Skin Cancer

There are three kinds of sun related skin cancer: basal cell cancer, squamous cell cancer, and melanoma.

All are related to the sun but in different ways.  Basal and squamous cell cancers are related to direct sun and directly related to sun. This means they occur where you get sun—primarily the face. And if you get them, it is almost definitely from sun. Meanwhile, melanoma is related to a list of risk factors: family history of melanoma, five or more severe blistering sunburns, growing up in a tropical environment if you are white skinned, and use of a tanning booth. Finally, and most importantly, if you are not black or Hispanic you are at risk for sun related melanoma. Melanoma can occur anywhere—even your armpit or the bottom of your foot. It can occur in your eye, mouth, or genital area. Of course in these places it is not related to sun.

Prevention of skin cancer is important, but it is becoming clear to dermatologists that it is not as simple as complete sun avoidance (sun has beneficial as well as harmful effects). Therefore I advocate the “common sense” approach to protecting your skin. First, do not try to get a tan. Lying on the beach at noon exposes you to a whole lot of sun all at once, and causes damage not only to your skin cells but your immune system. Peak hours of the day are 10 to 4, and during that time in the sunny seasons a hat, t shirt and shade are great ideas. I mention sun block last not because it is not important, but because it is not as effective as the other methods, and it remains somewhat controversial. Sun block makes sense if you know you are going to be out for a long time and not able to protect your skin. I recommend zinc and titantium based sun blocks such as dermatone spf 36 fragrance free, cotz brand, and vanicream spf 30 or 60.

Because you cannot turn back time and erase your past sun exposure, and because melanoma is not just related to sun, it is important to know what signs to look for with skin cancer. I hope the following can help you make sense of what is somewhat confusing information about skin cancer.

Signs to look forward with skin cancer:

  • Basal cell cancer—“bleeding”
  • Squamous cell cancer—“sandpaper”
  • Melanoma—“milk chocolate”

Basal cell cancer can bleed spontaneously, and this is often how we find it. It is most often on the face. It starts out pink or pale—a little bump that slowly grows. It may take a year or two to become noticeable, and it often eventually bleeds. These are not life threatening. They almost never metastasize (spread throughout the body). However, they can cause “local destruction” and be quite devastating, especially if on the eyelid, nose, mouth or ear. Treatment is excision, Mohs’ micrographic surgery, Aldara cream or rarely, radiation.

Squamous cell cancer usually presents as a “sandpaper” spot on the face or back of your hand. It is not just rough or warty (like the “barnacles” on your body), but picky like a grain or sand or even little piece of glass embedded into the skin. When caught at this stage they usually resolve with liquid nitrogen or Aldara or 5-FU cream, and they are known as an “actinic keratosis” or pre cancer. However squamous cell cancer can be aggressive—rapid growth, pain, older age of the patient are signs for concern. Treatment sometimes requires excision and even more aggressive treatment. This is fortunately less common.

Melanoma is the most concerning of the three skin cancers. It is the cancer of moles, and it can occur at any age. With melanoma, change in general is the most important thing to be aware of, but there are specific changes we focus on. I use the term “milk chocolate” to get you thinking of brown color. Milk chocolate as a color of a mole is usually GOOD—its dark chocolate and licorice (dark brown and black) you must look for.

More specifically, with melanoma you are looking for change in an existing mole, or a new mole that is dark or changing.

Color, size and shape are all changes we look for, but especially dark color.

Furthermore, melanoma usually starts out FLAT. This may come as a surprise. It is not the raised moles you need to focus on, but the flat ones. In fact, people often mistake their flat moles for freckles.

Here is a way to understand the distinction of raised and flat moles. Your body is constantly surveying itself to make sure there is nothing in it that is harmful.  From the time you are born, your body is trying to get rid of your moles. Your moles are collections of the cell called the melanocyte, and moles are induced primarily from sun exposure. You could say your body considers them abnormal and potentially dangerous, and so your body wants to get rid of them. It tries to do so by slowly raising them up over time. Thus, a mole is most benign if it is slowly raising up. It is not “fighting back”. A flat mole, on the other hand, is fighting back. It’s a little more aggressive. A flat mole has more “potential” to go bad.

Most flat moles are of course normal, but you want to watch them more closely for change than you would a raised mole. Raised moles can become irritated and even bleed, but this tends to occur from irritation rather than because it is becoming dangerous. So, watch for color, size or shape change especially of flat moles.

The exception to the “raised/flat” rule is an important but rare exception called nodular melanoma. Nodular melanoma is a rare, extremely aggressive melanoma. It is red or black, and erupts over a couple of months. This kind of melanoma is an emergency.

The bottom line is, if you are worried about a spot; please show me or your regular dermatologist. Sometimes the spot you are worried about is a “seborrheic keratosis” (barnacle). These spots are so raised up they are almost falling off. A clue with these spots is you can practically get the edge of your fingernail under the edge.

Body Mole Map