Skin Cancers and Skin Lesions, Body Mapping, In Memorium: Rita Herkel

Skin Cancers and Skin Lesions'}
Body Mapping
In Memoriam: Rita Herkal

Skin Cancers and Skin Lesions

In mid-August we sent out a newletter extra linking to a report (no longer available without charge) suggesting that the widely touted "epidemic" of melanoma may be more hype that truth. That said, melanoma is the one condition we don't want to miss. If you have any question about something on your skin, we can answer it with a brief look or, at most, a ten-minute biopsy.

This month we'd like to give you more detailed information about bumps and spots on the skin, both cancerous and benign. Skin lesions sit right on the surface where you can see them. It is easy for your physician to remove a piece of skin, send it to the lab, and find out what it is. If something looks funny, ask your doctor. He or she is used to seeing these spots and will know if it should be biopsied.

To add to the following written descriptions of skin conditions, we're giving you web links to graphic photos. You'll need broadband access to see the images in a reasonable amount of time. Don't click on these links while you are eating.

WARNING

This brief survey of skin lesions doesn't show every possible variation. Something can look entirely different from any of these pictures and still be dangerous. Check with your doctor if you have any question.

Moles

The most common skin lesion anyone sees are the moles, or in technical terms, "nevi." Most moles are benign and need cause you no worry unless they change. Warning signs include asymmetry, irregular border, and variation in color.

Here's a mole, unchanged since birth, benign:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1079405212.

Most moles are benign, but sometimes they can develop into melanoma. Here is one that has some warning signs. This one turned out to be benign on biopsy:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1611469625.

This is a person with a family history of multiple moles: these have fuzzy borders and some variation in color but are benign:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=-1651416487.

Cherry Angioma

Cherry angioma are small, smooth red bumps. These are always benign. They are very common as we grow older, and here's what they look like:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=-871732569.

Seborrheic Keratosis

Another very common benign type of barnacle is the seborrheic keratosis. The outer, horny layer of the skin thickens, fails to flake off as it should, and builds up a tenacious brownish lump.
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=-1174005986
Sometimes these are a sign of vitamin A deficiency. When these irritate people, we shave them off under local anesthetic. There is always normal skin underneath.

Actinic Keratosis

Actinic keratoses are growths on the outer layer of the skin. Actinic means "caused by the sun" and keratosis refers to a growth of the outer, keratinous layer of the skin. Dermatologists call this condition AK. Actinic keratosis lesions appear as whitish scaly patches, easily scratched off. They then reappear. Estimates vary, but about 8 percent of these spots progress to squamous cell cancer (described below), usually over a period of years.

You can prevent AK by avoiding excessive exposure to the sun. People with fair skin that burns easily need to take extra care.

If you do find one of these spots, you have a choice of treatment. Freezing is quick and easy; the area will return to normal in two or three weeks. However, if you have several of these spots, or they tend to re-occur, you might wish to treat them with 5-fluorouracil (5-FU). Basically, 5-FU is a poison which, taken intravenous, will hammer certain cancers (and make you quite sick as well). Applied to the skin, all it does is chemically burn off the actinic keratosis. Once a day for three weeks will do it. Applying this ointment is more work for you but much less expensive than freezing. Retin-A (the anti-wrinkle cream) is often effective but takes even longer. Retin-A may prevent actinic keratoses in those prone to them. Here is a picture of an actinic keratosis:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1192148361.

Squamous Cell Carcinoma

Squamous cell carcinoma, (dermatologists shorthand is "SCC") is a cancer that affects the middle layer of the skin. It is relatively slow growing. It is usually painless at first but may develop into a painful ulcer.

An SCC can just "look funny." The main tip-off is rapid growth over a period of months. SCC is rarely invasive or metatastic, but the lesions will grow, so they should be removed.

The following web links show how squamous cell carcinoma may look. This one appeared at first to be a wart:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1290941203.
Here's another, on the neck:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=-682507583 and another on the forehead, appearing to be a "horn":
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=275472706.
Here's a "funny looking bump" on the nose that wasn't benign. It is an SCC:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=149977275.

If a squamous cell carcinoma is ignored for some time, it can look like this. Even at this stage, the likelihood of metastasis is small. The lesion can be removed, though a noticeable skin graft will be required to replace the missing skin:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=2128736319.

Basal Cell Carcinoma

The second of the "big three" skin cancers is the basal cell carcinoma. This is the most common cancer, the least threatening and the one linked to UV skin exposure. These carcinomas tend to develop in areas exposed to the sun. The cure rate is high. Often just removing the skin lesion for biopsy is all the treatment required. But if ignored, they continue to grow.

Here's a typical basal cell carcinoma. The tip-off is that the edges tend to heap up and the center ulcerates:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=-451564798.

Usually we see these at an earlier stage - this is more typical in size and in subtlety of the central ulceration. The dilated blood vessel, not always present, is called a telangiectasia:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=-1147321311.
Here is another common one -- this is the "sore that doesn't heal" the American Cancer Society warns you about:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1608076122.

Don't ignore these lesions. They don't get smaller. Here's one after seven years:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1456859743.

A final word on basal cell carcinoma - these lesions can be subtle. Show your physician anything that is growing larger:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=-128017454.

Melanoma

Melanoma is the most dangerous kind of skin cancer. It affects the pigment (melanin) of the skin. It can develop on a mole or on unblemished skin. It is rare but rapidly spreading and requires quick attention. Show your physician anything that looks at all "funny" or is changing.

Here is a mole with a melanoma developing off to one side:
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1432575415.
That's pretty obvious; this one isn't.
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=1172892284

Body Mapping

While we tell patients to mind their ABC's of dangerous moles (A for asymmetry, B for irregular Border, C for variation in color as well as D for diameter greater than 1/4 inch), the real warning sign is E -evolution. If something is changing, take action. For people with many moles, how do you tell when one is changing? The answer is photography. Many dermatology centers will take a series of 36 images of the skin, carefully arranged to cover every bit of skin and to be sure it is clear what piece of skin is in a particular photo. You can have this done for $75 to $250 at a medical center.

I don't know how practical it would be to do this at home with your digital camera. If you try it, be sure to include a ruler in every photo and take the pictures in such a way that you'll be able to remember what area of skin you are looking at. Use natural light and check to be sure the color in the photo accurately mirrors what is really there. If you can locate a useful method on the Internet, or develop one yourself, let me know. I'd like to share it.

Final Digital Camera Tip

Any time you have a rash, take a picture with your digital camera. That rash may be like a rare spring flower, here today and gone tomorrow. So when you see me two days later and the rash is almost gone, we can still have "show and tell!"

In Memoriam: Rita Herkal

Last week Rita Herkal died in a bus accident in Africa while managing construction of schools in Malawi. A passionate 27-year-old humanitarian, she worked with Building with Books (www.buildingwithbooks.org), a non-profit organization that builds schools in developing countries and works to establish self-reliance through education. Previously she had worked with the Peace Corps and on behalf of US environmental efforts.

Rita was the daughter of our office RN, Pat Herkal and her husband Steve. Her last letter to her parent ends "I am so impressed with and proud of the people I am working with on this school. Their dedication to it astounds me over and over. The number of volunteers from the community is still amazing and well above what we asked for or expected... I am happy and healthy and so satisfied with my life and what I am doing. It truly is an incredible feeling to have each minute permeated with contentment and gratification."

We are proud that Rita lived so fruitful a life in the few years given to her, and we mourn her passing. There will be a celebration of her life at 3:00 PM on Saturday, September 3 at Chetzemoka Park. All are welcome.

CJK April 6, 2006