Skin cancer

Eight Signs of Malignant Melanoma: The ABCDE Rule

February 9, 2013 by Dr.Deepak 1 Comment

Early detection of melanoma is the key to prognosis of melanoma. The earlier it can be detected the more chances of easy treatment. However, there are such circumstances where it can be misdiagnosed. So there are no any specific characteristics that can confirm the diagnosis of melanoma. The well-known rule of ABCDE of melanoma detection continues to be a useful tool for both doctors and the public. In this article we’ll brief the most common eight signs of malignant melanoma. Do remember that self-diagnosis may sometimes put you in trouble, so always seek expert advice if you suspect any abnormal moles in your skin.

Eight Signs of Malignant Melanoma

A Asymmetry in shape, which means that one half is not identical to other half. Although not included in ABCDE rule, age can also be another factor. The development of a new pigmented lesion with characteristics of either any of ABCD rule, in an individual above 40-50 years can also be highly suspected for melanoma.

B Border is irregular, notched, scalloped, ragged, or poorly defined as opposed to smooth and straight edges.

C Color is not uniform, varying shades from one area to another, different colors ranging from brown, black, gray, red and white.

D Diameter is usually large, greater than 6mm, approximately the tip of pencil eraser. Some suggest D for difference that denotes difference from other lesion. Experts think that a pigmented mole should globally share a common appearance or family resemblance. Even in an individual with multiple atypical moles, the mole should be morphologically similar. So, the mole that is different from other pigmented moles on a particular individual should always be suspected for melanoma.

E Evolution of moles, if the mole has gone through recent changes in size, shape and color. Some use E for enlargement, which signify an increase in size of lesion. Another is Elevation which is always present and is irregular with surface distortion.

Lesion having above characteristic may potentially be harmful melanoma. In addition to increase in size and change in colors that are two early signs of melanoma, persistent itching is also an earlier symptom. Inflammation, tenderness, ulcer and bleeding denote that the lesion has advanced. If you suspect any of the above changes seek medical advice immediately.

Nevoid melanoma is a rare melanoma that resembles harmless moles and doesn’t follow the ABCDE rule. Early nevoid melanoma usually has smooth borders, small (less than 6mm) and even color lesion, which can be mistaken for harmless lesion according to ABCD rule.

Lets summarize the 8 signs of melanoma

Asymmetry in shape
Border is irregular
Color is not uniform
Diameter is usually large
Difference from other lesions
Evolution of moles
Enlargement of mole
Elevation above the surface

Others

Persistent itching
Inflammation
Tenderness
Ulcer
Bleeding

Morpheaform Basal Cell Carcinoma

March 17, 2012 by Dr.Deepak Leave a Comment

Morpheaform basal cell carcinoma (BCC), also called as sclerosing BCC is a rare variant of basal cell carcinoma with more aggressive characteristics and atypical clinical presentation. The vast majority of basal cell carcinomas are nodular or superficial. Morpheaform basal cell carcinoma is considered a potentially more aggressive subtype

Causes of Morpheaform Basal Cell Carcinoma

The exact cause still remains unexplained, but genetic and environmental factors are believed to be predisposing factors for mBCC. Researchers suggest that ultraviolet rays from the sun may play an important role in genetic mutation.

Clinical features of Morpheaform basal cell carcinoma

MBCC present as solitary, pale, yellowish or skin colored, firm, ill-defined, flat or slightly depressed waxy or scar like lesion resembling many other benign lesions like Desmoplastic trichoepithelioma. mBCC is most frequently seen on head and neck areas, especially on the face [1,2,3] and less frequently in the trunk and limbs.

Treatment of Morpheaform Basal Cell Carcinoma

Several treatment modalities are being tried including imiquimod 5% cream, photodynamic therapy, Cryosurgery, Radiation Therapy, Curettage and Desiccation and local surgical excision. Although local surgical excision or other alternatives may be sufficient for most of the BCC or mBCC, recurrent rates may be high. For this reason Mohs micrographic surgery is suggested to avoid recurrence and for the high-risk and disfiguring anatomical sites like face where tissue conservation is very important [4].

