Understanding Skin Cancer: A Comprehensive Guide

Skin cancer can occur in all ethnicities. Any skin that changes colour, is continuously itchy, bleeds, or becomes an ulcer should not be ignored. Skin cancer can also occur on the soles of your feet, the palms of your hands, or under your nails. The most common types of skin cancer are basal cell carcinoma, squamous cell carcinoma, and melanoma. Each type has different characteristics and treatment approaches.

Types of Skin Cancer

Basal Cell Carcinoma (BCC)

Basal cell carcinoma (BCC) is the most common form of skin cancer. About 40% of Caucasians will get a BCC in their lifetime. There are six subtypes of BCC, and they do not all require surgery.

• Nodular: Usually a small raised, shiny lesion with visible small vessels, described as being "dome-shaped." It almost never recurs after appropriate excision.

• Infiltrative: Usually hardish skin, white scar-like, often with ill-defined borders, and higher recurrence rates than the other types.

• Superficial: Appears as a red, scaly area that may be a little itchy.

• Ulcerated: An ulcerated lesion that doesn't heal and continues to enlarge.

• Pigmented: Although BCCs are usually not pigmented, this subtype contains melanin-producing cells and appears brown to black.

• Baso-squamous carcinoma: A mixture of BCC and SCC, treated like an SCC.

  
  

Rarely, BCC can be genetic, such as in Gorlin's syndrome or linked to arsenic ingestion.

There are many options for treating BCCs, depending on their subtype. Surgery is always possible, but certain superficial types can be treated with Photo-Dynamic Therapy or specific topical medications (creams like 5 Fluoro-Uracil/Aldara) and some with radiotherapy.

Squamous Cell Carcinoma (SCC)

Squamous cell carcinoma (SCC) is the next most common skin cancer in white people but is the most common skin cancer in Black patients. While SCCs in white people usually appear on sun-exposed skin, the reverse is true for Black people. Itchy, inflamed, growing lesions in areas of skin that rarely see sunlight should be biopsied. SCCs are indurated (thickened and palpable areas in the skin), can be an ulcer, and may appear white, red, or darker than the surrounding skin. If it ulcerates, it typically has "rolled edges."

SCCs take time to evolve and often start as actinic or solar keratoses (AK). A sign that they may have become deeper is if they become painful or develop a "horn." If they arise in non-sun-exposed areas, the skin may also be indurated, ulcerated, rougher, painful, and darker.

A special mention must be made of SCCs arising in unstable skin, such as old burn scars. These are called Marjolin's ulcers and take a long time to appear. If you have an old scar and notice an ulcer, it is time to biopsy!

SCCs can spread. While AKs and early or in-situ SCCs can be treated with creams, the mainstay of treatment is surgery, sometimes combined with radiotherapy. Radiotherapy can also effectively treat SCCs on its own, but it is sometimes given after surgery.

There are several types of SCCs:

• Verrucous ("warty"): Slow-growing and less likely to metastasize.

• Ulcerative: Rapidly growing ulcer.

• Spindle cell: Can be confused with malignant melanoma or sarcoma.

• Keratoacanthoma: A rapidly growing dome-shaped lesion with a central depression that regresses spontaneously if left alone over weeks or months but looks exactly like an SCC under a microscope.

  
  

If the SCC has spread to the local lymph node basin (leg-groin, arm-armpit, head-neck), I also remove the lymph nodes. This is done under general anaesthetic in the main operating room.

Melanoma

Melanoma is one of the most aggressive forms of skin cancer. It can develop from existing moles or appear as new ones, including under the nails and on the palms and soles of the feet. Early detection is crucial.

There are several types of melanoma:

• Nodular: A bumpy, darker mole with irregular borders.

• Ulcerative: Has an ulcer, making it difficult to determine the thickness of the melanoma.

• Subungual: Located under the nail, affecting the entire nail. Changes in colour or width of the stripes on your nail can occur, and the melanoma can lift the nail off.

• Acral: Found on the soles of the feet or palms, the most common melanoma in Black people.

• Superficial Spreading: The most common melanoma overall, appearing as a slightly darker skin patch with variable colour and border definition.

• Lentigo Maligna: A slow-growing subtype usually found on the faces of older white people. It may start to deepen when dark spots appear in the pigmented area.

