, and blue, green, or gray eyes are at highest risk of developing SCC. But anyone with a history of substantial sun exposure is at increased risk. Those whose occupation require long hours outdoors or who spend extensive leisure or recreation time (especially playing golf and other sports) in the sun are in particular jeopardy. Anyone who has had BCC is also more likely to develop an SCC.

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SCCs are at least twice as frequent in men as in women, partly because of more time spent in the sun. They become increasingly common with advancing age. However, in recent years, SCCs are also being diagnosed more frequently in younger patients. In the last 30 years, the incidence of SCC among women under age 40 has increased nearly 700%. 

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The majority of skin cancers in African Americans are SCCs, usually arising on the sites of preexisting inflammatory skin conditions or burn injured. Though naturally dark-skinned people are less likely than fair-skinned people to get skin cancer, it is still essential for them to practice sun protection. All skin types are at risk of skin cancer. In fact, recently there has been a large increase in new SCCs diagnosed in Latinos and other people of color. 

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CAUSES OF SQUAMOUS CELL CARCINOMA

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Cumulative exposure to sunlight over one's lifetime causes most cases of SCC. Frequent use of tanning beds also multiplies the risk of SCC; people who use tanning bed are 2.5x more likely to develop SCC than those who don't. Another source of SCC is injuries such as burns, scars, ulcers, long-standing sores and sites previously exposed to x-rays or certain chemicals (such as arsenic and petroleum by-products).

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Chronic infections and skin inflammation can also give rise to SCC. Furthermore, HIV and other immune deficiency diseases, chemotherapy, immunosuppressive (anti-rejection) drugs used in organ transplantation, and even excessive sun exposure itself all weaken the immune system, making it harder to fight off disease and increasing the risk of SCC and other skin cancers. Studies have shown that organ transplant recipients are up to 250 times more likely than the general population to develop SCC.

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Occasionally, SCCs arise spontaneously on what appears to be normal, healthy skin. Some researchers believe the tendency to develop these cancers can be inherited. 

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NOT TO BE IGNORED

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Squamous cell carcinomas usually remain confined to the epidermis (the top layer of skin) for some time. However, the larger these tumors grow, the more extensive the treatment needed. They eventually penetrate the underlying tissues, which can lead to major disfigurement, sometimes even the loss of a nose, eye, or ear. A small percentage - estimated run from 2% to 10% - spread (metastasize) to local lymph nodes, distant tissues, and organs. When this happens, SCCs frequently can be life-threatening. 

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Metastases most often arise on sites of chronic inflammatory skin conditions and on the ear, nose, lip, and mucosal regions, including the mouth, nostrils, genitals, anus, and the lining of the internal organs. 

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Because most treatments involve cutting, some scarring from tumor removal should be expected. This is most often cosmetically acceptable with small cancer, but removal of larger tumor often requires reconstructive surgery, involving a skin graft or flap to cover the defect. Mohs surgeons are trained in reconstructive surgery, so a visit to a plastic surgeon is generally unnecessary. 

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WHEN SQUAMOUS CELL CARCINOMAS RECCUR

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Anyone who has had one squamous cell tumor has an increased change of developing another, especially on the same skin area or nearby. That is usually because the skin has already suffered irreversible sun damage. Such recurrences typically occur within two years after surgery. An SCC can recur even when carefully removed the first time. Thus, it is crucial to pay particular attention to any previously treated site, and any changes noted should be shown immediately to a physician. SCCs on the nose, ears, and lips are especially prone to recurrence. 

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Even if no suspicious signs are notices, regularly scheduled follow-up visits including total-body skin exams are essential in post-treatment care. Should the cancer return, the physician may recommend a different treatment the next time; certain methods, such as Mohs surgery, can be highly effective for preventing and treating recurrences. 

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MALIGNANT MELANOMA

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Malignant melanoma is a form of skin cancer. This skin cancer can spread quickly. Finding and treating melanoma before it spreads is important. With an early diagnosis and treatment, melanoma has a high cure rate. 

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THOSE AT RISK FOR MELANOMA

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Anyone can get this type of skin cancer. Melanoma occurs in people of all skin colors and all ages. The number of Americans who get melanoma keeps rising. Many of these melanomas could have been prevented. Protecting your skin from the sun and not using tanning beds reduces the risk of getting all forms of skin cancer, including melanoma. 

