Question: My dermatologist gave me a topical cream with special ingredients to prevent skin cancer where he thought it might be forming. How is that even possible?
Answer: It is now possible and FDA-approved. There are some new topical medications that target different mechanisms to halt cancer cells from growing.
5-fluorouracil (5-FU): This long-standing chemotherapy drug has been used internally and is also now FDA-approved for use on top of the skin to prevent and treat superficial Basal Cell Carcinoma (BCC). It is the active ingredient in proprietary topical skin cancer prevention formularies and several prescription creams with 5-FU or related medications available by prescription.
When applied on the skin topically, 5-FU selectively targets and destroys only cancerous or precancerous skin cells damaged by sun and aging while leaving normal skin cells alone. It's something you can use at home, under a doctor's supervision, on many parts of the body such as chest, neck, hands, legs and back.
A course of treatment usually lasts approximately 14 days. After several days of initial application, the appearance of redness, scaling, and eventually crusting occurs on treated areas and indicates that precancerous cells are dying; how soon they appear and their severity depends on the strength of the 5-FU product and how often it is applied. The end result is a healthier looking, more attractive skin with a reduced tendency to develop skin cancer.
Imiquimod: This cream is FDA-approved to treat superficial BCC’s that works by stimulating the immune system and causing the body to produce interferon, a chemical that attacks cancerous cells. The cream is rubbed in the the lesion 5 times a week for 6-8 weeks (sometimes longer). This treatment can also produce some discomfort, redness, irritation and inflammation.
Cure rates for both are 80-90 percent because they kill active cancerous or precancerous cells over time instead of all-at-once.
Never self-diagnose or try to use these medications without a doctor's supervision, as in the rare case a BCC is locally advanced or metastasizes (spreads), the cancer can become dangerous, even life-threatening.
Have you tried 5-FU or any of the topical skin cancer prevention treatments?
Question: My dermatologist said my scab was a Basal Cell Carcinoma...Now what? Do I have cancer?
Answer: Relax. A Basal Cell Carcinoma (BCC) is rarely the spreading cancer that requires the systemic chemotherapy you're thinking of. Cure rates for BCCs are close to 100 percent, and are easily treated when caught early.
After having your skin examined, the diagnosis of BCC is confirmed by biopsy, which is when the skin is numbed with a local anesthetic and a sample of your lesion is removed and sent to be a lab for examination under a microscope. If tumor cells are present, treatment is required. BBCs rarely spread beyond the original tumor site so we simply remove them by any number of methods depending on the type, size, location and depth of the tumor as well as your age and general health. Since BCCs are visible on the surface of the skin, we also take the likely outcome to your appearance into consideration.
Usually, treatment is performed on an outpatient basis in a dermatology office.
A local anesthetic is almost always used so pain during the procedure is minimal, although you may have some mild discomfort afterwards. After removing a small BCC, wounds heal and the scars are usually cosmetically acceptable (and there are many other methods or repairing or improving any resulting damage that is undesirable to you).
The types of treatment include:
- Curettage and electrodesiccation: The growth is scraped off with a sharp, ring-shaped instrument (called a curette), and the tumor is dried out (dessicated) and destroyed with an electrocautery needle. The procedure is often repeated during the same procedure to ensure that all the cancer cells are eradicated. It has a 95 percent success rate for smaller lesions (and often for the first biopsy), although often not useful for aggressive BCCs or in those sites that where any scarring would be highly undesirable as sometimes a white scar is left at the surgical site.
- Mohs Micrographic Surgery: A physician specially-trained in Mohs Micrographic Surgery removes a thin layer of tissue containing the cancer and while the patient waits, the frozen previously removed sections are examined under a microscope by the Mohs surgeon. If skin cancer is still present in any of the tissue, the procedure is repeated only on the area where those cancer cells were identified, until the last layer is cancer-free. This technique saves a great amount of healthy tissue and has a high cure rate of 99 percent or better. It is often used in cosmetically important or large, critical areas and in those areas that have recurred, are hard to pinpoint or in critical areas with little tissue to spare such as around the eyes, nose, lips and ears.
