INTRODUCTION TO SUN DAMAGE

Soaking up the sun’s rays used to be considered healthy…before we learned about the dangers of ultraviolet rays. Sunlight can be used to treat some skin diseases, but we all need to avoid overexposure to the sun. Too much sun can cause wrinkles, freckles, skin texture changes, dilated blood vessels, and skin cancers.

The sun’s rays

The sun produces both visible and invisible rays. The invisible rays, known as ultraviolet A (UVA) and ultraviolet B (UVB), cause most of the problems. Both cause suntan, sunburn and sun damage. There is no safe UV light.

Harmful UV rays are more intense in the summer, at higher altitudes, and closer to the equator. The sun’s harmful effects are also increased by wind and reflections from water, sand, and snow. Even on cloudy days UV radiation reaches the earth.

Protection from the sun

While sun damaged spots and skin cancers are almost always curable when detected and treated early, the surest line of defense is to prevent them in the first place. Here are some sun-safety habits that should be part of everyone’s healthcare:

• Avoid unnecessary sun exposure, especially during the sun’s peak hours (10am to 4pm).

• Seek the shade.

• Cover up with clothing, including a broad-brimmed hat, long pants, a long sleeved-shirt, and UV-blocking sunglasses.

• Wear a broad-spectum sunscreen with a sun protection factor (SPF) of 15 or higher. Apply 20 minutes before going outdoors and reapply after 20 minutes and then every two hours after swimming or strenuous activity.

• Avoid tanning parlors and artificial tanning devices.

• Examine your skin from head to toe every month.

• Have a professional skin examination annually.

Harmful effects of the sun

• Sunburn. Your chances of developing a sunburn are greatest between 10AM and 4pm, when the sun’s rays are strongest. It is easier to burn on a hot day, because the heat increases the effects of UV rays.

Sun protection is also important in the winter. Snow reflects up to 80 percent of the sun’s rays, causing sunburn and damage to uncovered skin. Winter sports in the mountains increase the risk of sunburn because there is less atmosphere the block the sun’s rays.

If skin is exposed to sunlight too long, redness may develop and increase for up to 24 hours. A severe sunburn causes skin tenderness, pain, swelling, and blistering. Additional symptoms like fever, chills, upset stomach and confusion indicate a serious sunburn and require immediate medical attention. If you develop a fever, your dermatologist may suggest medicine to reduce swelling, pain and prevent infection. Unfortunately, there is no quick cure for minor sunburn. Wet compresses, tub baths and soothing lotions may provide some relief.

• Tanning. A tan is often mistaken as a sign of good health. Dermatologists know better. A suntan is actually the result of skin injury. Tanning occurs when UV rays enter the skin and it protects itself by producing more pigment or melanin. ndoor tanning is just as bad for your skin as sunlight. Most tanning salons use ultraviolet-A bulbs and studies have shown that UVA rays go deeper into the skin and contribute to premature wrinkling and skin cancer.

ACTINIC KERATOSIS

Actinic keratosis (AK), also known as solar keratosis, is the most common type of precancerous skin lesion. Exposure to sunlight over the years irreversibly damages the cells in the skin. After enough exposure the damaged skin begins to form rough, scaly spots called actinic keratoses (AKs) which may never heal. These AKs are precancerous and if neglected, may become skin cancer.

The more time individuals spend in the sun over the years, the greater their odds of developing one or more AKs. That is why these lesions are more common in older people and outdoor workers. People with fair skin, blonde or red hair, and blue, green, or grey eyes are at greater risk because they are more susceptible to sun damage. But anyone can develop these precancerous growths, just as anyone can develop skin cancer.

The more AKs that are present, the greater the chance that one or more may turn into skin cancer. Once an AK becomes a cancer and invades more deeply into the skin, it may bleed, ulcerate, become infected, and even spread to internal organs.

How to spot an actinic keratosis

AKs typically occur on the face, lips, ears, scalp, neck, back of the hands, shoulders, forearms, and back--the parts of the body most often exposed to the sun. Ranging in size from 1 mm to 1 inch (most often about 2 mm to 4 mm) in diameter, AKs usually appear as small crusty, scaly, or crumbly bumps or horns. The base can be dark or light skin-colored and may have additional colors such as tan, pink, or red.

Early on, AKs may come and go. Sometimes, they are more easily detected by feel than by sight. They are dry and rough to the touch and may be raw and sensitive. Occasionally, AKs itch and cause a prickling or burning sensation. They can also be inflamed and surrounded by redness. In rare instances, they may even bleed.

