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How are skin cancers, including melanoma, treated?

Updated: May 19, 2023



 

Disclaimer: The information in this article is not meant as specific individual medical advice. Please consult your dermatologist or other medical professional about your skin or medical condition.

 

What is Skin Cancer?


Skin cancers are abnormal skin cells that are reproducing and growing out of control.


Skin cancers form as a result of accumulated DNA damage to the cells.


When left untreated, skin cancers increase in size and destroy the healthy tissue around it.


Cancerous skin growths have the ability to destroy underlying fat, muscle and bone tissue over time.


Some skin cancers also acquire the ability to travel to lymph nodes and other organs in the body (metastasis) and form more growths there.


Ultimately, skin cancers that has spread extensively to other organs can be fatal.



What causes skin cancers?


Exposure to harmful ultraviolet (UV) radiation from the sun and tanning is the predominant cause of most skin cancers.


UV radiation causes DNA damage to skin cells which lead to genetic mutations.


When enough genetic mutations accumulate in a skin cancer, a skin cancer can form.


This is the main reason why dermatologists recommend that everyone, especially people with naturally fair skin, avoid excessive sun exposure and take sun protective measures when outdoors.


(It’s not because we are neurotic. I’ve personally treated too many skin cancers and heard too many people regret not protecting their skin from the sun when they are younger.)


There may also be other factors such as genetics, naturally fair skin, chemicals like arsenic, and certain medications that suppresses the immune system, that increase the risk of skin cancer forming.



Common types of skin cancers


The three most common types of skin cancers are:

  • Basal cell carcinoma (BCC)

  • Squamous cell carcinoma (SCC)

  • Melanoma



A photo showing a pearl like pink bump next to the right eye
Basal cell carcinoma


Basal cell carcinoma (BCC)


Basal cell carcinoma (BCC) is the most common skin cancer in people with naturally fair skin.


These cancers tend to appear like a flesh colored to pink raised bump with a characteristic shiny pearl-like appearance.


Sometimes, it may appear as a pink-red pearl-like patch.


Over time, it may become an ulcer or wound that does not heal.


BCCs tend to develop after many years of sun exposure, sunburns or indoor tanning.


As a result, they tend to occur in parts of the skin where there had been more sun exposure such as the face, ears, neck, arms and legs. However, they can form anywhere on the skin.



A photo showing a large growth on the left arm called a squamous cell carcinoma
Squamous cell carcinoma


Squamous cell carcinoma (SCC)


Squamous cell carcinoma (SCC) is the second most common type of skin cancer found in people with naturally fair skin.


The predominant cause for SCC is also frequent sun exposure, sun burns and indoor tanning.


They can also develop in people with chronic wounds and scars, arsenic exposure or suppressed immune systems.


The medications which are used in organ transplants as well as to treat certain autoimmune diseases suppress the immune system and hence, can increase the risk of SCCs.


SCCs may initially look like a pink scaly patch on the skin.


Sometimes, they start a pink-red hard bump on the skin that grows quickly in size.


Other times, they may appear as a sore or wound that increases in size and does not heal.


They tend to form in areas of the skin that gets exposed to the sun such as the face, ears, neck, arms and legs. Unfortunately, they can grow in any part of the skin.



A photo showing an irregular brown spot on the skin
Melanoma

Melanoma


Melanoma are considered the most serious of the common skin cancers.


The reason why they are considered serious is because melanoma has a tendency to spread.


They originate from pigment cells, called melanocytes, that produces the color in our skin.


Most melanomas are also caused by frequent sun exposure, sunburn or indoor tanning.


There may also be inherited genetics that increase the risk of melanoma, which is why melanoma can sometimes run in the family.


Melanomas tend to appear as an irregular shaped or colored mole that changes and grows over time.


It may form as a new unusual looking spot on the skin, or form within a mole that has been present for a long time.


While melanomas also tend to form on sun exposed parts of our skin, they may form even in areas that had no previous sun exposure.



How to recognize a melanoma (ABCDE)


An acronym ABCDE has been developed my dermatology societies to help people recognize a melanoma early:


A stands for Asymmetry, meaning one half of the spot does not appear like the other half.


B stands for Border, or irregular border.


C stands for Color, meaning the spot may have varying colors of brown, black even white, red or blue.


D stands for Diameter, meaning the spot is larger than 6mm.


E stands for Evolving, meaning the spot is changing in size, shape or color over time.


The ABCDE acronym is not used to diagnose a melanoma. It is simply a guide to help people recognize an unusual looking spot or mole.



Other types of skin cancers


There are other rare forms of skin cancers such as cutaneous T-cell lymphoma, Merkel cell carcinoma, sebaceous carcinoma and dermatofibrosarcoma protuberans, which will not be covered in this article.



How are skin cancers diagnosed?


Some fast-growing skin cancers, unusual looking brown spots, and slow-growing but non-healing sores, are recognized by people and brought to their dermatologist’s attention.


However, skin cancers are often found without a person’s prior knowledge during a skin cancer screening session with their dermatologist.


This is why fair-skinned individual who are at risk of developing skin cancers from previous sun damage or indoor tanning are encouraged to get regular skin cancer screening.



Skin biopsy


When a spot or growth looks suspicious for a skin cancer, a skin biopsy is first taken to confirm the diagnosis.


A skin biopsy refers to taking a sample of the growth under local anesthesia.


The sample is then sent to the pathologist, usually a dermatopathologist, to be examined under the microscope.


