While PCPs understand the need to survey patients for suspicious lesions, they may have trouble incorporating skin checks into routine physical exams or lack confidence in distinguishing benign growths from concerning ones. Here's help from board-certified dermatologist Divya Seth, MD, MPH, who describes strategies for efficient skin evaluations in everyday practice, notes factors to cover while taking a risk-assessing history, presents images of frequently seen skin malignancies (and of their harmless imitators), and offers practical tips on everything from biopsies to patient education.
So, hello everyone. Good afternoon. Um My name is Devia Set. I am a Mos surgery fellow at U CS F this year. Um And I'm also a board certified dermatologist and I'm so excited to talk to you today about a topic that's um a passion of mine and uh close to my heart, which is skin cancer. Um I know that most of you are out there kind of seeing everyone on the front lines and seeing everyone's skin. And I think my goal for today is to kind of provide an overview of some of the most common types of skin cancers that we see on our end as dermatologists and um skin cancer surgeons and um some of the features that you can look for um as you're seeing your patients, I'm just adding my ducks there. Um I have no financial disclosures and in an effort to promote diversity and our um improvement of understanding of skin cancers. Um I've attempted to use images from a broad spectrum of skin tones that are currently available. So a little overview of our agenda today, I'll first talk about how to take a targeted patient history to better assess someone's skin cancer risk overall. Then we'll talk about a full body skin exam and how we um generally tend to perform it in dermatology and how you can sort of adopt a version of this exam into the existing physical exam that you may already be performing for your patients. Um I'll also then go over several types of skin cancer and pre-cancerous lesions such as actinic keratosis, squamous cell carcinoma, a basal cell, and melanoma. And then I'll also talk about some common mimickers such as se keratosis, sebaceous hyperplasia, cherry angioma. We'll walk over three cases, um patients that we have seen. Um and that might be interesting in terms of what to do next and then some practical tips about how to advise your patients um and how to proceed from there. Um Please let me know of course, at the end, we'll have a Q and A and please let me know if you have any questions, I'm happy to expand further. Um And um answer any questions that you may have. So the kind of the assessment of a patient's skin cancer risk really starts as soon as they come in through the door. So when I'm seeing a first new patient, I try to ask them about their personal history of skin cancer for some patients. It might be the fifth time that they're coming to me with a skin cancer and they have a really good understanding of what it means um what it entails for other patients. It might be the first time ever that they have heard the C word or cancer. Um And I can kind of get a sense of where I wanna start the conversation just based on understanding where they are in their personal journey with skin cancers. Um And of course, the personal history of skin cancer also really impacts someone's risk of developing a second skin cancer. So, particularly with Melanoma, as well as with the other skin cancers, most patients are most likely to develop a second skin cancer within the first two years of having their first skin cancer. And so how this plays out in our recommendations is that we actually recommend that for patients who have had a first time skin cancer, we recommend a full body skin exam with a dermatologist every six months after having their first skin cancer for non melanoma skin cancers. And then if you've had a melanoma that after having your first melanoma, we recommend full body skin checks every three months after having had their first melanoma. And that accounts for this um interesting history that we note that after the first two years of having a skin cancer, that's the time period that you're most likely to develop a second skin cancer. And then equally as important is the family history of skin cancer. So that allows you to get, get an assessment to see. Is there some sort of genetic risk that's going on here. Um There are rare circumstances such as basal cell nevus syndrome, which is a condition where patients are very likely to develop basal cell cancers. And that can happen from a very young age, um including adolescence. Um And so, understanding the family has a risk of skin cancer and understanding how early their parents or their siblings might have had their first skin cancer, um allows you to get a better assessment of this genetic risk. Um, then we'll talk about history of blistering sunburns. So history of blistering sunburns having five or more blistering sunburns actually doubles your risk of a melanoma. And this, um, is a history that goes all the way back to childhood. So the way I typically ask this question is I ask, um, in your childhood or growing up, did you ever get a blistering sunburn? And people usually remember these really rough sunburns. So where they were in pain, they might even have needed some pain medications. Sometimes they remember going to a doctor for it or really feeling like, oh, my back really blistered up that one time that I would, um, swimming at this lake. Um And then I try to ask them, do you remember how many times that might have happened in your lifetime? And most of the time again, people are, people might not be able to remember an exact number, but they can remember a ballpark, then tanning bed use