References:

1. Burdon-Jones D, Thomas PW. One-fifth of basal cell carcinomas have a morphoeic or partly morphoeic histology: implications for treatment. Aust J Dermatol 2006; 47: 102–105.
2. Scrivener Y, Grosshands E, Cribier B. Variations of basal cell carcinomas according to gender, age, location and histopathological subtype. Br J Dermatol 2002; 147: 41–47
3. Erba P, Farhadi J, Wettstein R, Arnold A, Harr T, Pierer G. Morphoeic basal cell carcinoma of the face. Scand J Plast Reconstr Surg Hand Surg. 2007;41(4):184-8.
4. Rowe DE, Carroll RJ, Day CL Jr: Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 15:424, 1989

Microcystic Adnexal Carcinoma

March 16, 2012 by Dr.Deepak Leave a Comment

Microcystic adnexal carcinoma is a rare adnexal neoplasm that usually develops on the head and neck area, particularly the central face. Clinically Microcystic adnexal carcinoma may present as slow growing, flesh-coloured, firm and indurated plaque or nodule with diffuse, ill-defined margins, sometimes with overlying telangiectasiae. Microcystic adnexal carcinoma can be highly aggressive, leading to substantial local destruction and potential chances of metastasis.

What cause Microcystic adnexal carcinoma?

Long term ultraviolet radiation has been suggested as a predisposing factor for Microcystic adnexal carcinoma as most commonly it occurs in sun exposed sites like face.

Treatment of Microcystic adnexal carcinoma

Despite subsequent widespread recognition of MAC as a discrete clinicopathologic entity, it can easily be confused with other benign adnexal tumors, especially Desmoplastic trichoepithelioma and syringoma [1], often leading to inappropriate initial treatment.

Microcystic adnexal carcinoma has tendency of recurrence if not completely excised. Several treatment approaches has been documented in literatures including radiation therapy, wide excision, and Mohs Micrographic Surgery (MMS). Radiation therapy may be ineffective as the tumor is relatively radioresistant, and most authors agree that surgical excision is probably the most definitive method of treatment [2]. However, even with the wide local excision, the recurrence rates may still be higher.

To avoid the chances of high recurrence, Mohs Micrographic Surgery has been suggested [3]. The author recommends that microcystic adnexal carcinoma managed with Mohs Micrographic Surgery has lower recurrence rate than other alternative wide excision methods supporting the previously published series on Mohs Micrographic Surgery.

References:
1. Goldstein DI, Barr RJ, Santa Crux DJ. Microcystic adnexal carcinoma: a distinct clinicopathological entity. Cancer 1982; 50: 566—72.
2. Mayer MH, Winton GB, Smith AC, Lupton GP, Parry EL, Shagets FW. Microcystic adnexal carcinoma (sclerosing sweat duct carcinoma). Plast Reconstr Surg 1989;84:970-5.
3. Leibovitch I, Huilgol SC, Selva D, Lun K, Richards S, Paver R. Microcystic adnexal carcinoma: treatment with Mohs micrographic surgery. J Am Acad Dermatol. Feb 2005;52(2):295-300

Merkel Cell Carcinoma – a Rare and Aggressive Skin Cancer

March 9, 2012 by Dr.Deepak 1 Comment

Merkel cell carcinoma (MCC) is a rare but aggressive and lethal neuroendocrine carcinoma of the skin. Merkel cell carcinoma is more common in the elderly (age greater than 65) and mainly in Caucasians. MCC rarely occurs in patients with dark skin. Vast majority of these tumors present on sun exposed sites.

What causes Merkel Cell Carcinoma?

Excessive sunlight, prolonged ultraviolet radiation exposure, and photochemotherapy are all associated with an increased risk of MCC. Immunosupression due to solid organ transplant, HIV infection or chronic lymphocytic leukemia is also associated with merkel cell carcinoma.

Recently it has been suggested that a new virus named Merkel cell polyomavirus which was found in 8 out of 10 cases of merkel cell carcinoma may play role in etiology of Merkel cell carcinoma. [1]

Clinical Features:

Merkel cell carcinoma usually presents as firm, raised, reddish-blue or skin colored papule or nodule. Most initial lesions are less than 20 mm in diameter which grows rapidly with in 1-3 months. Ulceration of the lesion is rare. They re usually seen on sun exposed areas but not always. They are locally aggressive and later spread to distant lymph nodes in axilla, neck and groin.

Treatment for Merkel Cell Carcinoma

The current preferred treatment is surgical excision with sentinel lymph node biopsy followed by lymph node removal if biopsy comes positive. This may be followed by radiotherapy and this approach loco-regional control and disease free survival [2, 3]. Chemotherapy is not routinely recommended.

References:
1. Feng H, Shuda M, Chang Y et al. Clonal integration of a polyomavirus in human Merkel cell carcinoma. Science 2008; 319: 1096–100.
2. Mojica P, Smith D, Ellenhom JD. Adjuvant radiation therapy is associated with improved survival in Merkel cell carcinoma of the skin. J Clin Oncol 2007; 25:1043–7.
3. Eng TY, Boersma MG, Fuller CD et al. A comprehensive review of the treatment of Merkel cell carcinoma. Am J Clin Oncol 2007; 30: 624–36.