- Excision surgery: We use a scalpel to remove the entire growth along with a surrounding border of apparently normal skin (called a safety margin) and then the site is closed with stitches. A specimen is sent to the laboratory for microscopic examination to verify that all cancerous cells have been removed. Although cure rates are above 95 percent, if the tissue analysis shows cancer cells at the margin of tumor, a repeat excision may be necessary.
- Radiation: X-ray radiation may be used in tumors that are hard to manage surgically, elderly patients or other patients in poor health. The radiation is directed at the tumor, with no need for cutting or anesthesia and total destruction usually requires several treatments a week for a few weeks. Cure rates are around 90% because the technique is not precise in identifying and removing cancer remaining at the margins of the tumor
- Cryosurgery: While not often used, sometimes we can destroy very superficial BCCs by applying liquid nitrogen to the growth with a Q-tip or a spray to freeze it, which also does not require cutting or anesthesia. After the treatment, it may be blistered, crusty and fall off within weeks and the procedure can be repeated.
- Erivedge™ (vismodegib): The first oral medication approved by the FDA for the treatment of advanced BCC which is used for the limited circumstance where the nature of the cancer prevents the use of other treatment options. (Should not be used in woman who are pregnant or child-bearing.)
- Topical medications: Certain prescription topical creams, gels and solutions are FDA-approved to treat limited specific BCCs and some are used to prevent possible BCCs from growing.
The best treatment for BCCs is prevention: Always wear sunscreen of SPF 30 or higher on exposed skin exposed and wear a hat whenever possible!
What's your story about BCCs?
Answer: Those brown spotted areas on your face are called melasma, and the discoloration is caused and worsened primarily by sun exposure. The result can be a mask-like, spotted or confetti-like appearance that generally involves cheeks, forehead, upper lip, nose, jaw line or chin. Melasma occurs more frequently in Fitzpatrick Skin Scale types III, IV and V, (which I described in my last post about post-inflammatory hyperpigmentation), and 63% of all cases of melasma are in darker-skinned Caucasians. Melasma doesn't cause any other skin symptoms aside from the unwelcome skin discoloration which is usually (unhappily) matching on both sides of the face.
The hormonal influence…it’s a woman thing
Female hormonal triggers play a large role so the condition generally affects women. In fact, melasma occurs in 50%-70% of pregnant women, usually during the 2nd or 3rd trimester, and is called chloasma or, “the mask of pregnancy.” In women who use oral contraceptives, we see melasma on the upper lip, both sides of the forehead and jaw line. We also see melasma form on post-menopausal women when hormone replacement therapy includes progestational hormones.
How sun exposure (UV radiation) stimulates melasma formation:
- Skin cells which produce melanin (skin pigment) are stimulated by UV exposure
- This causes a rapid onset of melasma and speeds up formation once a hormonal trigger is in place
3-Step Rx for melasma
Good news: Melasma is usually treatable when it occurs in the epidermal (outer) layers of the skin, which is 70%-90% of cases. Here’s how we get rid of epidermal melasma:
- Sun Protection: Avoiding sun (UV radiation) exposure is the first line of defense for treating melasma now and avoiding melasma in the future. Wear sunscreen on your face daily and use additional protection such as a hat to protect your skin from further discoloration.
- Use a 4% hydroquinone cream: Considered the gold standard in skin discoloration treatment, this ingredient inhibits the enzyme activity responsible for melanosome formation (melanin-containing cells) and the conversion of tyrosine to melanin which forms the dark spots. Treatment is usually 20 weeks.
- Use a retinoid cream in addition: Retinoids (vitamin A derivatives) increase the rate of epidermal skin cell turn-over so the excess pigmentation is carried out of the skin where it can be sloughed off. Retinoid treatment is also 20 weeks.
A new topical cream we are using is called Tri-Luma® Cream because it contains a combination of 4% hyrdroquinone, a retinoid and an anti-inflammatory all-in-one. In studies, 29% of patients experienced complete clearing of skin when used for only 8 weeks of treatment.
For those with an allergy to hydroquinone, alternative ingredients include kojic acid and azalea acid, although considered weaker hyperpigmentation agents. They are also often used in conjunction with other topical medications. For more severe cases, peeling agents or laser treatments may be indicated but must be balanced against the risk of post-inflammatory hyperpigmentation afterwards.