Treatment

When it is not clear whether a growth is a precancerous AK or a fully developed skin cancer, it may be necessary to remove a growth for microscopic examination (biopsy). The appropriate treatment can then be determined. The Cheyenne Skin Clinic offers several treatment options for patients with AKs, some are discussed below.

• Cryosurgery. At present, this is the most widely used treatment for AKs. It is especially useful when a limited number of lesions are present. Liquid nitrogen is applied to the growths on a cotton-tipped applicator or spray device. This freezes them without requiring any cutting or anesthesia. They subsequently shrink or become crusted and fall off. Some temporary redness and swelling can occur. In dark-skinned patients, some pigment may be lost.

The skin where the liquid nitrogen is placed will swell and may blister and form a crust. If this happens, clean the area twice a day with hydrogen peroxide and apply an antibiotic ointment, such as Bacitracin, Polysporin, or Bactroban . After treatment, healing takes 1-3 weeks, depending on the size of the lesion, the body location, and your general health.

• Levulon Kerastick (aminolevulinic acid HCI) for topical solution, 20%. Levulon is an advanced treatment for nonhyperkeratotic AKs (AKs that have not become enlarged and thick) of the face and scalp. The system is unique because it is the only one that uses light to destroy AKs. The treatment regime includes applying the solution, an acid that occurs naturally in the body, to make the AKs more sensitive to light. After waiting 14-18 hours, the patient returns to the dermatologist’s office where the AKs are exposed to a special blue light. This light then destroys the Aks.   Eight weeks after treatment, it had cleared 100% of AKs in about two out of three patients. The system more effectively cleared AKs on the face than those on the scalp.

• Topical Medications. When there are numerous AKs, topical creams and solutions are especially useful. They treat both visible and invisible lesions with a minimal risk of scarring compared with other therapies. The most commonly used topical medication for AKs is 5-fluorouracil (5-FU) cream or solution. It can be used on all affected areas but works best on the face and ears. The skin becomes very red and inflamed for the 3-4 weeks of treatment.

Prevention

Sun damage is permanent and accumulative. Once sun damage has progressed to the point where actinic keratoses have developed, new keratoses may appear even without further sun exposure. It is important to avoid excessive sun, but it is not necessary to totally deprive yourself of the pleasure of being outdoors. Reasonable sun protection should be your aim.

BASAL CELL CARCINOMA

Basal cell carcinoma (BCC) is the most common form of skin cancer, affecting about 800,000 Americans each year. In fact, it is the most common of all cancers. One out of every three new cancers is a skin cancer, and the vast majority are basal cell carcinomas. These cancers arise in basal cells, which are at the bottom of the epidermis (outer skin layer).

The major cause

Chronic exposure to sunlight is the cause of almost all basal cell carcinomas, which occur most frequently on exposed parts of the body-face, ears, neck, scalp, shoulders, and back. Rarely, however, tumors develop on non-exposed areas. In a few cases, contact with arsenic, exposure to radiation, and complications of burns, scars, vaccinations, or even tattoos are contributing factors.

Who gets it?

While anyone with a history of sun exposure can develop BCC, people who are at highest risk have fair skin, blond or red hair, and blue, green, or grey eyes. Workers in occupations that require long hours outdoors, and people who spend their leisure time in the sun are particularly susceptible. Geographic location is also a factor; the closer to the equator, the higher the number of cases, particularly among fair-skinned individuals.

Not a trivial cancer

When removed promptly, BCCs are easily treated in their early stages. The larger the tumor has grown, however, the more extensive the treatment needed. Although this skin cancer hardly ever spreads or metastasizes to vital organs, it can damage surrounding tissue, sometimes causing considerable destruction and even the loss of an ear, eye, or nose.

Risk of recurrence

When the first BCC is diagnosed, the physician may find one or more additional tumors. Also, people who have had one BCC are at risk of developing others in later years. These may be in the same place or elsewhere on the body. BCCs on the scalp and nose are especially troublesome. The recurrences typically take place within the first two years following surgery.

The five warning signs of basal cell carcinoma:

1. An open sore that bleeds, oozes, or crusts and remains open for three or more weeks. A persistent, non-healing sore is a very common sign of an early basal cell carcinoma.
2. A reddish patch or irritated area , frequently occurring on the chest, shoulders, arms, or legs. Sometimes the patch crusts. It may also itch or hurt. At other times, it persists with no noticeable discomfort.
3. A pink growth with a slightly elevated rolled border and crusted indentation in the center. As the growth slowly enlarges, tiny blood vessels may develop on the surface.
4. A shiny bump , or nodule, that is pearly or translucent and is often pink, red, or white. The bump can also be tan, black, or brown, especially in dark-haired people, and can be confused with a mole.
5. A scar-like area which is white yellow or waxy, and often has poorly defined borders. The skin itself appears shiny and taut. Although a less frequent sign, it can indicate the presence of an aggressive tumor.