Dermatofibrosarcoma Protuberans

March 8, 2012 by Dr.Deepak Leave a Comment

Dermatofibrosarcoma protuberans (DFSP) is very rare, slow growing malignant soft tissue neoplasm that arises from the dermis and has characteristics of asymmetrical infiltration into deeper subcutaneous tissue. They account for around 0.8% to 1 % of all cancers diagnoses each year.

Dermatofibrosarcoma protuberans lesions are mostly seen on the trunk followed by lower extremities, upper extremities, head and neck respectively. DFSP is slightly common on men than in women.

What causes DFSP?

Although the cause is still known, recent laboratory findings have suggested that chromosomal aberrations may contribute to the pathogenesis of DFSP. However no evidence of familial history or hereditary exist in literatures. Several studies agree that injury to the affected skin like surgical scars and site of vaccination may be the predisposing factor.

Clinical presentation:

Although clinical features of DFSP may vary with the stage of disease, DFSP initially may start with a small nipple-like projection or slightly raised asymptomatic papules or plaque like mass on the area of repeated trauma, vaccination site, scar which may likely be ignored. The tumor may gradually enlarge into larger nodular mass.

They are firmly fixed to the overlying skin and not attached to deeper underlying structures, but there may be multiple satellite nodules at the periphery of the main lesion. The tumor is usually skin colored with a brown-yellow or red tinge and pressure on the area of the lesion causes blanching.

Treatment of Dermatofibrosarcoma Protuberans

The treatment of DFSP consists of wide surgical excision with margin control or Mohs micrographic surgery. Radiotherapy may sometimes be used in addition to surgery. Previously tried chemotherapy is ineffective.

Prognosis:
Prognosis of DFSP is good. The overall distant metastasis is around 5% and rate of regional metastasis is around 1%. Previously recurrent rate of DFSP were high but with the introduction of Mohs micrographic surgery, the rates have decreased.

References:
1. Rutgers EJ, Kroon BR, Albus-Lutter LE, et al: Dermatofibrosarcoma protuberans: treatment and prognosis. Eur J Surg Oncol 1992; 18:241-248.

ABCD of Melanoma

May 29, 2011 by Dr.Deepak 3 Comments

Melanoma is the most dangerous and lethal type of skin cancer. Melanoma is less common form of skin cancer than others but it causes majority of death then other form of skin cancer. The survival rate for melanoma is directly related to early detection. If it is detected early it can be treated and cured. If the cancer has already advanced and spread to other parts of the body than it is most dangerous and difficult treat and death may occur.

So it is critically important to understand and learn to see and detect the early signs of melanoma. You can perform a self skin examination from head to toe for any sign of melanoma. While doing the self skin examination you should remember the “ABCD rule of melanoma”. This can help you detect any changes in your skin lesion or moles which will help early diagnosis of melanoma so it can be treated effectively and cured. Follow the following ABCD of Melanoma.

ABCD of Melanoma:
Asymmetry: Look for any asymmetry of the lesion, which means if the shape of one half doesn’t match the other, then there is a problem.
Border: Check the border or edges of the lesion. If the border of the lesion is rough, irregular or blurred, then its time to immediately visit your doctor.
Color: Check for the color of the lesion or mole. If the lesion has variation of color like black, tan, brown, red and blue, it could indicate a problem.
Diameter: Melanomas are usually larger then 6mm which is around the size of the eraser on a pencil.
Evolution: In addition to above ABCD, you also must pay attention to evolution. Remember if the mole has changed over time.

So, if you remember and follow the above ABCDE rule of melanoma, it will help in early detection of melanoma and can be treated easily and cured.

Remember: When doing self skin examination do not forget to see the back (your partner can assist you), because many of the melanoma cases have been diagnosed on the back too.

If you find any suspected lesion after going through ABCDE of the lesion immediately consult your dermatologist. It is wise to visit a dermatologist for any suspected lesion as early as possible. Don’t try to diagnose it yourself just by following ABCDE rule.

Merkel Cell Carcinoma

September 12, 2010 by Dr.Deepak 1 Comment

Merkel Cell Carcinoma also known as neuroendocrine carcinoma is a rare and very aggressive form of skin cancer. They are thought to arise from the uncontrolled growth of Merkel cells in the skin. MCC can be lethal with overall 2 years survival rate of 50-70%, So immediate aggressive treatment is required.