is also a significant risk factor. As many of you probably already know um for skin cancer risk. So those who have tanned endures have an 83% chance increased risk of developing a squamous cell cancer and a 29% increased risk of developing a basal cell cancer. Um And then the it also increases your risk of getting these skin cancers at an earlier age. This risk also transfers to melanoma. And so patients who've had tanning bed use have a significantly increased risk of developing a Melanoma. The other thing that this question is really important to assess is where these skin cancers might occur. As you can imagine, tanning bed use um increases your UV exposure throughout your entire body. And so there might be actually skin cancers developing in places like the bottom of the feet or the hands places where you might not see otherwise, if someone was just having sun exposure, for example, those are usually sun protected areas. But when you have a history of tanning bed use, um you're actually getting this UV risk throughout your entire body. And so it's important to ask this question. And again, I asked this without any stigma, I just ask a very open ended question. Um you know, growing up or currently, do you use any tanning beds? And people usually um are pretty honest about that. And then I try to get an assessment of the number of sessions and usually the cut off is around 10 sessions. So I say, do you think that you had more than 10 sessions or fewer than 10 sessions? Uh And people will sometimes say things like, oh, actually I had a membership to this tanning salon for this period of time and you can kind of get a sense of um how many tanning bed sessions they might have had and then immunosuppression. So, um and change in your immune system, especially with immunosuppression such as related to transplant. Um, medications have a significantly higher risk than the general public to develop skin cancers. And specifically, it's typically squamous cell cancer. The risk for the other skin cancers is also higher. However, it's really the squamous cell cancers that we look out for in this population. Um It's important to take, keep a really close eye on these patients because not only are they at higher risk of developing these skin cancers, but they're also at higher risk of developing more complicated versions of these or more complex versions of these um skin cancers. And so these are the patients where we're usually acting pretty fast to get them into care, have the skin cancer removed and think about adjuvant therapy such as radiation or other therapies that they might need. Um So again, these are patients where you really want to be looking over their whole body because they're having a much higher risk of developing skin cancers everywhere. So now I'll move into sort of talking about a full body skin exam and try to give you some pearls on how to um incorporate this into your own practice. I know you're busy and probably seeing a lot of patients and it probably seems daunting to try to do this for every single patient that you're seeing. But once you get into a rhythm, I think it's really nice to incorporate this into your practice. Um, And keep a note of what you're seeing as you're going. So I think the first thing is to try to stay as systematic as possible, meaning whatever flow works for you try to keep that from patient to patient. It just really helps you develop an internal clock and internal map of OK, I look at the right arm first and then I'll look at the left arm. Um So for me personally, I start off for the patient's back. So I have them seated on the table in their um patient gown and I start off by looking at their back. Um That allows me to try to get a sense of this person actually has a lot of moles. They don't have a lot of moles. Um I then move on to the, the arms and the chest and the abdomen and then I move on to the legs. Um and then I um end with the feet. So I just check the bottom of the feet and in between the toes and then I usually switch my gloves at that point and then I'll take a really close look at the face. Um, the reason I save the face for last is because that's usually where we're actually going to end up doing a lot of our biopsies potentially. And so I wanna do a really close assessment of every part of the face, including, um, some spots that sometimes go miss. So like the corners of the nose, the nasal ala um and the corners of the eyes were also common spots to develop skin cancers. And then I also make sure that I look through the hair at the very end, making sure that there's no lesions growing in the scalp. So we're really tall patients, you know, we're looking at every nook and cranny. Um we're trying to get be the skin doctors, you have skin everywhere for um certain patients who are comfortable. I check underneath the underwear as well, having a chaperone in the room. And then for others, some people say, you know, I actually see my um gynecologist and I prefer that they see them, those areas and I say that's totally fine. Um I think it's also important as you're developing the system, whatever is most consistent for your practice to mark the suspicious lesions as you go because it's easy for patients who have really busy skin to kind of forget. Oh, that was a mold that I was a little um I wanted to come back to. So I usually um have a skin marker like this one and I kind of go along and I um either dot out the lesions that I want to come back to or that I want to treat later on and that way, um I know exactly where things are in while here in dermatology. You know, we are only performing full body skin exams. Um I know for um your practice, you might think about ways of integrating it into