Learn the signs of basal cell carcinoma and examine your skin regularly-as often as once a month if you are at high risk. Be sure to include the scalp, backs of ears, neck, and other hard to see areas. A full-length mirror can be very useful. If you observe any of the warning signs or some other change in your skin, consult your physician immediately.

Treatment

After the physician’s examination, the diagnosis of basal cell carcinoma is confirmed with a biopsy. In this procedure, a small piece of tissue is removed and examined in the laboratory under a microscope. If tumor cells are present, treatment-usually surgery-is required. Fortunately, there are several effective methods of eradicating BCC. Choice of treatment is based on the type, size, location and depth of penetration of the tumor, as well as the patient’s age and general health. Treatment can almost always be performed on an outpatient basis in the physician’s office or at a clinic. With various surgical techniques, a local anesthetic is commonly used. Pain or discomfort during the procedure is minimal, and pain afterwards is rare.

SQUAMOUS CELL CARCINOMA

Squamous cell carcinoma (SCC), the second most common skin cancer after basal cell carcinoma, afflicts more than 100,000 Americans each year. It arises from the epidermis and resembles the squamous cells that comprise most of the upper layers of skin. Squamous cell carcinoma may occur on all areas of the body including the mucous membranes, but are most common in areas exposed to the sun.

What causes it?

Chronic exposure to sunlight causes most cases of squamous cell carcinoma. That is why tumors appear most frequently on sun exposed parts of the body: the face, neck, bald scalp, hands, shoulders, arms, and back. The rim of the ear and the lower lip are especially vulnerable to the development of these cancers.

SCCs may also occur where skin has suffered certain kinds of injury, burns, scars, long standing sores, sites previously exposed to x-rays or certain chemicals such as arsenic and pertroleum by-products. In addition, chronic skin inflammation or medical conditions that suppress the immune system over an extended period of time may encourage development of SCC.

Not a trivial cancer

When detected in its early stages, squamous cell carcinoma is almost always curable. The larger the tumor has grown however, the more extensive the treatment needed. Localized tumors that are not treated promptly can result in loss of an eye, ear, or nose, making early detection critical. Although squamous cell carcinoma rarely metastasizes to vital organs, when it does it is frequently fatal.

Who gets it?

Anyone with a substantial history of sun exposure can develop squamous cell carcinoma. But people who have fair skin, light hair, and blue, green, or gray eyes are at high risk. Those whose occupations require long hours outdoors or who spend extensive leisure time in the sun are in particular jeopardy.

What to look for

SCCs occur most frequently on areas of the body that have been exposed to the sun for prolonged periods. Usually, the skin in these areas reveals telltale signs of sun damage, such as wrinkling, changes in pigmentation, and loss of elasticity.

Other signs include:

1. A persistent scaly red patch with irregular borders that sometimes crusts or bleeds.
2. An elevated growth that occasionally bleeds. A growth of this type may rapidly increase in size.
3. A wart-like growth that crusts and occasionally bleeds.
4. An open sore that bleed and crusts and persists for weeks.

Treatment

After a physician’s examination, a biopsy will be performed to confirm the diagnosis of squamous cell carcinoma. This involves removing a piece of the affected tissue and examining it under a microscope. If tumor cells are present, treatment (usually surgery) is required.

Fortunately, there are several effective ways to eradicate SCC. The choice treatment is based on the type, size, location, and depth of penetration of the tumor, well as the patient’s age and general state of health. Treatment can almost always be performed on an outpatient basis in a physician’s office or at a clinic. A local anesthetic is used during most procedures. Pain or discomfort is usually minimal with most techniques, and there is rarely much pain afterwards.

The possibility of recurrence

Anyone who has had one squamous cell tumor has an increased chance of developing another. That is because the damage the skin has already received from the sun cannot be reversed. Having had a basal cell carcinoma also makes it more likely that a squamous cell carcinoma will develop, because both types of skin cancer are usually caused by excessive sun exposure.

Even though a squamous cell tumor has been carefully removed, another may arise in the same place nearby. Such recurrences typically occur within the first two years after surgery. SCCs on the nose, ears, and lips are especially prone to recurrence. Should the cancer recur, the physician may recommend a different type of treatment the second time.