This process alone is usually sufficient to confirm the diagnosis of a skin cancer, including the type of skin cancer.



Treatment of basal cell carcinoma and squamous cell carcinoma


The treatment of skin cancer depends largely on the type of skin cancer, the pathology findings, its size and location.


Basal cell carcinomas (BCC) and squamous cell carcinomas (SCC) are usually removed by a surgical procedure.


Excision


The most commonly performed surgical procedure is an excision.


In this procedure, an elliptical piece of tissue around the skin cancer is removed under local anesthesia, and the wound edges are brought together with sutures.


The tissue is sent to the pathologist to confirm that the margins are not involved by skin cancer (also known as clear margins).


Mohs Micrographic Surgery


The other commonly performed surgical procedure is Mohs micrographic surgery under local anesthesia.


This procedure is usually performed for skin cancers located in areas where skin conservation is important, such as the eyelids, lips, ears, nose, scalp or fingers.


In Mohs surgery, a very narrow margin of tissue is removed around the skin cancer and immediately examined under the microscope for clear margins. This process is considered a ‘stage’.


If margins are positive, this is mapped on a diagram, and another narrow section of tissue is removed where the margins are positive. This is considered another ‘stage’.


This process continues until all the margins are clear of skin cancer.


As you can imagine, this is a tedious and time-consuming procedure that can take several hours, depending on how many ‘stages’ are required to completely remove the skin cancer.


The final wound defect is then repaired.


Rarely, when BCCs and SCCs are advanced, radiation therapy and chemotherapy may also be used.



Treatment of SUPERFICIAL basal cell carcinoma and squamous cell carcinoma in-situ


Basal cell carcinomas and squamous cell carcinomas are considered superficial when they only involve the top layer (epidermis) of the skin.


Superficial squamous cell carcinomas are termed squamous cell carcinoma in-situ.


While these superficial skin cancers may be removed by excision or Mohs surgery, there are other less invasive treatment methods that can be used because of their superficial nature.


Electrodesiccation and Curettage


One common method is through a minor procedure called electrodesiccation and curettage under local anesthesia.


In this procedure, an instrument called a curette is used to scrap the skin cancer off the surface of the skin.


The instrument makes use of the difference in consistency or firmness between the skin cancer (which is softer) and health skin (which is firm) to remove the skin cancer.


The base of the treated area is then cauterized with a hyfrecator to destroy another thin layer of tissue.


The wound is then allowed to heal over like an abrasion.



Topical Fluorouracil and Topical Imiquimod


The other method of treating superficial skin cancers is by application of topical medication.


The two most commonly used topical treatments are imiquimod (Aldara®) and flurouracil.


These treatments use the body’s immune system to create severe inflammation where it is applied, and through this process destroys the skin cancer.


The typical treatment lasts between four to six weeks where the treated skin is red, swollen, painful and oozing.


After the treatment period, the inflammation usually subsides over a few weeks, and the skin is then rechecked visually by the dermatologist to look for signs of persistence.



Treatment of melanoma


The treatment of melanoma is more complex.


The treatment of melanoma is largely guided by how advance the melanoma is.


This is determined by pathology findings including how deep the melanoma has penetrated the skin (also known as the Breslow depth), findings on newly available genetic tests, and evidence of spread to lymph nodes or other organs.


When a melanoma is detected at an early state (stage 0, also known as melanoma in-situ, and stage 1a), the melanoma is typically removed by an excision with wide margins. The width of the margin is also determined by the stage of the melanoma.


When a melanoma is detected at a more advanced stage (stage 1b and above), it is common for your dermatologist to refer you to a surgeon for a sentinel lymph node biopsy.


The purpose of the lymph node biopsy is to determine if the melanoma has spread to lymph nodes, which is too small to be detected on a physical exam or imaging test such as CT scan.


This procedure is involves injecting a mild radioactive tracer to determine which lymph node the fluid (lymph) around the melanoma flows to. This tracer is accumulates in the lymph node.


The surgeon then removes one or more lymph in that traced location, and sends the lymph node to the pathologist to examine for microscopic melanoma cells.


The original melanoma is usually removed by a wide excision at the same time.


If a melanoma is found to have spread to lymph nodes or other organs, then further imaging by CT scan or MRI scan is usually performed to determine if there may be melanoma in other organs.


Unnecessary imaging tests are not recommended in early stage melanoma by the American Cancer Society.


When melanoma is found in lymph nodes or other organs, chemotherapy and immunotherapy by medical oncologists becomes the next level of care.



Skin cancer prevention


Avoiding excessive sun exposure, and taking sun protective precautions is the main preventive action people can take to reduce their risk of developing skin cancer.


These protective measures include:

  • Seeking shade especially when the sun’s rays are the strongest between 10am and 2pm.

  • Wearing sun-protective clothing such as sunglasses, wide-brimmed hat, and long-sleeved cloths. Certain sun protective clothing has a UPF (ultraviolet protection factor) label.

  • Applying a broad-spectrum water resistant sun screen with SPF 30 or higher

  • Reapplying sun screen every two hours

  • Avoiding use of indoor tanning beds



An annual skin cancer screening by your dermatologist can help with detecting skin cancer early.


When found early, skin cancers are mostly curable.


In addition, it is recommended that adults perform self-skin exams once every few months to look for suspicious spots or unusual looking moles.



I hope this article has been helpful with expanding your knowledge on the common skin cancers, including melanoma, and their treatment.

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