the physical exams that you may already be doing. So this is a really nice slide that I um uh I sharing from the American Academy of Dermatology, which talks about how to integrate the skin exam into your pre-existing physical exam. So for example, if you're listening to the bowel sounds, you can take a look at the abdominal skin at the same time. If you're listening to um the lungs from the posterior aspect, you can look at the patient's back um for the extremities again, looking at the skin really carefully before you're doing the physical exam that's relevant for those areas. And then, um, one quick Pearl is our sort of motto in dermatology, sort of leave no skin, um, unexamined. So, if someone has a band aid, we're usually taking off the bandaids, making sure thing what's underneath that is something that's not concerning to us. Um If they have socks on, I usually ask people to remove their socks. Um, and then if you know, if there's dressings on things like that, I usually get everything as uncovered as possible to make sure that I'm really giving them a full assessment. And so when you do find a suspicious lesion, it's really important to mark the lesion closely. Um, meaning mark, um, right around the lesion. Sometimes we'll get referrals, especially for surgery where a pretty large area, the doc have been placed around a large area. And it's hard to identify where within the marked lines. The true lesion lies especially after a biopsy is performed, the markings are lost and it's hard to sometimes do lesion identification. Here in most surgery, we try our very hardest and it's our um gold standard to make sure that we're not doing wrong site surgery. So if we cannot identify where a biopsy was performed or where a lesion is, we usually either tell the patient we have to repeat the biopsy or we'll send you back to your referring provider, ask them to mark out where they thought the lesion was. And then have you come back to us? And so for patients who are coming in from quite a distance away, we really hate putting them through that back and forth. And so really encouraging everyone to really um mark the lesion as closely as possible and then take at least two photos. The first is a close up photo of the lesion itself. So we understand what it looks like and what might have been the concerning features of that lesion and then also taking a more zoomed out photo that includes at least one an atomic landmark. So, for example, here in this picture, we're taking a photo of the upper arm. If we just took the close up photo, it would be hard to know where in relation to the elbow, this lesion might be. So if the biopsy heals really nicely, we might lose this lesion altogether. Um And so having the elbow as a marker allows us to see in relation to this um where the lesion was. It is also very helpful for us if you're able to obtain triangulation measurements. So you could, for example, in this photo measure from the lateral epicondyle, this was about 12 centimeters or um from the shoulder bone. This was this many centimeters and that allows us to kind of get into the ballpark as we're looking for treatment or if we're the ones performing the biopsy, making sure that we're in the right area to perform the biopsy. Sometimes I also get a photograph on the patient's phone just for reassurance. This really allows me to make sure that when the patient arrives, I know that the photo will be present with them because they'll usually have their phone with them as well. Um And then it also allows the patient to have a record of what the lesion looked like before the biopsy was performed. And so I find that it's a nice um assurance policy in case the photo was to get lost or not get transmitted appropriately or ends up being a lower quality photo than anticipated. I think it's nice to have a second backup photo somewhere. So now we'll move into the second part of this talk, which is talking more about pre malignant and malignant lesions. Um So the first topic we'll be talking about is actinic keratosis. So, these are pre-cancerous lesions that present in sun exposed areas, they typically present as pink gritty pules. And sometimes you might hear that you'll feel them more than you can see them. So areas where which um have this commonly is like the forehead, the scalp, the cheeks, the nose, really, the sun exposed areas. So sometimes if you run your hands over this area, you can feel that there's almost a sandpaper like texture. And that might suggest that actinic keratosis is present if left untreated. There is a risk of progression of actinic keratosis to squamous cell carcinoma in situ or a squamous cell carcinoma. And that's why it is important for these lesions to be treated. Um And although the risk of malignant transformation can be low at times, it can be less than 1%. However, I have seen reports as high as 8%. I'll say the data for this is of course, a little bit confusing because and hard to study because it would require leaving something untreated in a patient and seeing if it progresses to a malignancy, which as you can imagine is not really a very um uh i or be approved study. And so, and not something that we'd like to do to our patients. And so that's why that number varies quite widely. But there is this risk that actinic keratoses typically progress to either squamous cell carcinoma inside too or squamous cell carcinoma. So, here's what this can look like when these are solitary lesions. So you can see that there's this sort of pink gritty black that you can see on this corner of this eyebrow. And here it looks a little bit more subtle, but you can see that there's like a slight interruption of this patient's normal background skin and they