More then 95% of cases occur is a individual over 50 years of age. It is slightly common in men, although some authors reports women outnumber men by 4:1. MCC occurs more commonly in whites and is very rare in patients with dark skin. They commonly occurs in sun exposed areas.

What causes Merkel cell carcinoma?

It is not clear what exactly causes MCC, but potential risk factors are extensive sun exposure as 90% of cases occur in sun exposed areas (50% on head and neck and 40% on the extremities). Arsenic exposure and PUVA therapy may also be a potential risk factor. It has also been associated with immunosupression including HIV and organ transplant patients. Recently in 2008 a virus namely Merkel cell polyomavirus, was discovered which is thought to be frequently involved in causing MCC.

Sign and symptoms of Merkel cell carcinoma

Merkel cell carcinoma (MCC) occurs commonly face, head and neck. The lesions are raised , firm, painless, reddish-blue or flesh colored nodules or tumor usually seen on sun exposed areas. They are asymptomatic and may grow rapidly ,measuring between 0.5 to 2 cm or more. They are usually symptoms-less but if it has spread to other parts of body you may notice lymph node swelling and pain. If you notice any changes in size and color of the mole or bumps contact your doctor immediately.

Treatment of Merkel cell carcinoma

Various chemotherapeutic regimens have been purposed but none has proven to be better in improving survival rate. Treatment modalities are usually based on the stage of the disease. If the disease is in early stage and is localized in a skin, surgical excision followed by radiation therapy is recommended as a primary treatment. If the cancer has spread to the lymph nodes surgical excision with radio therapy and if needed systemic chemotherapy is administered.

For a patients with distant metastasis involving organ, radiation therapy with chemotherapy may be required. But, it is still unclear whether chemotherapy improves the survival rate in patients with Merkel cell carcinoma. The purpose of treatment of metastasis disease is to improve the quality of patient life by relieving symptoms like pain and help patients live comfortably.

The prognosis of a patients depends on the stage of disease at the time of diagnosis. If the cancer has not spread to lymph nodes, 5 year survival rate is more then 90%. If it has spread to lymph nodes, the 5 year survival rate is about 50%. The disease can reoccur in 50% of patients. It is important to keep in mind that these stats are based on the research of large group of patients and may not reflect each individual result or prognosis.

Effects of Cigarette Smoking on Your Skin

June 8, 2010 by Dr.Deepak 7 Comments

We have already known the fact about cigarette smoking and its association between lung cancer, heart disease and many other systemic diseases. But people may not be aware of smoking and its association with several skin conditions like premature aging of skin, wrinkle, and delayed would healing. Besides, several other skin disorders like psoriasis, skin cancer, cutaneous lupus erythematosus, hidradenitis suppurativa and many other oral and vascular diseases are also linked to cigarette smoking. In this article we’ll review some of those skin conditions and disease which are either influenced or are associated with smoking.

Premature Skin Aging and Wrinkles:

Several studies have shown that cigarette smoking promotes premature skin aging and skin wrinkles. These conditions tends to occur more likely in smokers than non smokers, research suggest. The exact mechanism by which smoking can cause premature aging and wrinkling is not clear. But they believe the following may be the likely mechanism:

Reduction in the blood supply to the skin due to the vasoconstrictive effects of nicotine in cigarette.
Decreased collagen synthesis due to reduction in blood supply.
Changes in the elastic fibres of the skin.
Chronic exposure to heat from the cigarette smoking resulting in burning of the skin.
Reduction in Vitamin A and moisture of the skin.
Pro-oxidant effects of smoking.

Poor Wound Healing

It has been shown from different research and studies that smoking has a harmful effect on would healing. Smoking can delays wound healing in any skin injuries. It also increase the risk of wound infection. The exact mechanism may not be unclear but the reason are the same:

Lack of oxygen due to vasoconstriction property of nicotine.
Decreased collagen synthesis
Increased blood viscosity and platelet aggregation.

All of these above mentioned factors might contribute to poor would healing.

Smoking and Skin Cancer

Compared to non-smoker, smokers have twice the risk of developing skin cancers like squamous cell carcinoma (SCC). The association between smoking and the risk of squamous cell carcinoma have been well documented in several studies. The risk may increase with duration and number of cigarette per day. There is also a high risk is of oral cancer. It is said that 75% of Oral cancer occurs in smokers. The risk might even be higher with smokers who consume excess alcohol. Oral leukoplakia often described as a pre-cancer lesion also occurs much more commonly in smokers. In some few cases it may undergo malignant changes.

