Actinic keratosis (AK) is a precancerous skin growth that is most commonly found on sun-exposed areas of the face, ears, scalp, neck, shoulders, back and upper extremities. They typically present as small scaly, keratotic pink papules which may resolve spontaneously or slowly enlarge. It is often believed that these rough keratotic papules are the precursor lesions that are on the same spectrum as squamous cell carcinomas (SCC). While a particular AK may not develop into an SCC, many of these skin cancers develop in association with the precancerous changes that are so commonly encountered. Typical treatments are directed at elimination of these precancerous spots. Destructive treatment most frequently consists of cryotherapy (“freezing”) of the individual lesions with liquid nitrogen. More extensive involvement of a particular area may benefit from field therapy with a topical cream (Efudex/Carac/Aldara/Zyclara) or photodynamic therapy (Levulan with blue light).
Basal cell carcinoma (BCC) is the most common type of skin cancer and represent nearly 80% of non-melanoma skin cancers. They are typically found on sun-exposed sites and are associated with ultraviolet damage. The clinical spectrum ranges from superficial ill-defined scaly papules to well-defined nodular lesions to scar-like plaques. These lesions are often recognized by patients as non-healing sores or pink pearly papules or even flat white plaques. The superficial BCCs may vary in size from a few millimeters to a few centimeters. The growth pattern tends to be more horizontal, but they can become more invasive and produce induration, ulceration and nodules. There are several high-risk sub-types, including micronodular, morpheaform, and infiltrative tumors. Treatment is tailored toward the individual lesion based upon the subtype, location, and other patient factors. Early superficial lesions can be treated with electrodessication and curettage (“scrape and burn”) or even with topical therapies (Imiquimod). Most lesions on the trunk, arms and legs can be easily treated with standard excision and repair. For high-risk subtypes, high-risk locations (face, nose, ears, neck, hands, feet and genitalia), or large or recurrent tumors, they are most effectively treated with Mohs micrographic surgery. This procedure combines excision of the skin cancer with careful histologic evaluation of the margins to ensure that the tumor is completely removed. This tissue-sparing technique allows for the smallest possible surgical defect and ultimately a smaller, less conspicuous scar after reconstruction/repair. In addition, superficial radiation therapy can provide a highly-effective non-invasive treatment and is an excellent alternative to destructive or surgical therapies for the appropriately-selected patients.
Squamous cell carcinoma (SCC) is the other type of non-melanoma skin cancer and also presents most commonly on sun-exposed sites. They also may present as superficial scaly plaques or hyperkeratotic pink papules. They may develop de novo or in association with pre-existing actinic keratoses. It may be difficult to distinguish these lesions from superficial BCCs or inflammatory conditions, so a biopsy is often necessary to make the formal diagnosis. Much like BCCs, the treatment of these lesions must be tailored to the individual. Once again, more superficial lesions may be treated with electrodessication and curettage (“scrape and burn”) or with topical immunotherapies (Imiquimod or 5-fluorouracil). Surgical excision remains the standard treatment for routine cutaneous SCCs on the trunk and extremities. Mohs surgery remains an excellent option for more challenging lesions, including high-risk locations, large tumors, recurrent tumors or more atypical/aggressive tumors.
Moles are well-defined black or brown growths on the skin. While they are often flat and round, they can grow into soft papules nearly anywhere on the body. These growths are made up of clusters of melanocytes, which are the pigment-producing cells in the skin. Congenital nevi are moles that are present since birth. They can vary in size from the more typical smaller moles to large to even giant nevi. These can be simply monitored for any irregularities or atypical changes over time. If they are a cosmetic burden or psychosocial stress, then these growths can be removed often without much difficulty. The most common moles are acquired over time and may continue to develop throughout ones life. While they are usually harmless, they can change in size, shape, color or texture, which may signal atypical or cancerous growths. The atypical nevus, or “dysplastic nevus”, can range from mild to moderate to severely atypical. It is essential to recognize these atypical lesions as early as possible to identify more dangerous lesions. The mildly dyplastic nevus should be completely removed, but it is not demonstrate very aggressive behavior and often can be monitored for recurrence/regrowth of pigment after biopsy. The moderate and severely dysplastic nevi are often completely removed with simple excision and repair. There are some patients who have the “atypical or dysplastic nevus syndrome” with innumerable atypical moles involving extensive areas of their body. For these patients (and all others), it is essential to have regular skin checks and to perform skin self-examination on a regular basis to identify changing lesions.
It can be helpful to use the ABCDEs of melanoma to help patients identify concerning lesions:
A = Asymmetry
B = Irregular Border
C = Multiple Colors
D = Diameter >0.6cm
E = Evolving (Changing)
(F) = “Funny-Looking”
Melanoma is the least common and the most dangerous type of the more typical skin cancers. These lesions often present as asymmetrical brown or black spots or growths on the skin. These cancerous spots can develop from pre-existing moles or may develop as completely new growth. Regular skin self-examination may help to identify a worrisome spot which breaks one of the “ABCDE” Rules as described above. It is essential to identify melanomas in earlier stages because this more aggressive form of skin cancer can spread to other parts of the body and can cause extensive destruction and even death. A simple skin biopsy is needed to make the diagnosis. Importantly, the most superficial melanomas, or melanoma in-situ, are confined to the skin and are effectively treated with surgery. For all other melanomas, the depth of invasion (how deep the melanoma extends) is the most significant predictor of overall survival. The standard of care for the treatment of melanoma remains surgery with a margin of normal skin. Patients with intermediate-depth melanomas may have a biopsy of the sentinel lymph node, which can help determine if the tumor has spread from the skin. While there remains no single cure for a metastatic malignant melanoma, there have been major advances in medical research, and patients now have access to newly-developed treatments (Ipilimumab, Vemurafenib, & others).
In sum, melanomas are dangerous and can be life-threatening if not discovered early enough. It is essential for patients to examine their own skin and identify new or changing lesions to be evaluated. Regular skin examination and visits to the dermatologist can help to save patients’ lives. The use of advanced techniques, such as dermoscopy, allows for earlier and more accurate identification of these skin cancers.
Mohs Micrographic Surgery is an advanced surgical technique utilized primarily for the treatment of non-melanoma skin cancers (BCC and SCC). This technique allows us to save as much normal skin as possible and remove the skin cancer with nearly 99% cure rate. The first step is to anesthetize the skin and to remove the skin cancer. The second step consists of processing, freezing, cutting, and staining the tissue to prepare the slides. Next, the slides will be examined to ensure that the margins are “clear” and the skin cancer has been completely removed. The final step involves repair of the surgical defect, which typically involves absorbable and non-absorbable sutures. The surgical reconstruction requires us to plan for the closure to minimize the appearance of scars and hide them in natural lines wherever possible. This final step is essential for achieving the best functional and cosmetic outcome for our patients.