have this pink sort of scaly Paule here and then similarly on this cheek, um you know, you can see that she has some background sun damage. Um But here there is this kind of almost gray again, sandpaper like lesion that's developing. And that is a really classic marker. This little scale that's present is a very classic marker of an actinic keratosis. And then sometimes these can be present in such abundant quantity that you don't even know one lesion from the next. And that's what we call field cancerization. Um So when something is a solitary lesion and they're sent to dermatology or perhaps in your office, they're treated with liquid nitrogen and it's quite easy to pinpoint a single lesion and treat that. Um But when you have such an abundance of lesions, it can be quite difficult to treat one lesion at a time. And so when these patients are referred to us, we have different treatment options including a topical chemotherapy cream. We have a blue light therapy um and we talk about those options with the patient, but our goal is to kind of help clear this field um before anything progresses to a skin cancers. And then the other thing I'll add is sometimes you'll notice that uh a skin cancer might arise within this bed of actinic keratosis. Um And you m you might have seen it in a patient that you have referred to us. We sometimes pretreat these areas with some field therapy or um in order to clear things before we do a surgery and that's so that we can have a better margin assessment and not run into more lesions as we're doing our surgery. Um actinic keratosis do not need to be treated surgically. They can be treated with these non surgical options such as liquid nitrogen, topical chemotherapy creams. And this blue light therapy that leads me into a skin cancer that um sometimes does need um surgery which is squamous cell carcinoma inside two. So, an important part of this um phrase is the inside two part, which is um addresses the fact that the skin changes and the cellular changes are confined to the top level of the skin. So this type of skin cancer is not invasive. It's resting in the top level of the skin. But we do recommend treating it because there is the risk that it could progress to invasive skin cancer. So again, it typically occurs in sun exposed areas. Um However, it can also happen in areas with HPV presence. So areas where you can get warts and so we have seen um these cases on the fingers. So patients who have had warts present for a very, very long time. I'm talking 10 or longer years. Um We've also seen them in the groin or the genitals of patients who have a history of HPV. And there are of course higher risk HPV strains that are more likely to result in skin cancers um and lower HPV strains. But kind of getting an assessment of how long someone has had their warts can help you identify how closely you should monitor these areas for um skin cancer risk and progression. And similar to those solitary actinic keratoses, these look like pink scaly plaques rather than that little amount of scale. They're usually pretty well defined. Um And they're more plaque like meaning you can clearly see where they start and end and they have that sort of mesa like um quality where they rise up from the skin and then end. Um and they can also be associated with immunosuppression and with patients with a history of radiation. So here are some um photos of some squamous cell carcinoma in situ. So here you can see this lesion has a clear border, clear margins, it is not perfectly circular. Um and sometimes these squamous cell carcinomas cus can be wider because they are in that top level of the skin rather than deep. So patients often ask, well, is this really invading deeply? And I might say, you know, this is more of a type that will be a larger surgery rather than a deeper surgery. Um Here's what this might look like on darker pigmented skin. So again, you have this pink plaque, um it can be surrounded with some hyperpigmentation and some patients hypopigmentation. Um but it clearly stands out from the surrounding skin. Here is an example of what this could look like on the um hand of a patient. So you can imagine this could have started off as an atina keratosis and if left untreated or sometimes even if treated, um it can progress to a squamous cell carcinoma inside too. Um Here's another lesion really well demarcated um on an otherwise pretty clear background um of skin. So, not much else going on here and this lesion is really standing out, which would also prompt me to wanna get a little bit of a biopsy. If I was to do a biopsy for these lesions, I don't have to biopsy the entire lesion. For example, here I could biopsy just one aspect of it. So doing a small shave biopsy. Um and I would recommend that for all of these four photographs here, you don't have to biopsy the entire site. You can biopsy an aspect of it. Um And that usually gets enough of an of a sample um to provide a diagnosis and determine next steps um that leads to squamous cell carcinoma. So this is the second most common type of skin cancer in the United States and actually the most common type of skin cancer worldwide. The important people to really make sure you're looking for squamous cell carcinoma is in your immunosuppressed patients. So, patients especially that have had a solid organ transplant are really at high risk of developing these high risk S ECs, especially on the scalp. Um and the neck where we want to be very careful and watching very carefully. You wanna make sure you're checking scars for these type of lesions and then nonhealing ulcers and then again, chronic warts. So there's again a relationship with HPV. For this type of skin cancer, the rate