It is important to examine the entire body periodically for warning signs of SCC. The possibility of recurrence makes it crucial to pay particular attention to any previously treated site. Any changes noted should be shown immediately to a physician, preferably one who specializes in skin diseases. Even if no suspicious signs are noticed, regularly scheduled follow up visits are an essential part of post-treatment care.

MELANOMA

Melanoma is the deadliest form of skin cancer. It is most often caused by intense, intermittent exposures to the sun-especially exposures that occur before age 18. In the past two decades, as outdoor recreational activities have increased and fashions have left more skin exposed, melanoma incidence rates have more that tripled.

Fair skinned people with light hair, eye color, and those who have had sunburns or tend to burn easily are at increased risk of developing melanoma. So are those who have a family history of the disease or have ever had a melanoma or other skin cancer. People with large, unusually colored, or irregularly shaped moles (dysplastic nevi, also called atypical moles) are also at higher risk.

In its earliest stages, melanoma is readily treatable. Left untreated, it will spread to vital organs, frequently becoming life-threatening.

How to spot a melanoma

Most people have some brownish spots of growths. Almost all of these are normal. But growths that change noticeably in size or have irregularities in shape and color could be melanomas. It is important to check the skin from head to toe every month, staying alert for lesions that have the “ABCD” signs of melanoma: A symmetry, B order, irregularity, C olor variability, and D iameter larger than a pencil eraser.

• Asymmetry. Most melanomas are asymmetrical: A line through the middle would not create matching halves. Common moles are round and symmetrical.

• Border irregularity. The borders of early melanomas are often uneven and may have scalloped or notched edges. Common moles have smoother, more even borders.

• Color variability. Varied shades of brown, tan, or black are often the first sign of melanoma. As melanomas progress, the colors red, white, and blue may appear. Common moles usually are a single shade of brown.

• Diameter. Early melanomas tend to grow larger than common moles-generally to at least the size of a pencil eraser (about 6 mm or ¼ inch in diameter).

It could be genetic: News about Dyplastic Nevi

Because the group of moles known as "dysplastic nevi" is associated with an unusually high incidence of melanoma, these moles warrant close scrutiny. The tendency to develop dysplastic nevi can be a familial trait that is often associated with a history of malignant melanoma, a serious form of skin cancer. They differ from normal moles by their variegated color in shades of brown, tan, and pink. They also feature ill-defined borders which blend into the surrounding skin. Those born with a dysplastic nevus syndrome may grow a hundred moles on their torsos over a period of years. This large number renders surgical removal of each and every mole impractical, thereby making periodic examination and removal of suspicious moles a necessity.

T hough we can visually identify some nevi that are obviously malignant, a number of innocent looking skin growths also turn out to be malignant. A biopsy (which involves microscopic examination of cells) is the safest way to determine whether or not a growth is malignant. Any new, unusual, or changed skin growth warrants being checked. Though many growths turn out to be harmless, the possibility of detecting a cancer early is well worth a visit to the dermatologist.

Treatment

• Excisional surgery. When melanomas are discovered at an early stage-when they are still thin and have not spread beyond the original tumor site-standard excisional surgery is frequently the sole treatment required.

• Mohs micrographic surgery. An alternative surgical method for melanoma, Mohs micrographic surgery, may be used selectively to remove certain types of early-stage melanomas at specific sites (head, hands, and feet). A greater amount of healthy tissue may be spared using this method. However, though Mohs is used regularly for BCC’s and SCC’s, it is not yet routinely used for most melanomas.

• Regional lymph node dissection. If stray cancer cells spread beyond the tumor’s original borders, they may reach nearby lymph nodes. This is a major concern because lymph nodes empty fluid into the bloodstream, and cancerous cell could be carried throughout the body.

To keep this from happening, surgeons may remove the entire group of lymph nodes closest to the tumor. Most now start by removing only the first one or two lymph nodes (the “sentinel nodes”) closest to the tumor. These nodes are examined microscopically and if cancerous cells are found, the other nearby lymph nodes also are removed. If no cancerous cells are found in the sentinel nodes, the remaining nodes are spared.

Other treatments. When cancer cells spread beyond the lymph nodes, the melanoma is considered advanced and a variety of treatment options are used. These additional treatments include radiation, chemotherapy, and immunotherapy (synthetic versions of natural disease fighting drugs such as interferon and interleukin). These techniques do not cure the majority of advanced cancers. However, they often delay the cancer’s advance and increase the life span of patients.