• Desmoplastic: Difficult to diagnose as it may not be darker than the surrounding skin. Any lesion that was not there before and grows should be examined.

• Amelanotic: Sneaky because it does not contain melanin and appears flesh-coloured in white people.

• Spitzoid/Juvenile: Resembles a Spitz naevus (mole) that usually appears in childhood and can be any colour but grows rapidly.

  
  

Who is at Risk?

If you are white, have blond or red hair, burn easily, have a history of sunburns as a child, have used sunbeds, or have many moles (>50), you should be vigilant. If you are Black or brown, watch for pigmented streaks under your nails that become broader or change, and any pigmented lesions on the soles of your feet or palms. Most pigmented streaks in your nails are normal, but if they change or are new, you should see a dermatologist or a plastic surgeon.

The mainstay of melanoma treatment is surgery. Specific margins of surrounding normal skin must be taken to reduce the chance of recurrence and spread. These margins are determined by the thickness of the melanoma. The pathologist will also run tests to see if the melanoma has specific genetic markers, which we use to determine the best-suited adjuvant immunotherapy for the patient.

The treatment of skin cancer is a multidisciplinary team effort involving surgeons, oncologists, radiologists, and pathologists.

The Importance of Early Detection

Early detection is key to successful treatment. Regular skin checks can help identify changes in the skin that may indicate cancer.

Patients should look for:

• New growths or sores that do not heal.

• Itching, tenderness, or pain in a specific area of the skin.

  
  

The ABCs of melanoma are:

• A: Asymmetrical lesion.

• B: Irregular border.

• C: Change in colour.

• D: Diameter (bigger than the end of a pen/pencil).

• E: Evolution - is it changing?

  
  

Additionally, watch for the "ugly duckling" sign: if you have large moles and suddenly notice a small mole, or vice versa, it’s time to monitor it closely and possibly seek an opinion.

If any of these symptoms arise, it is essential to inform your family practitioner and consult a dermatologist.

Patient Experience: What to Expect

Understanding what to expect during treatment can help alleviate anxiety. I believe it is important for you to know what comes next and what options are available.

Initial Consultation

During the first visit, I will assess your skin, discuss symptoms, and may perform a biopsy to confirm a diagnosis if the referring doctor has not already done this. If I have a diagnosis, we will discuss the surgery and reconstruction options available.

Treatment Plan

If I have a diagnosis, we will talk about the surgery and reconstruction I can offer. You should feel comfortable asking questions about the process, potential side effects, and recovery.

Follow-Up Care

Regular follow-up appointments are crucial to monitor for any signs of recurrence and to manage any side effects from treatment. This can be shared between your family practitioner, dermatologist, oncologist, and me, depending on the type and stage of skin cancer.

Lifestyle Changes and Prevention

In addition to treatment, it is important for patients to adopt lifestyle changes that can help prevent skin cancer.

Sun Protection

Wearing sunscreen with at least SPF 30, seeking shade, and wearing protective clothing can significantly reduce the risk of skin cancer. If you are close to the equator, consider wearing SPF 50. Normal clothing provides an SPF of about 15.

Regular Skin Checks

Performing self-exams and scheduling annual dermatology visits can help catch any issues early.

Support and Resources

Navigating a skin cancer diagnosis can be overwhelming.

Support Groups

Connecting with others who have experienced similar challenges can provide emotional support and practical advice.

Educational Resources

Look at reputable sources on the internet, such as National Dermatology Associations:

• British Association of Dermatologists

• American Academy of Dermatology

• Dermatology College of Australia

  
  

Counseling Services

Professional counseling can also help patients cope with the emotional aspects of a cancer diagnosis.

Final Thoughts

Skin cancer is a serious condition, but with early detection and appropriate treatment, many patients can achieve positive outcomes. I want to highlight the importance of understanding the various treatment options available and the need for proactive measures in prevention.

By staying informed and vigilant, individuals can take charge of their skin health and reduce their risk of skin cancer. Remember, your skin is your body's largest organ, and taking care of it is essential for overall well-being.

I usually only get involved in the treatment of skin cancer after a referral from a dermatologist or a family practitioner and after a biopsy to confirm the diagnosis.