Question: I had an injury to my shoulder earlier this year and while the wound has mostly healed and is no longer scabby, the resulting scar is still painful, raised, hard and lumpy. It's bigger and uglier than the original wound. What can I do?
There are two types of scars that resemble what you describe and there's a lot we can do in the dermatologists office to help them look and feel better.
This type of scarring is usually after local skin trauma (e.g., laceration, tattoo, burn, vaccination or surgery) or as a result of an inflammatory skin disorder (e.g., acne, bites or abscesses).
Scars are composed of new connective tissue that replaces lost tissue in the dermis or deeper parts of the skin, as a result of injury. Their size and shape are determined by the form of the previous wound. The process of scarring is characteristic of certain inflammatory processes. A resulting scar can be thin (atrophic) or thickened, fibrous and overgrown. Some individuals and some areas of the body (e.g., anterior chest) are especially prone to scarring. Scars may be smooth or rough, pliable or firm, they can be pink or violaceous or become white. They can also be hyperpigmented (darkened). Scars are persistent and normally become less noticeable in the course of time.
Keloids & Hypertrophic Scars
At times though, and in certain anatomical locations (e.g., shoulders, sternum, mandible and arms) they can grow thick, tough and corded forming a hypertrophic scar or keloid. Under normal circumstances, wound healing takes place through the rapid and repeated reproduction of fibroblasts (the most common cells of connective tissue) at the wound site. But when fibroblast activity continues unchecked and excessive collagen (protein found in connective tissue) is deposited at the site of injury, the scar gets too big and a hypertrophic scar or keloid is formed.
A Hypertrophic Scar remains confined to the borders of the original wound and most of the time, retains its shape. It is characterized by hardness, redness and irritation compared to the surrounding skin and can take the form of a firm papule or nodule.
Conversely, a Keloid is an overgrowth of dense fibrous tissue that you'll notice extending beyond the borders of the original wound. Like a hypertrophic scar, a keloid can be hardened, raised and often darkly discolored. Keloids do not regress, appear to get better or shrink over time on their own. Instead they grow in a pseudo tumor fashion and distort the size and shape of the original lesion. If you know you have a hereditary predisposition toward keloid scarring, mention that to your dermatologist because then we will not try to surgically remove them (called excision) because keloids tend to recur.
The differences… A hypertrophic scar can occur at an any age and usually stays within the borders of the original wound, whereas a keloid commonly occurs in the third decade and enlarges beyond the area of the initial wounding with web-like extensions. Keloidal growth can also be triggered by pregnancy and compared with hypertrophic scars, a keloid can often be painful and super-sensitive.
How we treat stubborn keloids and hypertrophic scarring
We often use a 3-step process in the office to attack raised, hardened scars as soon as we notice a scar is exhibiting signs of hardening, as early as one month-post op, in the case of a scar due to surgery. The earlier you treat a keloid or hypertrophic scar, the better your results will be.
We inject 5-fluorouracil "5-FU" (used primarily as an anti-cancer drug but also used for the prevention of scars in glaucoma surgery for at least 15 years) combined with a specific low-dose corticosteroid (to reduce further inflammation and any pain) along with Pulsed Dye Laser treatments.
5-FU works to reduce skin's metabolism rate and inhibits the over-production of the fibroblasts building up on and around the wound. We combine that with Kenalog (triamcinolone), the low-dose corticosteroid, and perform injections one to three times per week, at regular intervals such as Monday, Wednesday and Friday, depending on how red, hardened and inflamed the scar is. Once the scar softens, injections can be reduced to two times per week, once a week and then every other week, monthly and finally, every six months. The Pulsed Dye Laser is used to decrease any redness, to normalize the wound surface and improve skin texture at the scar and to further blend scar into surrounding skin and we perform those treatments in intervals of four to eight months apart.
While any keloid or hypertrophic scar can be treated with this technique, you'll get the best results the younger the scar is. The more inflamed and symptomatic the scar, the better the response to treatment. Older scars that have been hardened for many years and are not inflamed, red, itchy or painful, will not respond as quickly or as thoroughly. Hypertrophic scars respond better than keloids, which frequently recur, although small isolated keloids (less than 2 cm in diameter) usually completely resolve with this technique without recurrence.
No matter what, keep all scars out of the sun for best healing, at least until the “pink” of new skin is gone because exposure to the sun only makes scars darker.
I second the advice of the The American Academy of Pediatrics, the U.S. Food and Drug Administration and the American Cancer Society:
Keep babies under 6 months old out of the sun entirely and do not apply sunscreen on babies younger than 6 months.
