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Skin Cancers and Skin Lesions

You can simply scroll down in this window to read the entire discussion from start to finish or click on the question that interests you. Topics answered below include:

01. What are Actinic Keratoses?
02. What are some basic facts about Actinic Keratoses?
03. Why Are Actinic Keratoses Called The Early Beginnings of Skin Cancer?
04. What can be done for the prevention of Actinic Keratoses?
05. What treatments are available?
06. What is the chemical removal or destruction of AKs?
07. What are the three most common forms of skin cancer?

1. What are Actinic Keratoses? One of the most common pre-malignant and pre-cancerous lesions.

Actinic keratoses (AKs) are known as the early beginnings of skin cancer. This most common lesion of the outermost layer of the skin (epidermis) is caused by long-term exposure to sunlight (specifically to ultraviolet wavelengths). AKs are most likely to appear after age 40-50, and years of chronic exposure to the sun. However, in geographic areas with year-round high-intensity sunlight (e.g., Florida, southern California) AKs are now found in persons as young as the teens and twenties. The incidence of AKs is over 50 percent in older, fair-skinned persons in hot, sunny geographic areas.

AKs are defined as a cutaneous dysplasia of the epidermis (the outermost layer of skin). In everyday terms, AKs are an alteration in size, shape and organization of skin cells. The cells most affected in AKs are the keratinocytes, the tough-walled cells that make up more than 90 percent of the epidermis and give the skin its texture. Cellular alterations in AKs may extend into the dermis, the layer of skin under the epidermis. The most significant cause of actinic keratoses is long-term exposure to sunlight, and specifically to the ultraviolet wavelengths of solar radiation. The most significant predisposing factor to AKs is fair skin.

The alteration in growth and differentiation of keratinocytes is manifested in the clinical features of AKs-rough, scaly skin, "bumps" on the skin, mottled skin, and cutaneous horn. Generally, these are redish colored, scaly, lesions on the face, scalp, ears, neck, hands, forearms and shoulders in most people. Alterations in cell growth and differentiation also set the stage for transformation of AKs into invasive squamous cell carcinoma.

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2. Basic Facts About Actinic Keratoses

The sun is a symbol of health and well being and is generally associated with pleasant outdoor activities-hiking, gardening, fishing, golfing, surfing, etc. Even if we don’t seek to look like a surfer, a certain amount of exposure to sunlight usually makes most of us feel good and we generally believe it is good for us.

Over the past half-century, advances in the study of photobiology (the effect of solar radiation on biologic processes) have shown that long-term exposure to intense solar radiation can be an example of "too much of a good thing." Solar radiation (sunlight), and particularly its ultraviolet wavelengths (UV), is now known to be a major environmental factor in skin disease.

The harmful effects of ultraviolet (UV) radiation are influenced by a number of genetic and nongenetic factors:

· Duration of exposure;
· Frequency of exposure;
· Intensity of radiation-e.g., intensity is greater in Florida than in Canada;
· Genetically determined skin color-e.g., lighter skin color is more at risk for UV-caused skin disease; and,
· Genetically determined skin phototype-e.g., likelihood for damage from UV radiation.

Actinic keratoses (AKs) are one of the skin conditions that can result from UV damage to the skin-especially in persons with fair skin. AKs are unsightly and also are identified as the early beginnings of skin cancer as they have the potential to progress into invasive cancer.

The person at risk for AKs due to (1) duration, frequency and intensity of sun exposure, and (2) skin color and skin phototype is also at risk for:

· Sunburn-the fair-skinned individual tends to burn rather than tan;
· Photoaging-wrinkling, drying, mottling of skin due to solar radiation
· Immunologic changes in skin-phototoxicity or photoallergy
· Skin cancer; and,
· UV-induced skin conditions such as hives.

The person most at risk for the UV-induced skin conditions listed above is one with:

· Pale white to white skin;
· Freckles in childhood;
· Blue, hazel or green eyes;
· Blond or red hair; and,
· A history of burning rather than tanning when exposed to sunlight.

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3. Why Are Actinic Keratoses Called The Early Beginnings of Skin Cancer?