Smoking and Psoriasis

Several studies have found that risk of psoriasis increases with smokers. Psoriasis may be severe and extensive in patients those who smoke. It may be due to immunosuppressive effects of smoking. Palmoplantar pustulosis, a localized form of psoriasis tends to occur more in smokers than non smokers.

Hidradenitis Suppurativa

Hidradenitis suppurativa, also know as Acne inverse tends to occur more commonly in smokers. It is considered severe form of acne affecting the area of sweat glands and hair follicles, usually in breasts, underarms, groin, thighs and buttocks. Although exact mechanism poorly understood, it is thought that smoking alters sweat gland activity, causes overproduction of acetylcholine in the hair follicle causing blockage of hair follicle and thus promoting poor healing.

Discoid Lupus Erythematosus

Recent studies have linked cigarette smoking and the risk of developing Discoid lupus erythematosus . Cigarette smoking have also linked with decrease effectiveness of therapy in discoid lupus erythematosus.

Other Various Skin conditions that are linked to Cigarette Smoking:

Premature graying of hair.
Discoloration of distal hair of mustache often called as Smoker’s mustache.
Discoloration of fingers and nails of hands.
Oral lesions like oral candidiasis, oral lichen planus.
Black hairy tongue and hairy leukoplakia.
Chilblains.
Acute necrotizing uncreative gingivitis.
Antiphospolipid syndrome
Buerger disease.

Increased Incidence Of Skin Cancer Among Asian Living In Singapore

August 24, 2009 by Dr.Deepak 4 Comments

A Journal published at “Journal of the American Academy of dermatology” concludes that Incidence of skin cancer among peoples of singapore has increased from 1968 to 2006 and especially among older chinese.

The incidence rates of skin cancers in Caucasian populations are increasing. There is little information on skin cancer trends in Asians, who have distinctly different skin types. So this articles focus to study skin cancer incidence rates and time trends among the 3 Asian ethnic groups in Singapore.

These data of skin cancer were analyzed from the Singapore Cancer Registry from 1968 to 2006 using the Poisson regression model.

The data reports that there were 4044 reported cases of basal cell carcinoma, 2064 of squamous cell carcinoma, and 415 of melanoma. Overall skin cancer incidence rates increased from 2.9/100,000 in 1968 to 1972 to 8.4/100,000 in 1998 to 2002, declining to 7.4/100,000 in 2003 to 2006. Among older persons (?60 years), basal cell carcinoma rates increased the most, by 18.9/100,000 in Chinese, 6.0/100,000 in Malays, and 4.1/100,000 in Indians from 1968 to 1972 to 2003 to 2006. Squamous cell carcinoma rates among those aged 60 years and older increased by 2.3/100,000 in Chinese and by 1/100,000 in Malays and Indians. Melanoma rates were constant for all 3 races. Skin cancer rates among the fairer-skinned Chinese were approximately 3 times higher than in Malays and Indians, who generally have darker complexions.

Although appropriate population denominators were used, lack of data from 2007 could have affected the results for the last time period, which comprised 4 instead of 5 years.

Adapted from the article provided by Journal of the American Academy of dermatology

Successful Treatment Of Basal Cell Carcinoma With Imiquimod Cream

July 23, 2009 by Zenisha 2 Comments

Researcher at North Queensland Centre for Cancer Research,James Cook University,Queensland,Australia found out some good success rate in treating superficial basal cell carcinoma with Imiquimod cream.

Superficial basal cell carcinoma comprise up to 25% of all histological sub-types. They are more likely to occur on younger persons and females and although generally more common on the trunk, also occur frequently on the exposed areas of the head and neck especially in areas of high sun exposure. In the last decade, new treatment options such as topical applications that modify the immune response have been trialed for effectiveness in treating these lesions.
Imiquimod 5% cream has been shown to stimulate the innate and cell mediated immune system. The short-term success of imiquimod 5% cream in randomized controlled trials comparing different treatment regimes and dosing as a treatment for small superficial basal cell carcinoma (BCC) not on the face or neck is in the range of 82% for 5 times per week application.
A high proportion of participants with good response rates to topical treatment (58%–92%) experience local side effects such as itching and burning, less commonly erosion and ulceration, but the proportion of participants ceasing treatment has not been high.

To date one long-term study indicates a treatment success rate of 78%–81% and that initial response is a predictor of long-term outcome. Recurrences tend to occur within the first year after treatment. Future research will compare this preparation to the gold standard treatment for superficial BCC – surgical excision.