Babies who are 6 months or older should be protected with clothing, hats, a broad-spectrum sunscreen and shade. Look for broad-spectrum formulations specifically for babies and toddlers who have more sensitive skin than adults. The time that they spend in the sun should be very limited.
Did you know? More than half of a person’s lifetime sun exposure occurs before age 20.
Remember, skin keeps impeccable records, so every minute spent in the sun adds up as skin damage and possibly skin cancer. More than one million Americans develop skin cancer every year mostly from long-term exposure to ultraviolet radiation from the sun. UV exposure makes you look old before your time and causes:
- Leathering of the skin
Beginning with babies 6 months and older, limit time in the sun and protect skin with sunscreen and protective hats and clothing whenever exposed.
Question: As I've moved through my thirties and into my forties, I've noticed a marked change in my facial skin. I have some dark spots and discolorations and my face seems thinner overall and a little more sallow. I've heard about using a Retin-A cream but I thought that is for acne or wrinkles. Is it for me?
Answer: Actually Retin A is not just for acne or wrinkles. It is a simple, inexpensive topical cure-all for all pre-mature aging and photo-aging (skin damage caused by sun exposure). How your skin looks and feels as you age is influenced by many factors such as genetics, environmental exposure (sun, medication, mechanical stress), hormonal changes and metabolic processes. All of these factors, some of which have to do with your lifestyle and some you have no control over, cause a change in skin structure, function, and appearance as you age. Although, we dermatologists have studied and seen first-hand that solar UV radiation (sun exposure) is the single major factor responsible for the unwelcome, premature effects of skin aging on face, neck or back of hands such as:
- Coarser, rougher skin feel and appearance
- Irregular coloration and discolored spots or patches
- Discolored brown spots called lentigines
- Telangiectasias (little red visible blood vessels)
- Benign neoplasms (abnormal, yet non-cancerous, masses of discolored or raised tissue)
- Pre-cancerous lesions called actinic keratoses and lentigo maligna
- Cancerous lesions such as basal and squamous cell carcinomas and malignant melanomas.
So, what's a "retinoid?" First, a little science lesson. You may hear or read about a lot of terms that all have "retin" in them. That's because the retinoid family comprises vitamin A (retinol) and its natural derivatives such as retinaldehyde, retinoic acid and retinyl esters, plus many other synthetic derivatives. Vitamin A cannot be synthesized by our bodies, so it needs to be supplied and is naturally present in foods as the compound beta-carotene. Retinoids are required for a vast number of biological processes inside the body such as embryo development, reproduction, vision, growth, inflammation and cell differentiation, proliferation and apoptosis (naturally occurring cell death for normal cell growth stages). Retin-A (tretinoin) is the most popular retinoid for facial skin and is also the retinoid most studied for the treatment of chronological or photo-aging. I have tracked numerous studies which have repeatedly shown clinical improvement in photo-damage with tretinoin treatment, as well as with some other topically applied retinols such as isotretinoin and retinaldehyde (which are not my favorites because they are not as potent or stable.) Longer-term studies (6-12 months) on tretinoin were carried out once short-term studies showed that patients' skin condition continued to improve in appearance over time. Additionally, most of these studies compared the use of the various strengths of tretinoin to arrive at the optimal concentration for the treatment of skin aging.
How do retinoids work? Retinoids are known to speed up the cellular processes such as cellular growth and differentiation. Retinoids work on the skin surface by prompting surface skin cells to grow and die quicker and slough off faster, making way for new cell growth underneath. In this way, they cause discolorations and spots to lighten and they hamper the breakdown of collagen and thicken the deeper layer of skin where wrinkles start. Interestingly, current studies have found that the mechanism by which collagen and elastin are lost after skin is exposed to UV radiation may be blocked when topical tretinoin is applied before sun exposure. More studies are ongoing.
What about side effects? The most common and frequent adverse effect of topical retinoids is called the "retinoid reaction" which you may or may not experience as burning, peeling, reddened or inflamed skin at the sites of application or in skin folds such as around the nose or lips where additional product might be deposited by accident. It's this reddening and peeling that occurs within the first two weeks of use which cause many patients to give up therapy before realizing any of the benefits which can take two to three months or longer to see and feel. What most people don't know (or wait for) is that the skin builds up tolerance to the retinoid treatment and side effects eventually subside. Also, you can reduce application amount and days or try a lower potency formula to start if you experience these side effects.
The most important factor in success with tretinoin is to follow the entire course of treatment not to give up!
