Part III: Fun in the Sun / Nonmelanoma Skin Cancer
As I’m sipping my coffee on the oceanfront porch of our beachhouse rental while on family vacation, I think to myself, am I a total hypocrite? I am a dermatologist and dermatologic surgeon specializing in Mohs micrographic surgery in Charleston, South Carolina, one of the most touristed, beach-friendly, vacation-centric places in the Southeast. Every week I am inundated with patients young and old who are interested in taking care of their skin, preventing skin disease, skin cancer and optimizing their solar protection. However, while on vacation, I’m blown away by all of the vacationers who literally fry themselves to all shades of pink and red.
I think that a key part of helping my patients and intervening in a meaningful way is recognizing that the same people who are so interested in protecting their skin, are in fact, going to participate in the same cultural norms established over decades: fun in the sun. Whether it be fishing, boating, golfing, hiking, tennis, beach going, kayaking, kiteboarding, etc., human beings love being active and enjoying the great outdoors.
So while I’m sipping my coffee in the early morning sun, taking my heliocare and applying my second coat of sunscreen before 8 am, I notice partner is looking at me, rolling his eyes, as if I am slightly ridiculous. He lovingly jokes about my predictable type A, OCD, “wound up tighter than a tic” behavior and I smile. However I also realize that we have the power to rise above the hypocrisy. “Fun in the sun” doesn’t have to be mutually exclusive. All we have to do is honor our bodies and commit ourselves to photoprotection:
- Avoid peak sun hours
Seek shade when possible
Wear UV protective clothing
Wear a waterproof SPF 30 or higher sunscreen; apply regularly, every hour to two hours without exception
Take a B vitamin containing nicotinamide - known to prevent skin cancer
Take Heliocare - a natural, antioxidant complex that raises the threshold above which sun damage occurs
Get a skin exam every year with a dermatologist; if you have had a skin cancer, you’ll need to go every 4-6 months
Part three of skin cancer awareness month focuses on nonmelanoma skin cancer (NMSC). The type of surgery that I perform daily, Mohs micrographic surgery, deals with the surgical treatment of two types of skin cancers caused primarily by sun exposure: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).
Fortunately, these types of skin cancers are much more common than melanoma and much less severe, generally speaking. However if left untreated, these relatively indolent skin cancers can develop aggressive features and spread to lymph nodes and other organ systems. Therefore, it is essential to recognize and diagnose these cancers early in their evolution.
With some subtle differences and exceptions, NMSCs arise as pink or red, slightly rough/scaly, ulcerated/eroded, or waxy/translucent plaques on the skin. Many times patient will present with a “pimple that won’t go away”. These pesky facial lesions, often difficult to diagnose, especially in patients with rosacea or acne vulgaris, share a common feature: inflammatory lesions will resolve on their own; however, cancers will not. A general rule of thumb for me as a diagnostician, is that if a bump last longer than two weeks, a biopsy should be performed to exclude other pathology.
I am reminded how THOROUGH skin exams are so vital: basal cell carcinoma’s seem to hide themselves underneath full heads of hair, within axillary and inguinal creases and on the derrière. Certain types of squamous cell carcinoma have a predilection for genital skin and are often linked to the same human papilloma virus strains that can cause cervical and anal cancers.
Certain populations (i.e., Hispanic patients) grow basal cell carcinomas that express pigment, often causing concern for melanoma. However, by and large, Caucasians are most vulnerable to the damaging and carcinogenic effects of the sun, with rates continuing to rise.
Many of my patients are immunosuppressed, whether it be due to certain forms of leaukemias or lymphomas, the immunosuppressive effects of chemotherapies, or concurrent antirejection medicines in organ transplant patients. If you have leukemia or lymphoma, or on chemotherapy or antirejection medicines, please see a dermatologist every six months for a skin exam. This group of patients is very vulnerable to high-risk, aggressive SCC, especially on sun-exposed skin. SCCs that arise need to be diagnosed and treated ASAP, to avoid spreading.
Recent data show a dramatic increase in skin cancer incidence: A study in the Archives of Dermatology reveals that approximately two million people in the US develop over 3.5 million nonmelanoma skin cancers every year. This constitutes more than a 300 percent increase in skin cancer incidence since 1994. These new numbers are alarming but not completely surprising, as there has been a gradual and predictable rise in the rates of both nonmelanoma and melanoma skin cancers in the past several decades. In 1994, a report in the Journal of the American Academy of Dermatology estimated total US incidence of BCC and SCC at approximately one million cases per year. Since 1994, skin cancer procedures in several databases have jumped by 76.9 percent.
Dr. Brett Coldiron, at the forefront of dermatologic surgical research and leader in the American College of Mohs Surgery, thinks the dramatic rise can be attributed to several factors: it’s calculated the the number of skin cancers in 1994 was underestimated and probably closer to 1.5 million. In addition, it is suspected that the increase is due to sun exposurel, and, shockingly, a continued increase in the use of tanning parlors. Additionaly, the baby boomer generation is aging, and most skin cancer patients are over 65.
Check out these FAQs from the Skin Cancer Foundation:
NONMELANOMA SKIN CANCER
The diagnosis and treatment of nonmelanoma skin cancers in the U.S. increased by 77 percent between 1994 and 2014.6
About 90 percent of nonmelanoma skin cancers are associated with exposure to ultraviolet (UV) radiation from the sun.
Basal cell carcinoma (BCC) is the most common form of skin cancer. An estimated 4.3 million cases of BCC are diagnosed in the U.S. each year, resulting in more than 3,000 deaths.
Squamous cell carcinoma (SCC) is the second most common form of skin cancer. More than 1 million cases of SCC are diagnosed in the U.S. each year, resulting in more than 15,000 deaths
Organ transplant patients are approximately 100 times more likely than the general public to develop squamous cell carcinoma
Regular daily use of an SPF 15 or higher sunscreen reduces the risk of developing squamous cell carcinoma by about 40 percent
In conclusion, remember that YOU have the power to prevent skin cancer! We can still have fun in the sun, we just have to be smart. After reading this series of blog posts during Skin Cancer Awareness month, I hope to have helped patients understand the progression of skin cancers and sun-related precancerous damage, introduced methods of skin cancer prevention and empowered patients to have healthy, youthful, radiant, cancer-free skin. Remember to see your dermatologist regularly, wear sunscreen and know what to look out for. Skin cancer is entirely preventable so stay healthy, have fun and be safe everybody!