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CAUSES OF MELANOMA

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Exposure to ultraviolet rays clearly plays a role, especially in people who have fair skin. We get exposued to UV rays from the sun. Getting many sunburns, especially blistering sunburns as a child or teenager, raisers the risk of getting melanoma. Research now proves that using tanning beds also exposes us to harmful UV rays. However, not all melanomas are caused entirely by UV rays. Other risk factors increase a person's likelihood of getting melanoma. Risk factors include:​

• Light skin, hair, and eyes

  • Fair, sun-sensitive skin than tans poorly or burns easily​

  • Red or blonde hair

  • Blue to green eyes

• Moles​

  • 50 or more small ​moles

  • Unusual-looking moles that are often larger than normal and have uneven edges

• Past sunburns or indoor tanning​

• Had melanoma or other skin cancer

• Blood relatives (parent, child, sibling, cousin, aunt, uncle) who have had melanoma

• Weak immune system (due to disease, organ transplant, or medicine)

• Age 50 years or older​

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Being younger than 50 does not mean you cannot get this skin cancer. Melanoma is the most common form of cancer for young adults 25-29 years old and the second most common cancer if adolescents and young adults. 

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WARNING SIGNS OF MELANOMA

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A common warning sign of melanoma is change. Melanoma may start in an existing mole. A change to the shape, color, or diameter (size) of a mole can be a sign of melanoma. Other changes to watch for include a mole that becomes painful or begins to bleed or itch. 

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Not all melanomas start in a mole. Some melanomas begin suddenly on normal skin. A sudden, new growth could be melanoma.

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Performing skin self-exams, at least yearly, can help you detect thses warnging signs. When you examine your skin, it is helpful to look for the ABCDEs of melanoma detection. 

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During a skin self-exam, it helps to remember that moles are usually one color, round or oval, and has a well-defined border. Melanomas tend to show the opposite. 

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When you examine your body, it is important to examine your skin and nails. Melanoma can appear on any part of your skin. The most likely places are the upper back, torso, lower legs, face, scalp, and neck. Be sure to check all your skin, though. 

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Melanoma also begins under our nails, inside our mouth, on our genitals, and even in an eye. Be sure to check these areas, too. Under a nail, melanoma often appears as a dark streak of color. 

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If you remember one fact, it should be thisL melanomas show up in many shapes and sizes but share one key trait. Melanomas tend to look different from your moles. Dermatologists often tell their patients to look for the "ugly duckling."

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WHAT TO DO IF YOU HAVE A WARNING SIGN

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Make an appointment to see a dermatologist if you have any of these warning signs. The doctor will do a complete skin exam to look at your moles and new growths. 

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If your dermatologist finds a mole or growth that looks like melanoma or another type of skin cancer, the dermatologist will perform a skin biopsy. This is a simple procedure, which a dermatologist can do in the office. To perform a biopsy, your dermatologist will numb the area and remove the growth, or part of it. Your dermatologist will send this to a lab.

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A biopsy is the only way to tell whether a patient has melanoma or another type of skin cancer. At the lab, a doctor will use a microscope to look at what your dermatologist removed. The doctor is looking for cancer cells. If the doctor sees cancer cells, the doctor can usually tell what type of cancer it is. Sometimes the doctor also can tell the stage of the cancer. The biopsy report will tell what the doctor found. 

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Knowing the stage of the cancer is important. Each stage requires different treatment. If the stage could not be determined at the lab, your dermatologist may refer you to another doctor for more tests. 

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To determine the stage of melanoma, you may need imaging tests. These tests including x-ray, ultrasounds, computed tomography (CT scan), magnetic resonance imaging (MRI), and positron emission tomography (PET scan). Sometimes surgical biopsy of a lymph node is necessary to identify the stage of melanoma. When melanoma spreads, it often travels first to the closest lymph node. By removing one or a few of these lymph nodes, the doctor can tell whether the melanoma has spread to nearby lymph nodes. Not all patients who have melanoma need this procedure. Your doctor will tell you if you need it. 

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MELANOMA CAN RETURN

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Patients who have had melanoma have a higher lifelong risk of developing new melanomas. Melanomas also can recur. Melanoma can spread. Because of these risks, it is essential that you keep all appointments with your dermatologist. The earlier you find melanoma and treat it, the better the prognosis (likely outcome). 

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You can help find skin cancer by performing skin self-exams. Make sure you know the warning signs of melanoma and look for the ABCDEs. If you notice a changing mole or any other warning sign of melanoma, make an appointment to see your dermatologist right away. 

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