The other side effect associated with tretinoin therapy is photo-sensitization (you will be more sensitive to the sun's rays and burn easier), which normally occurs at the beginning of treatment. I always advise patients on tretinoin therapy to avoid excessive sun exposure and use a broad-spectrum sunscreen of at least SPF 30 (and a hat). Your skin’s response to UV radiation should also return to normal after a few months of treatment. We love combination creams I have found that the way to counter the side effects is to use a retinoid combination cream containing a corticosteroid to reduce inflammatory response and if discoloration or brown spots is one of your problems, you might want to add 4% hydroquinone (a known skin bleaching agent). We think that this combination may be even more effective than the individual components alone. Has tretinoin worked for you? How long did it take?
Question: Is it true that the sun’s UV rays are stronger in the South?
Answer: Yes, this is true. The closer your location is to the equator (the line that is equally distant from the South Pole and the North Pole which also separates the Northern Hemisphere from the Southern Hemisphere on a map or globe), the more potent the sun’s rays. This is because they hit the earth more directly for a greater part of the year which accounts for the higher skin cancer rates in “sun belt” locations. People who live or vacation in the Southern United States or in Central and parts of South America and Africa should be especially aware and diligant of the need for sunscreen, hats and protective clothing and eye glasses whenever outside.
You may see lots of tanner people in these locations and that’s because they are exposed so much more to the UV rays from the sun. Remember, there is no such thing as a healthy tan (no matter what society would lead us to believe) because tanning is the skin’s response to the sun’s damaging rays.
If you're unsure how close you are to the equator, check this global equator map.
Well, I've been saying this to my patients for years: Daily sunscreen use prevents the ugly results of photo-aging (spots, roughness and wrinkles caused by years of cumulative sun exposure which speeds up your skin's natural aging process) and finally a study published in a June issue of the Annals of Internal Medicine entitled, "Sunscreen and Prevention of Skin Aging," has proven this to be true.
Studies have already proven that sunscreen prevents skin cancer, but previous studies on photo-aging had always been done on mice so this new study performed on over 900 white people in Australia under the age of 55 and measured over 4 years just confirms what we dermatologists have been saying to our patients:
"If you want to keep spots and wrinkles at bay, use sunscreen every day."
Initially, the researchers weren't sure exactly what effect regular comprehensive use of sunscreen would have on skin aging caused by the sun over the years and they were also curious about the effect of taking dietary antioxidants such as β-carotene supplements to delay skin aging so they tested both.
The study was broken randomly into 4 sunscreen use groups:
- Specific daily use of broad-spectrum (protects against both UVA & UVB rays) sunscreen of SPF 15 applied to head, neck, arms, and hands each morning and after bathing, after spending more than a few hours in the sun, or after sweating heavily and 30 mg of β-carotene.
- Specific daily use (as described above) of the broad-spectrum SPF 15 sunscreen and placebo.
- Use of broad-spectrum SPF 15 sunscreen at the discretion of the participant and 30 mg of β-carotene.
- Use broad-spectrum SPF 15 sunscreen at the discretion of the participant and placebo.
Photos were taken of the backs of participants’ hands at the beginning of the study and 4.5 years later and were examined for microscopic changes of skin aging by researchers without the knowledge of which study groups the participants had been assigned.
The sunscreen use findings:
Interestingly, not all of those in the daily use group applied their sunscreen daily as directed. But more participants assigned to the daily sunscreen use group reported applying sunscreen at least 3 to 4 days each week compared to the participants in the discretionary-use group. Those in the daily-use group were 24% less likely to have increased skin aging after 4.5 years than were those in the discretionary-use group.
No overall effect of taking β-carotene supplements on skin aging was found.
My advice: If you want to prevent discolorations, spots and wrinkles from forming due to cumulative exposure to the sun's rays as you age, use a broad-spectrum sunscreen (and make sure it specifies so on the label) daily of at least SPF 15 whenever you are outside and exposed to the sun. Also, seek the shade whenever possible and wear a broad-brimmed floppy hat and sun glasses to protect facial skin and your eyes!
Question: My daughter is apparently allergic to many of the sunscreens I have tried on her and gets an itchy, burning rash. What is it in the sunscreens that is causing this reaction?
Most commonly, allergic reactions to sunscreens are caused by one of the original UVB sunscreen protection ingredients called para-aminobenzoid acid or PABA.
Read sunscreen labels and look for refined and newer ingredients called PABA esters (such as glycerol PABA, padimate A and padimate O) instead of the original staining, reaction-forming PABA.
New "broad spectrum" sunscreen ingredients
This year, the FDA requires sunscreens to protect against both UVB and UVA rays (labeled "broad-spectrum"), so new sunscreen ingredients have been developed and included such as include Mexoryl SX (ecamsule) and Parsol 1789 (avobenzone) which protect against UVA rays.