The skin lesions called early beginnings of skin cancer are those with a proven ability to evolve into skin cancer. Actinic keratoses are one of a group of keratinocyte lesions that are early beginnings of skin cancer, which includes:

· Keratoses associated with exposure to arsenic, tar or chemical carcinogens;
· Keratoses associated with chronic exposure to ionizing (x-ray) or infrared (heat) radiation;
· Keratoses associated with human papillomavirus infection (Bowenoid papulosis);
· Keratoses that develops at the site of a scar; and,
· Leukoplakia, a premalignant plaque on mucosal surfaces-e.g., the tongue.

Of this group of lesions that are early beginnings of skin cancer, actinic keratoses are by far the most common.

The skin cancer into which AKs can progress to is invasive squamous cell cancer, a cancer of the keratinocytes and the second most common cancer of the epidermis. The frequency of SCC varies in different geographic areas of the world and the United States, but is strongly associated with (1) sunny climate, and (2) large populations of fair-skinned people. The most significant causative and predisposing factors for SCC are the same as for actinic keratoses-long-term exposure to sunlight and fair skin.

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4. Prevention of Actinic Keratoses

Prevention of actinic keratoses should ideally begin early in life. In geographic areas of high-intensity sunlight, sun damage to unprotected skin begins in childhood and puts the child at high risk for actinic keratoses and skin cancer later in life. However, it is never too late to initiate prevention of new actinic keratoses lesions in adulthood.

The basics of prevention are:

· Avoid excessive exposure to sunlight-(1) stay out of direct sun exposure during peak sunlight hours (10 a.m. - 4 p.m.), (2) wear clothing that covers arms and legs, (3) wear a wide brimmed hat and/or carry a parasol or umbrella during peak sunlight hours;

· Use a sunscreen with sun protection factor (SPF) of 15 or higher, applying it at least 15 to 30 minutes prior to sun exposure for maximum sun protection;

· Select a broad-spectrum sunscreen that provides both UVA and UVB protection; and,

· Reapply sunscreen every two hours when outdoors, even on cloudy days.

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5. TREATMENTS AVAILABLE

Cryosurgery
Liquid nitrogen "freezes" surface skin, which subsequently flakes off to be replaced by new skin. Skin redness for a time is the chief side effect. Cryosurgery is the most commonly used treatment.

Surgical excision and biopsy
Actinic keratoses are surgically removed and the tissue examined under a microscope when there is suspected transformation into invasive squamous cell cancer.

Topical and systemic retinoids
Retinoids (vitamin A derivatives) are potent agents that can normalize abnormal growth and differentiation in keratinocytes. They must be prescribed by a physician after full skin and medical examination, and their use must be monitored regularly. Retinoids have a number of side effects, but skin irritation is the most common.

Topical chemotherapy
A topical anti-cancer agent (e.g., 5-fluoruracil) is applied to the skin to remove actinic Keratoses lesions. A localized red spot may remain for some time at the site of chemotherapy application. Patients frequently complained about the irritation, redness and ulceration that must occur usually over at least a four to six week course of therapy. Thus, most patients prefer cryotherapy.

Chemical peel
In a chemical peeling treatment, a chemical solution is applied to the skin causing the skin to blister and peel off over a period of days. As the treated skin blisters and peels, new skin forms to replace it. Your skin care physician will select a chemical solution to accomplish a mild or medium peel. The principal side effect is redness and swelling of skin for a period of time after the treatment. This can be very useful especially where the patient is also interested in some of the other benefits of "peels" on aging skin.

Dermabrasion
Skin is abraded away with a rapidly rotating brush or manual sanding method, down to the depth necessary to remove sun-damaged skin. New skin grows to replace the removed, damaged skin. Redness of skin and some discomfort are the chief side effects, usually resolving within 10-14 days. Your skin care physician can relieve the side effects with medications.

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6. Chemical Removal or Destruction of AKs

Topical 5-fluorouracil
The most frequently used treatments for AKs are cryosurgery and curettage (described in Part I) and topical 5-fluorouracil (5-FU).

An anti-tumor agent in use for decades, 5-FU destroys AK cells by blocking essential biochemical reactions of the cells.

Why is an anti-tumor agent used to treat AKs? 5-FU is a potent agent that is effective in treating multiple AKs. Also, while AKs are not cancer, they are tumors that have the potential to progress to the type of skin cancer called squamous cell carcinoma (SCC)-the second deadliest form of skin cancer after melanoma. The patient’s skin care physician determines if topical 5-FU is the most appropriate treatment for the individual. Among considerations to take into account, topical 5-FU can produce some unsightly and painful side effects that the patient must be prepared to endure in order to complete the course of therapy.