Basically, if you don’t want melasma, don’t give the sun any face time!
Have you ever noticed spots the sun has left on your face?
Question: My teenage daughters love using tanning beds, especially now that its winter. Tell me once and for all, is this a dangerous practice leading to skin cancer or a safe way to get some color? I’ve read conflicting reports online...
Answer: Did you know that 36 states currently restrict indoor tanning use by minors, and in October, 2011 California became the first state to prohibit the use of indoor tanning devices for all children and adolescents under the age of 18? Also, in 2011, the American Academy of Pediatrics called for a ban on youth tanning and the American Academy of Dermatology supports this ban. As a mom and a dermatology practitioner knowing what I know and seeing what I see every day in the office, I support this ban. But when teens want to do something its hard to persuade them of future danger as a reason not to do it...in this case, indoor tanning. You can only tell them the truth.
The use of tanning bed safety has been in debate since the first tanning bed came into use in the 1980’s. Since then there has been much research into the types of Ultraviolet (UV) rays emitted by tanning beds, in what concentrations as well as how they cause skin cell DNA mutations that lead to cancer. Currently, approximately 90 percent of all skin cancers are associated with exposure to UV radiation mostly from the sun.
But, in 2009, a group of 20 scientists from around the world convened for the International Agency for Research on Cancer (IARC), part of the World Health Organization, and added UV radiation from tanning beds to the IARC’s Group I list of the most carcinogenic (cancer-causing) forms of radiation.
The reason for the debate on tanning bed safety is that tanning devices use fluorescent lamps which emit mostly UVA rays (UVB rays represent less than 5 percent of the lamp’s output) to induce a quick tan. And, by the end of the 1980’s, scientists had documented the carcinogenic properties of UVB rays: That they caused pre-cancerous DNA cell mutations in skin, triggered growth of squamous cell carcinomas in rodents and that UVB rays were the primary cause of sunburn. There was no proof yet of any link between UVA exposure and skin cancer. With only a low amount of UVB emitted from a tanning bed, tanning salons could argue that tanning bed use was safe (or even safer than outdoor sun exposure) when obtained in a salon.
Since then, data has mounted and strengthened the evidence for a causal relationship between high doses of UVA exposure, indoor tanning and skin cancer, especially melanoma of the skin and eyes. Be wary of any safety or health claims made by indoor tanning salons, the American Suntanning Association or the Indoor Tanning Association:
- No scientific evidence supports a claim of a protective effect from tanning bed use against future sun damage (getting a "base tan"), as you may have heard.
- There is no such thing as a "safe" tan because a tan, and especially a sunburn, is skin's reaction to damage caused by UV radiation (whether from the sun or a tanning bed) and it causes DNA changes in the skin cells.
- The tanning industry jumped all over the news that Vitamin D from sun exposure is necessary for health, and that it was safer to get that Vitamin D from a tanning salon rather than outdoors. It is not.
Here are 5 strong findings from June 2009 IARC monograph that put tanning beds in the classification of most carcinogenic forms of radiation:
- UVA causes similar but deeper skin damage: The cancer-causing mechanisms of UVB differ, but often overlap those of UVA rays. Sun exposure causes a specific cell mutation pattern that was thought to be caused by UVB rays, but researchers have now tested and found the same pattern in the skin of UVA-exposed mice (the Tp53 gene of UVA or UVB-induced skin tumors of hairless mice and the TP53 gene in human actinic keratoses -precancerous sun spots- and malignant skin tumors). UVA rays actually penetrate the skin more deeply than UVB and can damage cells (including melanocytes, those that produce the skin pigment in a "tan") deep in the dermis whereas UVB rays cause damage to the epidermis, skin’s outermost layer. UVB rays cause DNA mutations directly and UVA rays cause more indirect damage. For example, recent evidence found that the body’s repair and removal of damaged DNA is impaired when caused by UVA rays.
- Time span of tanning bed use increases melanoma risk: Experiments in human volunteers show that tanning lamps produce the types of skin DNA damage associated with sun exposure but that the excess UV exposure in the stronger tanning beds used more often than routine sun exposure, over time, can weaken the immune system and increase vulnerability to cancer and other diseases.
