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For more information about skin conditions and treatment, contact:


Elizabeth H. Hamilton, MD, PhD
Amy Stein, MD

Julie Dodge, PA-C
4321 Medical Park Dr., #102
Durham, NC 27704
Telephone: (919) 220-7546 (SKIN)

Early On, Skin Cancer Is Silent

“Skin cancer is often a silent disease, and its most common form is basal cell carcinoma—which can often present very unimpressively at the onset,” observes Dr. Amy Stein, of Regional Dermatology of Durham.

Notes Dr. Stein, left: Photodynamic therapy is very often effective in the treatment of pre-cancerous growths called actinic keratoses.

“People come to us with dark spots because there’s a lot of publicity about melanomas, but they often ignore a basal skin cancer. The three most common types of skin cancer are basal cell, squamous cell, and melanoma. There are several less common skin cancers, as well.

“And it’s not unusual for a patient to come to us to treat a completely different skin condition, and we notice skin cancer at a different site as part of the exam. ‘It’s just a pimple; a little pink bump, and it doesn’t bother me at all,’ they may say, although it’s been present for several months. And the truth is, a pimple doesn’t last for several months. And so we initiate the process of identification and testing and treatment.”

Health&Healing: Is the basal cell cancer much more common?

DR. STEIN: Yes, by a sizable margin. There are millions of new basal cell carcinomas diagnosed each year. Each year there are more newly diagnosed skin cancers than breast, lung, colon and prostate cancers combined, and the vast majority are basal cell carcinomas.

More than 90 percent of these skin cancers occur on sun-exposed skin—the face, neck, ears, forearms, and hands most commonly. It may start as a red spot or shiny bump that is pink, red, or white. It may be crusty or have an open sore that fails to heal. It often looks like a pearly papule or bump on the skin.

Both basal cell carcinomas and squamous cell carcinomas have a high cure rate when found and treated early. A squamous cell carcinoma can typically present as a scaly non-healing papule or raised, wart-like growth; it can be fragile and bleed easily or be hard with a thick crust.

H&H: And of course melanoma is of the greatest concern.

DR. STEIN: Melanomas may be even more asymptomatic than non-melanoma skin cancers. A patient may say, “This doesn’t hurt and it doesn’t bleed, but I don’t like the way it looks,” or “It’s not raised.” There are a lot of symptoms people associate with skin cancer that are simply not true. The belief that there always are symptoms with skin cancer is one of them.

Generally, if they don’t have identifiable symptoms, patients believe there’s no problem. They tend to think that if a mole is raised, that’s bad, and if it’s flat it’s fine. That is not necessarily the case.

Most melanomas do start out flat, and that’s exactly the stage where we want to catch them—when they are flat and in what we call their early radial (horizontal) growth phase. Once they enter their vertical growth stage and start growing downward, they can present as more raised or palpable. Once they are invasive, the potential for metastasis can increase pretty rapidly.

We have, in our careers, seen and treated hundreds to thousands of skin cancers, from early-stage cancers to really serious melanomas, and so we have expertise in identifying what is and what is not a skin cancer. At the same time, viewing skin abnormalities requires use of all available resources, including intuition. Patients will often guide us to a problem. One may say, “I’ve got a lot of moles, but there’s something about this one that feels funny.” When I hear that type of comment, I will usually biopsy that mole. A surprising number of times such expressions of concern will lead to a biopsy result with some atypia in what might look like a clinically bland lesion. I always pay close attention when a patient says there’s a skin lesion “that just doesn’t feel right.”

H&H: It’s impossible, it seems, to over-emphasize the need to protect our skin from the sun.

DR. STEIN: We all know that over-exposure to the sun eventually produces skin with a tough, leathery look, as well as large freckles or age spots and scaly growths called actinic keratoses, which are pre-cancerous. The 20-year-old with a beautiful tan may look like a 60-year-old when in fact she’s in her forties—whereas the 60-year-old who has protected her skin from the sun may look 20 years younger than her age.

The cause of these problems is well-understood. Ultraviolet light rays from the sun enter the skin and damage the skin cells, causing visible and invisible injuries. Our cells manage to repair some of this damage, but in other instances the damage accumulates and builds over time until it erupts into something as serious as cancer. Some people also have allergic reactions to the sun, including raised areas, hives, blisters, or red patches.

The sun protection guidelines we offer to our patients include:

Use a broad-spectrum sunscreen with an SPF of at least 30 on all exposed skin, including the lips, even on cloudy days. Broad-spectrum means a sunscreen that protects both from UVA and UVB rays.

Reapply sunscreen frequently, at least every two hours (and more often when in the water).

Wear a broad-brimmed hat and sunglasses.

Sit in the shade whenever possible.

Wear protective, tightly-woven clothing.

Plan outdoor activities early or late in the day to avoid peak sunlight hours between 10 a.m. and 4 p.m.

The rate of all types of skin cancers continues to increase each year. The closer we are to the equator, the greater the intensity of UVA and UVB sun rays. If you live in North Carolina and plan to vacation in Mexico, the sun’s ray will be far more intense and it will be especially important to protect your skin with great care.

H&H: It sounds as if a regular skin check with a dermatologist is a good idea.

DR. STEIN: A baseline exam is a good idea, and beyond that, the need is individualized, ranging from perhaps once every  year or so for some, to every three months for others, depending on conditions we are monitoring. Some people come to us with a lot of moles and their exam is more extensive. Their moles may not be bad or look bad, but their skin is sufficiently complex that we may recommend a thorough skin check every year. Other people have a great deal of sun damage and a more significant family history of skin cancer, and they need to be seen more often.