Topical 5-FU is applied as a cream or solution as directed by the physician. The agent is usually applied by the patient or a care-giver. A typical course of treatment, approved by the FDA, is twice-daily application to AKs for four weeks. Application regimens may vary, however, depending on the progress of treatment as assessed by the physician.

Topical 5-FU is a treatment that requires the patient to be 100% compliant with the physician’s instructions. Cure rates of over 90% are reported when patients follow instructions; failure rates of up to 60% have been reported when patients did not follow instructions. Topical 5-FU must be applied as directed; doses must not be skipped or "doubled" in the hope of increasing the effect of the medication. Allergic reaction to 5-FU may occasionally occur, and any reaction to the medication must be reported immediately to the physician.

Chemical Peel
Chemical peeling is a common skin rejuvenation treatment to restore a youthful look to aging skin. It is also an effective treatment for AKs. In some patients, a chemical peel might serve the dual purpose of removing AKs and rejuvenating aging skin. The selection of chemical peeling as a treatment for AKs is made by the physician to meet the needs of the individual patient.

Chemical peels are performed to remove damaged skin at superficial or medium levels, depending on the depth of skin damage and the outcome desired. The treatment may be repeated as necessary if new AKs appear months to years later.
Chemical peels may prevent the appearance of new AKs for two years or longer.

Local anesthesia is sometimes used to ease discomfort during chemical peeling of medium depth peels. After-effects of discomfort, skin reddening and crust formation over peeled areas are relieved with medications and moisturization. After-effects usually disappear in 7-10 days and shorter for more superficial peels.

In some instances chemical peeling is combined with other AK treatments for optimal results.

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7. Skin Cancer

Some cancers are more common in aging skin. The underlying cause of skin cancer in older people is often the accumulated damage of many years of excessive exposure to the sun. In some cases there may be a genetic predisposition to skin cancer-either "cancer in the family" or the inheritance of a type of skin that increases risk for skin cancer. All skin cancers can be successfully treated if they are discovered and treated early. All are potentially disfiguring, and potentially fatal if they metastasize (spread) to other parts of the body.

The three most common forms of skin cancer are:

· Basal cell carcinoma - develops in 300,000 to 400,000 persons every year in the United States
· Squamous cell carcinoma - develops in 80,000 to 100,000 persons per year in the United States
· Melanoma - 45,000 to 50,000 new cases are diagnosed every year in the United States. Melanoma is the deadliest form of skin cancer-6 of every 7 deaths from skin cancer in the United States are due to melanoma

Basal Cell Carcinoma

Basal cell carcinoma arises in a layer of skin (basal layer) beneath the skin’s surface. It seldom metastasizes, although it may do so if the cancer invades lymph or blood vessels that can carry cancer cells to distant organs. The major spreading mechanism of basal cell carcinoma is by local invasion of surrounding skin tissue. If left untreated, it may become large and disfiguring.

The major risk factors for developing basal cell carcinoma are:

· excessive and chronic sun exposure over many years
· a fair (white) skin complexion, especially when hair is blond or red

While basal cell carcinoma has traditionally been a cancer associated with older people, it is now seen in more young adults than in the past.

Early detection of basal cell carcinoma can lead to early treatment and prevention of disfigurement. The most likely places for basal cell carcinoma to develop are areas exposed to sun-face, scalp, ears, neck, shoulders and back. Criteria to look for in self-examination:

· a small, pearly nodule, which may or may not have telangiectasia (small enlarged blood vessels) on the surface; the nodule increases in size slowly and may form an ulceration in its center; there may be some pigmentation
· a solitary, flat or slightly depressed lesion that is hard to the touch; it may be yellowish or whitish and have indistinct borders
· one or more reddish, scaling plaques that slowly enlarge; these lesions may resemble dermatitis or psoriasis

Any suspicious lesion should be examined immediately by a physician and biopsied if the physician deems it necessary to determine proper treatment.