of metastasis is about 4% and it's t typically to the regional lymph node. So, if a patient has um a squamous cell carcinoma of the head, for example, I usually do do a lymph node exam of the neck of the pre ARIC lymph node basin, the post ARIC lymph node basin. Um and then I, you know, similar to that check basically the draining lymph node um basin. So if something's on the arm, I'll check the axilla. Um and so on and so forth, we act fast in transplant patients because their risk of metastasis is so much higher. Um In my experience, these patients typically have very fast growing squamous cell cancers. And so we want to move to a biopsy and treatment as fast as possible. And when these are larger, this might after surgery also include radiation, sometimes includes a sentinel lymph node biopsy. So there's a, a sequence of events that takes place after the biopsy has taken place. Um Here are some squamous cell cancers. And here you can see in comparison to our actinic keratosis or our um um squamous cell carcinoma inside too. There's more substance to these skin cancer. So you can see that they're raised, there's almost this little volcano of crust in the center. Um That really tells me this needs to be biopsied. Um Here's a lesion on the ear, that's an area that's often missed by patients. Um People often wear baseball hats, but those don't protect the top of your ears. And so we are the dermatologists that are always telling people wear your broad brimmed hats, they're in make them fashionable again. Um And really encouraging them to protect the tops of their ears because not only can it become a very high risk in cancer given its um, head and neck location, but it can also be quite challenging, reconstructive after a skin cancer surgery to put that area back together. Um, and then the lower lips are another common area, especially at the corners where, um, patients are often developing either actinic Kocsis or also the squamous cell carcinoma. Um, and there might be a confusion there. People might think it's a cold sore. Um And so I usually ask how long has the spot been there for? They say, well, doc like I've had this spot for actually about a year now. Well, it would be pretty unusual for a cold sore to be present consistently in the same location for about a year. Um And so I really use that history to guide whether or not I wanna do a biopsy in that location. Um And then I want to highlight these special scenarios, which is that SCC can also arise in chronic HPV or wart patients. So this is a photograph of um an a wart on a fingernail. Um So this was um a wart that had been persistent for quite some time. You can see that the nail itself has been impacted, meaning that the wart and the skin cancer is probably growing down into the nail matrix, which is where the nail grows out from back here in the cuticle. Um And so in this scenario, we would recommend doing a biopsy and, you know, this can be a challenging area to biopsy. So some oftentimes these patients are referred directly to us and we are the ones who perform the biopsy and then also the treatment. Um and then here is a lower leg wound that was persistent for quite some time. It initially started off as an injury. Um and then was non healing due to chronic venous stasis. You can see that they've been applying compression to this area. Um but given that it did not heal for many, many months and almost um past a year, we did do a small biopsy to make sure that this was not something called a margarine ulcer, which is basically in this chronic non healing ulcer. Um squamous cell atypia can arise and grow into a skin cancer. I'll now move into talking about basal cell cancers. So there are different subtypes that vary um on histology and they can manifest in different morphology. This is the most common type of skin cancer. And it's also actually the most type of most common type of cancer that you'll see in the United States. And it's actually on the rise pretty rapidly and that's an area of research um as to why this is happening. It's most commonly due to UV exposure and, and um something that we've witnessed anecdotally in our practice here. But also that has been reported in literature is that there's been an increase in um basal cell cancers in patients who are younger than 40 years of age. And so it's important to be looking at for skin cancers um even in younger patients rather than kind of having it on your radar for just your older patients. Um So this classically pre presents as this Pearly Popes. That's sort of our dermatology phrase for a basal cell. It's a pearly pople. Um And you can see it's kind of shiny, it's different than the squamous cell. And in that it doesn't quite have as much um grittiness or scale to it, but it is quite smooth and often has this rolled border. And then the other feature that we look for is this blood vessel. So you can see that there is this um tal ectasia which we call an Arbor vessel, meaning this larger vessel um that's supplying vessels uh supplying um blood supply to this skin cancer and that can sometimes be very present um and visible in this type of skin cancer. This might be a little bit of more of a subtle lesion where you might wonder is this actually a squamous cell cancer or a basal cell? And one of the features is this kind of shiny quality that you can see at the edges, which actually raises concern for um a uh basal cell um rather than even a rash or um a a squamous cell. But again, it totally OK, a biopsy and consider that and the whole lesion does not need to be biopsied, but one aspect of it. So, taking a little um piece at the end will help us get a sense of what leash, uh what we're working with here, here are a couple