- Intensity of tanning beds increases melanoma risk: We now know that tanning bed units may be 10-15 times stronger than midday sunlight on the Mediterranean Sea, which subjects indoor tanners to UVA doses above those experienced during daily life or even when specifically tanning or active outdoors. Reviews of epidemiological (specific population) studies provide strong evidence that the intermittent, intense sun exposure (the type from outdoor weekend activities or sunny vacations) which leads to sunburn, is the main environmental risk factor for melanoma (the most dangerous form of spreading skin cancer) and that this pattern of over-exposure is simulated by indoor tanning bed use designed to induce a quick tan.
- Youth tanning bed use increases melanoma risk: Tanning beds have greater potential to cause melanoma at younger ages than even chronic sun exposure. Currently, 30 million people tan indoors every year in the U.S. and 2.3 million of them are teenagers, like yours. Also, melanoma is now the most common form of cancer for young adults aged 25-29. Although epidemiological studies have not consistently shown that tanning bed use is always a risk factor for melanoma that starts in the skin, a 2006 IARC meta-analysis (review of many studies) found a significant increase in melanoma risk (40-228% increase) when indoor tanning bed use started as a teen or young adult. An overall 75% increase in melanoma risk was found when indoor tanning bed use began before age 35.
- Not just skin cancer, but dangerous eye cancer, too: Even scarier, 4 case-controlled studies consistently reported an increased risk for ocular (eye) melanoma with a clear causal relationship among indoor UV tanners and an even greater risk for subjects who started indoor tanning before age 20. Eye cancer is a risk even with goggle use because the rays can get in around the goggles.
All the recent research on UV rays substantiated a role for both UVA and UVB in human skin cancer development and especially melanoma, the most dangerous form of cancer that starts in the skin and can spread. So, the entire UV spectrum and UV-emitting tanning devices were classified as carcinogenic to humans.
It's true that teenagers think they are impervious to danger. But at least you can provide them with the current scientific facts...and a reason to check their bodies for any suspicious, new or changing freckles, moles or scabs or spots that could be pre-cancerous or more.
If anyone has found a way to get their teens to stop indoor tanning, please share it here!
- Reduce Retin-A use. The great thing about Retin-A is that you can cut down your usage and it still continues to work. Instead of using your Retin-A twice every day (at bedtime) try applying it every other day or even two or three times a week. Experiment with the amount you can use without causing the drying effects.
- Switch out the Alpha Hydroxy Acid lotion. Instead, use an emollient (thick) cream moisturizer to help avoid cracking, peeling and chapping. You can even apply this over your Retin-A.
- Leave the long, hot showers. Hot, hot water irritates skin's top layer and also strips it of its natural oils, leaving it unprotected and open to cracking and peeling. Instead take a quicker, lukewarm shower, less than 10 minutes tops, and pat skin dry gently (no harsh rubbing on skin or hair). While skin is still damp, apply a super-rich cream moisturizer for hands, feet and anywhere else you are dry and cracked.
- Don't forget the sunscreen. Just because it's not summer doesn't mean the sun is not strong. Skin is always vulnerable to the sun's damaging UV rays so I always recommend patients use a daily facial SPF of at least 30. Especially protect skin when doing winter sports such as skiing or ice-skating outdoors - some of the most severe sunburns occur while skiing since snow reflects sunlight (plus the wind-burn). Don't forget to protect lips with a sunscreen, too.
- Try a humidifier. If the heating air in your home is especially drying to your skin, turn on a humidifier all day and all night to help keep skin and nasal passages from drying out.
Question: I have been using Rogaine for 6 months and I have recently noticed several deep wrinkles forming under my eyes, specifically the side I sleep on. I know there are some testimonies on the internet and on Wikipedia about minoxidil causing collagen depletion so I’m wondering if this is true or just an internet rumor?
Answer: So, I dug down to the research for your answer. Minoxidil has been shown in cell culture (outside of the body, also called, in vitro) studies to have range of inhibitory effects on skin fibroblasts (a type of cell that produces collagen). It has also been reported that minoxidil hinders collagen synthesis and inhibits the effects of specific growth factors, substances that are capable of stimulating cellular growth, in cultured hair dermal papilla of rats (yes, rats, not humans!) But applying these results obtained in cell culture studies or rats to the use of minoxidil in humans is uncertain.