Early, effective treatment of basal cell carcinoma by your skin care physician has a cure rate of more than 95%. However, new basal cell carcinomas can develop after treatment, so continued self-examination and regular examination by a physician are important. It is the patients responsibility along with his primary care doctor to follow up and keep regular visits for examining and prevention of skin cancers and then to make referral when appropriate to a skin care center.

When basal cell carcinoma is discovered early and the diagnosis confirmed by biopsy, treatment may be carried out in the skin care physicians office or an outpatient setting. Treatment procedures include:

· Curettage: A scalpel shaving or curett is used to scrape away malignant tissue. Electrocautery may be used after curettage to "mop up" any remaining cancer cells. Curettage is used chiefly for carcinoma not previously treated.

· Cryosurgery: Liquid nitrogen is applied to the lesion to destroy malignant tissue by ultra-cold freezing.

· Topical chemotherapy: Cancer cells are destroyed by pharmacologic agents applied to the surface of the skin.

· Surgical excision: The cancer is surgically removed and the skin closed with stitches. This technique is used when the carcinoma is in deeper tissues.

· MOHS microscopic surgery: Surgical removal is performed under a microscope. In this technique, the surgeon can perform surgery layer by layer into the skin, under direct microscopic observation.

· Laser surgery: Cancerous tissue is destroyed by laser beam.

The physician will discuss with the patient the type of treatment that will be most appropriate.

Squamous Cell Carcinoma

Squamous cell carcinoma develops in the outer layers of the skin. It is capable of metastasizing to other areas of the body if not treated early. It also spreads locally and may cause significant disfigurement.

The major risk factors for developing squamous cell carcinoma are:

· excessive, chronic exposure to sun, over many years
· overexposure or chronic exposure to x-rays
· long-term treatment with immunosuppressive drugs
· white skin, especially with blond or red hair

Criteria for self-examination:

· commonly appears as an ulcerated nodule or superficial erosion with poorly defined margins on the skin or lower lip; the lesion persists and does not heal
· a wart-like growth or plaque
· premalignant forms of squamous cell carcinoma include actinic keratosis, cutaneous horns (hard, fibrous growths), and
Bowen’s disease (scaling, inflamed-looking plaques)

A suspicious lesion should be examined immediately by a physician, and biopsied if deemed necessary by the physician to determine proper treatment. More aggressive cases may be referred to plastic surgeons or for MOHS surgery.

Squamous cell carcinoma can be significantly disfiguring if not treated early. When a diagnosis of squamous cell carcinoma is confirmed by biopsy, treatment options are similar to those for basal cell carcinoma.

Melanoma

As with basal cell carcinoma and squamous cell carcinoma, excessive and chronic sun exposure is a major risk factor for melanoma . There also is a tendency for melanoma to "run in the family", and to be associated with a familial trait of having many moles on the body. Melanoma often arises in a pre-existing mole or pigmented lesion. Early diagnosis and treatment of melanoma is essential. Any person with many moles or a family history of melanoma should be examined regularly by a physician. Every adult should self-examine at regular intervals to detect any early indications of melanoma. Self-examination is done using the A-B-C-D criteria:

A = Asymmetry (the left side of the lesion is unlike the right side)

B = Border Irregularity (the lesion has a scalloped or poorly defined border)

C = Color Variation (not all parts of the lesion are the same color; within the lesion may be patches of tan, brown, black, pink, white or blue)

D = Diameter (a melanoma is usually larger than 6 millimeters in diameter,about the size of a pencil eraser).

A melanoma is usually described as one of four types:

superficial spreading melanoma — the most common type overall

nodular melanoma — tends to increase in thickness more rapidly than in diameter

lentigo maligna melanoma — melanoma developing in a "sun-induced" freckle

acral lentiginous melanoma — melanoma appearing on palms of hands, soles of feet, nailbeds, and mucous membranes; relatively rare in white-skinned people, but accounts for about half of melanomas in non-whites.

Please stay out of the sun as much as possible and get your skin checked regularly by your physician. Always use sunscreens, if you cannot stay out of the sun. Keep an eye out for any new changes in moles or lesions and see your doctor.

This procedure requires a brief medical office visit for evaluation. The usual medical office visit fee is $40 for a brief office visit (10 minutes). The office visit fee of $40 does not include treatment or medication costs (if necessary). Our office accepts Medicare payments for skin cancers.
Call our office at (913) 962-1869 to schedule an appointment.

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