of more subtle examples. So this um on the nose is a very classic area where we see basal cells. Um And I think what tends to happen here is that the patient themselves might anchor on this being some sort of acne bump. And that's usually the classic thing that I hear, which is that well, I just thought it was an acne bump, but it just really wouldn't heal. And I tried all these different things for it and once you've tried different things and it really staying in the same spot and not getting better at all. Um I usually proceed with a biopsy at that point, especially if you're really feeling like it might have some of the skin cancer features that we've been talking about. The lower eyelid is another area where we often see um basal cells. Um And here, um there are again a whole host of differential diagnosis diagnoses that can present on the lower eyelid that look very similar like a sty. Um But here, um the features that kind of catch our eye is that the eyelash line is interrupted. It's probably something that has been there for a while and it hasn't really been waxing or waning but has been persistent and sometimes, um it's totally reasonable to try the normal ST treatments, you know, warm compresses and things like that. And it e even after that, things that are really not budging, that's kind of a time when to start thinking about. Well, maybe we need to refer you to ophthalmology or optometry or dermatology to do a biopsy of this area. And then I wanna present a variation of pigmented, um a basal cell is called a pigmented basal cell. They often look quite scary because they can look like melanoma. And so I think it's totally reasonable to biopsy. It thinking it is a Melanoma um until we know otherwise. Um And so this is a more common type of skin cancer that presents in um darker skin types. Um So here we have a lesion on the cheek of a patient that I actually saw recently and she was OK with me using this photograph. Um And so for a long time, this was thought to just be a mole on her skin and then she felt like it was growing and becoming a little more pigmented. Um and therefore, um ended up having a small biopsy and end up ended up being a pigmented basal cell. And then here is a similar lesion on the scalp. Um where um again looks a lot like a Melanoma. It's kind of breaking all the melanoma rules. And so ended up being biopsy thinking it was a Melanoma and it ended up being a basal cell um the other differential here, which I'll show you some photos of as well as a se keratosis, which can be a benign growth. Um And one of the things that kind of stands out to me here is the color here. It has a little bit of an ulceration almost. And then it's, there's not much else going on on this patient's skin. So it's really standing out and that's another reason why I would proceed with a biopsy. So then we'll move on to Melanomas. Um So this is a malignancy of melanocytes. It occurs on the skin, but it can occur where wherever you have melanocytes. So that includes the mucus membranes, the nails and the eye. Um The risk factors include UV radiation family and personal history, tanning bed use as well as sunburn. So similar to what we've talked about, I will say anecdotally. And there's also been some case reports of this is that um while there has been a decrease in tanning bed use, overall, there has been an increase in um for example, gel manicures and actually gel manicures use a UV lamp afterwards for the setting process. And so we've seen several um very much younger patients with Melanomas of the nail um and also of the fingertips um that have had a history of these jaw manicures. So that's something that I try to also get a um that's a question that I sometimes ask patients when I see the skin cancers on the nails. Um, prognostic factor factor is the depth of invasion, which you might see reported as the Breslow depth. And that gives us a sense of how um deep the skin cancer is and what kind of treatment is necessary. Early Melanomas um have very high survival rates and they do not impact um typically the patient survival. So we're looking at survival rates in the 97% at five years and 95% at 10 years. Um The reason that everyone um is so on top of me, Melanomas is because the risk of metastasis is to really any organ most commonly the liver and the lung. And so it can have really um intense consequences if these are not caught early. Um Most people, um you know, we hear about this pretty often the ABC DS of Melanoma. So what we look for is asymmetry, meaning that one half of the lesion is unlike the other half, the border can be um irregular or scalloped. And then there might be color changes and you might see more than one color, which is usually another flag where you want to either start monitoring this leisure or just go ahead and do a biopsy. Um And sometimes it can look like what we call a gray veil. So this is like bluish grayish hue over this color area and that um can prompt you to do a biopsy. Um The diameter if it's larger than six millimeters um should also prompt close observation and close management of these lesions. And then of course, if there's change over time. So for that reason, I think photographing these is helpful, asking the patient to keep an eye on these and really empowering your patient, they are going to be keeping a close eye on their skin um every day versus maybe a visit every year or every six months to us as dermatologists or to you primary care physicians. Um So it's just really important to take, um to really empower them to take a look at their own skin and also become familiar with their own moles if they have many moles. So I tell patients who have a lot of moles, you know, get to know your