There are no human studies demonstrating that minoxidil causes collagen depletion or wrinkles as a side effect (and there are many studies of minoxidil effects on humans). Even though there are anecdotal reports online stating this, minoxidil has been used for over 25 years and there are no real complaints or published reports in clinical practice (with patients).
You are smart to ask a professional when faced with internet rumors, especially when it comes health issues, because side effects of medications and even over-the-counter products are largely personal. Also, facial wrinkles are known to form in response to repetitive muscle movements such as facial expressions and patterns over time, such as the side you sleep on. A good idea would be to schedule an appointment with a dermatological practitioner to review your age, medical history, lifestyle (such as sun exposure) and skin and hair loss condition as well as your usage of minoxidil to see if any alterations (a weaker percentage or foam instead of liquid) or additions to your treatment plan need to made.
Answer: Of course the answer’s not that simple! Everyone’s propensity to form a dark spot in response to anything that causes skin redness and swelling, (medically called post-inflammatory hyperpigmentation) varies depending on skin type, ethnicity and racial group as well as the severity of the inflammation and its duration. That’s because the amount melanin (light-absorbing pigment) and type of melanosomes (pigmented skin cells) have a significant impact on the formation of a dark spot in your skin. To avoid dark spots from forming at all costs, it’s a good idea to first know what skin type you have. Your Fitzpatrick Skin Scale type depends on genetic disposition and your skin's reaction to sunlight and tanning. Dark spot intensity and duration is linked to skin hue and more pronounced in skin of color, especially phototypes IV-VI. Click the link above to take the quiz and find out if you’re more at risk for developing dark spots, then read on. What causes dark spots?
- Any skin disease, infection or injury-producing inflammation
- Insect bites
- Razor bumps (pseudofolliculitis barbae or PFB)
- Allergic or contact irritation (dermatitis)
- Surgical or cosmetic procedures
Treat recurring conditions immediately! The darkness, or intensity, of the spot, area or scar left behind depends on the duration of the inflammatory process underneath the skin and whether or not is has a chance to reach deeper tissues and cause damage. In response to a skin eruption or inflammation, melanin is over-produced at the site causing the skin-darkening. The longer the period of inflammation, the darker the postinflammatory hyperpigmentation response so action should be taken to avoid or intervene on any known causes of inflammation such as acne and PFB and treatment should be instituted as quickly as possible to stop the inflammation from damaging skin’s deeper tissues and causing the dark spot response. Skin conditions with a recurring nature such as acne or PFB intensify the hue of dark spots as do skin diseases that disrupt skin's basal layer such as lichen planus, psoriasis eruptions and lupus) Stay out of the sun! In addition to any post-inflammatory response, UVA and UVB exposure also stimulate increased melanin production so limit sun exposure by walking on the shady side of street, wearing a hat, sunglasses and use sunscreen daily on exposed, inflamed, irritated or healing areas. Sun exposure frequently darkens hyperpigmentation and chronic sun exposure may result in a longer resolution period of any dark spots. Don’t let scabs form! For any skin eruption (acne, insect bite), injury or surgery where the skin is open (no matter what the cause) never let a dry scab form and never pick at, squeeze or further exacerbate the inflammation! Acne surgery can be performed by medical professionals to help acne heal faster to avoid skin damage and spots. Keep the area covered with antibiotic ointment until there is no crust at all and new skin is formed. And keep that area out of the sun the whole time it is healing and protected with sunscreen at all times until skin has returned to normal. Rx for already-formed dark spots Hydroquinone 4%: This melanin-inhibitor is the most widley-used active ingredient to fade dark spots. It is available at 4% strength by prescription only and at weaker concentrations (which you can try first) over-the-counter. Depending on the age and darkness of a dark spot, therapy may be required for 20 weeks, although you may see results much sooner than that. If only used on one spot, sometimes a light ring of lighter skin surrounds the area like a halo, and this halo effect disappears when the hydroquinone is discontinued. Do not use hydroquinone if it is a known allergen and watch out for any irritation or further discoloration (called exogenous ochronosis) in which case hydroquinone should be discontinued. Azelaic acid: An alternate, but slightly weaker ingredient for treatment if you're allergic to hydroquinone. Similarly, kojic acid and glycolic acid are two more ingredients for hydroquinone-intolerant patients. Combinations: We have even found that combinations, depending on your skin type and condition, including hydroquinone , and/or a corticosteroid, retinoid and Combinations are more effective than 4% hydroquinone alone. These can be prescribed if necessary by a dermatologic practitioner. Chemical peels: Chemical peeling agents have been found effective in removing dark spots, but be mindful to start with the lowest concentration and then move upward because you want to avoid any additional postinflammatory hyperpigmentation caused by chemical peeling agents Follow my advice and you will see spots fade and fewer spots form!