Physical sunscreens including titanium dioxide and zinc oxide have been around for decades. Remember Zinc Oxide on the noses of lifeguards back in the day? These ingredients physically block and scatter UV rays. These singular sunscreen formulas have no other chemical ingredients and so may be a better choice for sensitive skins. They also go on thicker and appear “whiter,” but they also stay on longer and are gentler to sensitive skins.
Despite advances in technology, formulating products with these ingredients without the skin-whitening effect has proven difficult. Zinc oxide has recently been approved by the FDA, like titanium dioxide, in microsized or ultrafine grades as an allowable active ingredient in sunscreen products with the ability to provide more full-spectrum protection. Zinc oxide is less whitening in this form than titanium dioxide and provides better UV protection. You can now find sunscreen products that contain these ingredients in combination with other sunscreen ingredients to increase their stability in water and sun and decrease unwanted "whiteness."
But remember sunscreen protection is all in the proper application. And, a lot has changed in how we recommend sunscreen to be purchased and used, so it pays to stay up on the news about sunscreen so you don't get burned (literally!)
Other buzz words for sensitive skin
You will notice lots of colorful kids' sunscreen products on store shelves you might want to stay away from. Try to avoid any sunscreen products containing dyes or perfumes, which are known allergens. And, for acne-prone or oily sensitive skins, definitely check for specific products labeled, "non-comedogenic" or "won't clog pores."
I cannot stress enough how important it is to be aware of sunscreen ingredients, especially when allergic reactions are concerned, and take the time to stand in the store aisles and read those labels!
Question: I've read many accounts online about an alternative therapy of using an herbal "Black Salve" to treat skin cancer, but then I also saw many scary photographs and read many scary stories of disfiguring skin damage from the treatment. What's your opinion? Just say "NO" to Black Salve and alternative cures you see online as skin cancer cures!
Answer: My opinion is firm: When it comes to any type of skin cancer, medical treatment has more than a 90 percent cure rate when lesions are caught early and removed and conventional medicine has an excellent track record in successfully treating skin cancer and restoring health.
In fact, while there may be a genetic predisposition (family history or skin type) to skin cancer, statistics show that 90 percent of all skin cancers are caused by long-term, unprotected exposure to the sun's UV rays. Those at highest risk are people with fair skin, blond or red hair, and those with blue, green or grey eyes and workers in outdoor occupations. So skin cancer prevention falls on you for keeping unprotected sun exposure to a minimum and in checking your own skin for suspicious growths and actively having them checked at least once per year by a dermatologic practitioner.
The skin cancer fear factor…
Once cancer is diagnosed, patients can get scared and can fall prey to online cure scams and alternative therapies that can do more harm than good, according to a 2009 FDA release entitled, "Beware of Online Cancer Fraud." "Anyone who suffers from cancer, or knows someone who does, understands the fear and desperation that can set in," said Gary Coody, R.Ph., the National Health Fraud Coordinator and a Consumer Safety Officer with the Food and Drug Administration's (FDA) Office of Regulatory Affairs. "There can be a great temptation to jump at anything that appears to offer a chance for a cure."
Black Salve on the FDA list of Fake Cancer Cures
From what I've read, Black Salve is the most the most widely known alternative therapy you will find online. It is an herbal topical treatment classified as an escharotic which is a substance applied to the skin that causes tissue to die and fall off. The types of Black Salve available on the internet today can be made from ingredients such as zinc chloride, chapparal (larrea tridentata) or bloodroot which are all caustic (or escharotic) to the skin.
The FDA release outlines how the salves are sold online despite being illegal and how they are sold with false promises that they will cure cancer by "drawing out" the disease from beneath the skin. "However, there is no scientific evidence that black salves are effective," says Janet Woodcock, Director of FDA's Center for Drug Evaluation and Research (CDER). "Even worse, black salves can cause direct harm to the patient." The corrosive, oily salves "essentially burn off layers of the skin and surrounding normal tissue," says Woodcock. "This is not a simple, painless process. There are documented cases of these salves destroying large parts of people's skin and underlying tissue, leaving terrible scars."
Black Salve does not distinguish diseased from healthy skin.
If you are questioning an alternative cancer cure you see online, check the FDA list, "187 Fake Cancer Cures Consumers Should Avoid."
That being said, I would not recommend desperate attempts at using Black Salve or other alternative therapies once skin cancer has already taken hold, especially since Melanoma is dangerous and can spread. Here's why:
- Alternative therapies have not been medically and scientifically tested for efficacy and safety .
- The use and sale of alternative therapies online is completely unregulated so you cannot be sure the purity or concentration of ingredients you are putting on your skin.