moles, know what they look like, know where you have them. And if I find a mole where they might not be able to see something, I say, hey, just so, you know, there's a mole on the bottom of your foot. This is what it looks like right now, I can take a picture on your phone just so you have a photo of that mole. Um And that can be very helpful for the patients. Um And then an ugly duckling sign. So there's a couple of different ways that you can interpret the ugly duckling sign. One is this is the darkest spot on your body. It looks different than all of the other moles you have and I want to either take a photo of it and monitor it or I want to biopsy and sample it today. The other option can be this is actually the lightest spot on your body. Everything else is darker or within a family of pattern. So maybe you make these dark spots but they all look similar to each other and you make these larger but you know, again, similar brown spots, but this spot is actually looking like it's lighter and it's just different than all the other spots. And that's the reason that I might want to biopsy. And then finally, this is just the only spot on your body. Um You have nothing else going on and there's this one spot that's really standing out to me. Um And that could be a reason that you might wanna go ahead and take a sample. So here are some examples of Melanomas. So here, you know, the patient makes some brown spots and some pink spots, but this is clearly the darkest spot on their back. And that is a reason um to go ahead and do a biopsy, it's also has a couple of different colors. It's not symmetric, it has irregular borders. Um Those are all flags that would prompt us to think about Melanoma. Here, you can see that color variation. And if you really look, there's almost this grayish veil that's going on and that really makes us concerned about Melanoma. Melanomas can also occur in the nail itself. Sorry, let me go back. Um And usually we're looking for this band that's quite wide, it can be evolving over time. Um And if you're unsure about this, that's a very common reason that we seek consults um is to get a sense of whether something is a normal band, you, you know, you can also get normal moles in the nail as well that can lead to this kind of band. But we have to decide whether or not to do a biopsy, which in this area can be quite traumatic. It requires us removing the nail and doing a whole procedure. And so we wanna monitor these areas quite closely. Um And then for the nail, you also really want to get a really good history about a history of trauma. So if a patient is a runner and they have this on their toenail has been growing out over time, could it just be a blood blister or traumatic hemorrhage underneath the nail? Getting that sense from the history is very helpful. So, common mimickers, you know, a se keratoses are these benign lesions of the skin. Um The cause is actually not clearly identified. Um But they present us this almost like warty um plaque like growth. We call them sort of um these uh barnacles that you might get over time. I call them wisdom spots. And I tell patients you're gonna get more as you get older. Um So it's totally OK to keep them um treating these is not covered typically by insurance unless they're inflamed. Meaning that they're itchy or really bothersome to the patient, then we can go ahead and treat them usually through um liquid nitrogen therapy. But as you can imagine, these are quite dark, um they fit some of the criteria for melanoma. And so what we look for here is these little cyst like openings in these lesions. You can see this patient has quite a few of the same looking spots and that can provide a lot of reassurance, sebaceous hyperplasia are these little almost dells shaped um skin color pules that can happen on the forehead, the cheeks and the nose. Um and they are just an overgrowth of the oil gland. Um They can sometimes end up looking like a basal cell and that's why I wanted to include them here. And again, if you have so many of these, that's kind of can be a sign that perhaps this is not a whole bed of basal cells, but rather something more benign. And then finally, cherry angioma which are um small red papules. These are just blood vessels that are coming close to the surface of the skin um and typically do not need treatment. Um So this brings us to the third part of my talk which is going through some cases. So case one, a 74 year old man presents to his primary care physician with a new growth above his eyebrow. It has been present for six months and it occasionally bleeds. He tells you that he is not sure if it started off as an acne bump. What is the next best step? So you can treat it as an acne with clindamycin solution and benzoyl peroxide, you can biopsy to rule out a skin cancer or you can measure and monitor a couple of the features that really stand out to me in this lesion. Um Well, first of all, let's talk about the history. So a couple of the features that stand out to me in the history is that it's been present for six months and it occasionally bleeds. If it was acne, I would anticipate more of a history of waxing and weaning maybe some drainage, but usually not something that's really fixed there in that area with bleeding history for that long. Um You can see it kind of has that shiny quality that we talked about with basal cells and there is these blood vessels present. So for this, I would go ahead and do a biopsy to really rule out skin cancer. So the signs that point towards biopsy is the history of the bleeding lesion, not healing lesion. And then in this area, the best type of biopsy would be a shave biopsy. Um So if you had something that was more pigmented and you