Question: My hair has been thinning considerably for several years now, and my hairdresser recently found some strange spots on my scalp. What are they?
Answer: Watch out for basal cell carcinoma (BCC), the most common, treatable form of skin cancer, on your scalp, especially if you are balding or your hair is noticeably thinning.
Think about it: The top of your head, forehead (and also your nose) is exposed to the sun's harmful rays more than any other part of the body. Once you lose the cover of your thicker hair, your scalp is highly vulnerable.
The tricky thing about BCCs is that those who have had one BCC are at an increased risk for developing more tumors later in the same area or elsewhere on the body and you may also be at risk for other types of skin cancer. And the recurrence of scalp BCCs is even higher within the first two years after surgery because of the constant sun exposure.
No matter where you (or someone else) notices any type of strange lesion (there are 5 warning signs of a BCC), check in with a dermatologic practitioner regularly so your entire skin surface can be examined, especially in places like the top of your head that you cannot easily see yourself...and wear a hat!
Has anyone else ever found strange spots on you? What did they turn out to be?
Question: I've noticed a small sore like a scab on my left upper arm that will not go away. What could that be? What should I do about it?
Answer: Your sore could be a Basal Cell Carcinoma (BCC), so don't take it lightly.
Sometimes a BCC can resemble something else like a mole, psoriasis or eczema, a scar or any irritation. My rule of thumb is to watch it for one month: If it does not go away or it enlarges or changes get it check out by a dermatologist, for an accurate diagnosis. The reason is because BCC is the most common type of skin cancer we see and anyone with a history of sun exposure is at risk of developing BCCs. A BCC is medically defined as any abnormal, uncontrolled growth or lesion that occurs in the skin’s basal cells (which line the deepest layer of the epidermis, the outermost layer of skin). They can start out as a barely noticeable lesion or rough patch, and while they rarely metastasize (spread) to larger organs beyond the original tumor site, they can be highly disfiguring and destructive to surrounding skin, if allowed to grow.
Who is at risk for BCCs? Aside from extensive exposure to UV sun rays such as in workers or athletes or even those who spend a lot of leisure time outdoors, we consider those with fair skin, blond or red hair, and those with blue, green or grey eyes to be at highest risk.
BCCs have generally been seen in older people but lately it seems the patients we are treating are younger and younger. And men have historically outnumbered women, although the number of women under age 40 diagnosed with BCC has more than doubled in the last 35 years.
There are five warning signs of a basal cell carcinoma; two or more are usually present in one tumor:
- Any non-healing open sore that bleeds, oozes or crusts and remains open for more than 3 weeks can be a very early sign of BCC.
- Any reddish or irritated area on the face, chest, shoulders, arms or leg which can be patchy or crusty may itch or hurt or may not have any sensation at all.
- Any pink growth that is slightly elevated with a rolled border and a crusted indentation in the center. If left to grow, tiny blood vessels may develop on the surface as it enlarges.
- Any shiny bump or nodule, often confused with a normal mole, that is pearly or clear, pink, red, white or even tan, black, or brown, especially in dark-skinned, dark-haired people.
- A scar-like area that is white, yellow or waxy and often has poorly defined borders or skin that looks shiny and taut, which indicate an aggressive, invasive BCC that is larger than appears on the surface.
BCCs are easily treated when caught early and cure rates are close to 100 percent, so any lesion that has been around for one month should be checked as soon as possible and treated and monitored by a dermatologist.
Do you have a growth that worries you? What does it look like?