- Alternative therapies can contain unknown compounds with questionable benefit and the potential for great harm and they are promoted on the internet illegally without full consideration or information about potential toxicity.
- With alternative therapies instead of surgical procedures and medically researched treatments, there is a large risk of incomplete tumor removal and tumor growth and metastases (spreading).
- Alternative therapies untested on healthy skin leaves unwary patients open to damage of surrounding healthy tissues and marked scarring with poor cosmetic outcomes
If you think you have a lesion, spot or growth that could be skin cancer, go directly to the dermatologist who will test the tissue via a biopsy and advise you whether the tumor needs to be removed. In cases such as skin cancer, when medical treatment has a high success rate, don't look elsewhere at alternative therapies.
Have you been tempted by Black Salve? Did the online photos scare you away?
Question: I have a dark brown oval-shaped spot on my forehead and a cluster of them on my upper chest. I've heard them called age spots, sun spots and liver spots. What are they and how can I get rid of them?
Answer: These spots are medically called solar lentigines because they resemble the shape and color of a lentil bean and are flat (not elevated or depressed). It's a discolored oval spot. Usually, they are caused by sun exposure and the incidence is age-related (hence the term “age spots”) because the older you get, the more you’ve been exposed to the sun, the more likely they are to become visible.
They closely resemble freckles, but are usually larger and darker than freckles (remember the lentil?) Freckles are usually genetically determined whereas, unfortunately, solar lentigines are often a mark of photo (sun)-damage.
It's important to remember that this type of hyper-pigmentation can be a mark of malignant melanoma or other type of skin cancer such as a basal cell carcinoma or a squamous cell carcinoma and they may be accompanied by other chronic degenerative changes in the skin caused by sun damage. Early lesions of lentigo maligna (melanoma in situ) may be light to medium brown and mimic solar lentigines. Lentigo maligna, benign solar lentigo and pigmented actinic keratosis all occur on sun-damaged skin and multiple lesions of different types in the same area are common.Always see a dermatologic practitioner when a brown spot appears or changes, as a biopsy may be appropriate (remember the ABC's of spots?)
That said, we have many means of removing them and normalizing the discoloration, depending on where they are located and how many you have there:
Cryotherapy: Melanocytes (pigmented skin cells that cause the darkened spot) are very sensitive to cold temperatures and can actually be destroyed at -4°C to -7°C, therefore we effectively use liquid nitrogen cryotherapy applied to a singular spot for 5-10 seconds. The brown spot will turn white and crusty and new skin will emerge underneath in about a month. For one simple spot that is not on your face, cryotherapy is a great and inexpensive option.
Chemical peels: Medium depth chemical peels such as Trichloroacetic acid (TCA), for example, have been studied and had a fair response, but we use them cautiously because of irritation and redness. A chemical peel can be a good choice for a larger area or cluster of spots such as on the upper chest, but may need to be repeated to achieve desired results because you are only removing the outer-most layers of the skin each time.
Laser therapy: Of all the lasers available, some are more pigment-specific and attract the discoloration and act on it better than others. I have found Argon, Q-switched ruby and Er:Yag lasers are all effective on solar lentigines. We also use Intense pulsed light idepending on skin type, location and other variables. I also love fractionated laser technology for solar lentigines such as the Fraxel DUAL 1550/1927 or the Deka DOT Laser. I usually use fractionated lasers to treat the whole face, arms, legs or chest because it works so well for larger clusters of spots, although it is the most expensive option. Complications such as post-inflammatory pigment alterations (discoloration) can occur afterwards, so sun protection after laser is a must.
Topical treatments: The use of topical prescription retinoid preparations definitely takes longer, but they are an effective and certainly less expensive alternative to laser therapies for both a large cluster of spots or one spot, no matter where it is located. In studies comparing 0.1% tretinoin versus placebo, after the initial 10 months of treatment, there was an 83% improvement versus 29% in the placebo group and the upper extremities responded as did the face. After an additional 6 months of treatment, the lesions that had resolved during initial treatment did not recur during the 6 month follow-up period and patients continued to Improve. The major side effect: redness and irritation. Bleaching creams containing 4-5% hydroquinone used over a period of several months will lighten solar lentigines but possibly only temporarily. We have found that a combination of the tretinoin and 4% hydroquinone plus a corticosteroid may be even more effective for your specific spots than the individual components alone, although tretinoin alone does work beautifully on Asian skin.
No matter what your age, if you never want to see solar lentigines pop up on your skin, always use sunscreen labelled "broad spectrum" that blocks both UVA and UVB rays.
Have you successfully gotten rid of age-spots and solar lentigines? Share what worked best for you!
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?