were worried about a Melanoma, a punch biopsy that either captures the whole lesion or the darkest part of the lesion is great. Um But when you have something like this, that's a basal salt doing a shave biopsy is a perfect way to assess um the qualities um of this lesion, a basal cell. Um in terms of this timeline for treatment is a little um is we still want to get this treated in a timely manner and that would usually be it o OK, within a couple of months or about 2 to 3 months. Um We do want it treated the risk of it kind of um being untreated is that first of all, it's causing an impact on the quality of life of the patient. They're having a bleeding nonhealing lesion and it can keep growing. And so the surgery that they might end up having later on could be much larger if it goes untreated for a longer period of time. Um This is a 68 year old woman who reports that she developed a tender, rapidly growing bump on the lower leg and it has grown and emerged in the last month. Um So again, features that stand out to me is that it's rapidly growing, it's tender and she really doesn't have that much else going on on her leg. So this is actually a Corrao Aano, this is considered a subtype of a squamous cell cancer. It tends to grow quite rapidly and it sometimes can self resolve. Um It can occur in areas of trauma such as the shins or surgery sites. So it can sometimes happen at the edge of some place where the patient had a surgery. Um and comes up as this almost like volcano like lesion that erupts very rapidly. If it does not self resolve, then we treat this just as we do a squamous cell cancer. So we typically cut these out um and treat it very rigorously. But if sometimes they can just go away on their own as well. And then case three, this is um a little typo here, but this is actually a 48 year old woman who presents with a several month history of a rapidly growing nodule on the left chest. Um This had grown quite rapidly. It was initially thought to be a cyst um and thought to be an inflamed cyst. Um And then because it didn't really act or drain the way that it was anticipated she was referred to us for biopsy. Um So this ended up actually being a very rare type of skin cancer called a Merkel cell cancer. Um I just include this as a way to highlight that sometimes we think things are quite benign such as a cyst or an acne bump and they can be um more alarming such as a Merkel cell or a different type of skin cancer. And so this is very common. Um and it's hap you know, it's very common to happen. And so especially for Merkel cell, which is um a very rare type of skin cancer. It usually happens in sun exposed areas or in immunosuppressed patients. Um About 88% of patients had a painless lesion, but they had rapid growth and there was sometimes a long time to biopsy because a lot of people think that this is completely benign. Um and you can see that, you know, has features that would make us think it could be a basal cell or a different type of skin cancer. So just important to kind of keep an open mind um as you're Eva um evaluating these patients and really keep a close eye on their history as well. Um So in general, if you have meet a patient, um that has something that you might be concerned about, that has a skin cancer. Um You know, some of you might be doing biopsies on your own, which is awesome. And if you'd like us to do a biopsy, then you can place a routine dermatology referral if you feel um like it's a high risk lesion, like a transplant rapidly growing or other risk factors. Um You can contact um us through an urgent referral and that should come in pretty fast and those are um re reviewed pretty frequently. Um And then for those are within those of you who are within the U CS F system. So I I learned recently that this is actually limited to the U CS F system. Um You can upload a high quality photo and then also place a dermatology e consoled. Um What might happen to your patient when they come to us after a referral? If there is a lesion that's concerning for a skin cancer, we first perform a biopsy and then typically a shave biopsy for nonpigmented lesion and either a punch or a scoop biopsy for pigmented lesions, sc are performed in local anesthesia, um lidocaine with epinephrine and then just as a way to guide your patients, surgical treatment could be excision with healthy margins um or most surgery depending on the tumor and the patient characteristics. Um And then of course, the, the questions that patients always ask, how do I prevent this from happening? Um Sunscreen is wonderful. A broad brimmed hat like I talked about is wonderful. And then of course, then avoidance as much as possible. Um For sunscreen. Um Here are some of my pearls. I ask patients to look for broad spectrum to ensure protection against both the U VA and UVB. You want something that's SPF 30 or higher um mineral sunscreens I like. Um but it can be difficult sometimes because they can leave that white sheen and so it can be hard to wear on a daily basis, but they contain both zinc. Um they can contain both zinc oxide and titanium oxide and um help protect against both U VA and UVB and some brands. Um I've just included those. I have no financial relations to any of these brands. These are just things that either I like or my patients have reported back to me. Um I will say the best sunscreen is a sunscreen that your patient will apply every day. And so maybe it's a different brand than this, but whatever they're willing to use every day and use consistently is the best brand for them. Um Well, thank you for um spending this um lunch hour with me and um here's my email address if you have any questions and I'm happy to take any questions now.
