Skin Cancer

Telling a dermatologist that you've had skin cancer is sometimes not very helpful. If you walk into the office and have had years and years of unprotected sun exposure, we can probably guess you have had (or have) this nebulous entity called "skin cancer."

"Skin cancer" is the most common cancer in the entire United States. However, it is quite a broad term. There are MANY types of skin cancer. Three of the most common (the rest will not be discussed in this post) are (in order of decreasing frequency):

1) Basal cell cancer (referred to as BCC)

2) Squamous cell cancer (referred to as SCC)

3) Melanoma (referred to as MELANOMA)

1 - Basal cell cancer is THE most common skin cancer in the United States. If the type of "skin cancer" you've had is BCC, you still need to see your dermatologist, but breathe a sigh of relief. These cancers, we often tell our patients, are like cavities on the skin. If you deal with them early, you're golden. But, if you wait a decade or two, they can become nasty looking cavities. We've seen the earliest...and the latest... of them.

Below are some examples of BCCs:

(The one above is your classic "pearly" slightly eroded papule)

(Note the very characteristic arborizing telangiectases (superficial blood vessels))

(The photo above is what happens when you take too much time before seeing a dermatologist)

2 - Squamous cell carcinoma is the second most common skin cancer in the United States. It is undoubtedly related to the amount of one's cumulative sun exposure. I cannot emphasize enough that you will avoid these skin cancers with adequate sunscreen and sun-protective clothing. The most common locations for these critters are on the backs of the hands (wear sunblock while driving!), face, scalp (Wear a hat!), and tips of the ears (Make that a wide-brim hat!). Unlike BCCs which have little, if any, potential to spread to other parts of the body, SCCs have a higher potential for spread. High risk locations for SCCs include in particular the ears and the lips. Don't put off treatment of SCCs if you don't have to.

Below are some examples of SCCs:

(This is your typical SCC - note the keratotic central core)


(The lip area is a higher risk area for metastatic spread - you definitely don't want to let these go untreated)


(Again - these don't pop up overnight, most of the time. They take many months to grow. You really should have seen someone by this stage)

3 - If there's any cancer you don't want, it's melanoma. Melanoma can be invasive or "in-situ." Melanoma in-situ refers to melanoma that is sitting on top of your skin and doesn't have access to your blood vessels. These are the best melanomas to have because they are stage ZERO. They are nearly 100% curable with surgery and have a 99%+ 5-year survival rate. Melanomas that are invasive originally come from melanomas that are in-situ, so treat these as soon as they're found! Invasive melanomas are graded by various characteristics and will be discussed in a separate post. In the interim, learn how to recognize these suckers. They are *usually* pigmented with various colors - light brown, dark brown, black, blue, & red (a mix of any). They are generally irregular in shape and may be large in size. If you have a mole that looks *different* (we call this the ugly duckling sign), appears to be changing, itching, or bleeding, consider having it looked at.

Below are some examples of melanomas:

(Irregular, asymmetric, with variegated pigment)


(Not good)

(Nails can be involved, too!)

Treatment of skin cancers will be discussed separately.
BCCs, SCCs, and melanomas have intra-individual lesion variability. Hence, do not take the above images to represent these classes of skin cancers in their entirety.

(Courtesy to Google for providing the images above from some of the following sites: USUHS, UCSF, skincancerspecialists.org)

The Road Not Taken

How does one become a dermatologist?

After university there are four years of medical school, followed by four years of dermatology residency (the first year of which is an intern year in medicine, surgery, or possibly a few other things), followed by a one to two year fellowship (if applicable).

Before my three-year dermatology residency, I practiced one year as an intern in internal medicine (which makes me 1/3 of a general practitioner, although it's in that first year that you learn the most).

I have to say that dermatology is one of the most difficult specialties in which a physician can become licensed. I dare say it is THE most competitive of any specialty (including neurosurgery, and possibly plastic surgery) - If you ever see a dermatologist, congratulate them for surviving the ultimate haze. Everyone in medical school seems to want to be a dermatologist (or at least envies those who are in a dermatology residency). Why? I'm not quite sure. I suspect it's most desirable for its financial compensation relative to the amount of hours of work put in (and likely the idea of $cosmetics$. Read: "Insurance keep out!"). I hope that most of today's trainees truly enjoy what they do, and don't entirely desert the vast medical aspect of this field.

That being said, I love what I do. I look forward to each day's challenges. The more complicated, the better. The quirkier looking the rash, the more exciting it is to solve the puzzle. Medical mysteries are my forte.
Although most of what appears here won't be a medical mystery, it will certianly quench the visual appetite, so to speak.

Shall we begin?

What you see is what you get

I want to express that I have the utmost respect for all medical fields (specialty and sub-specialty, inclusive) should anything I write suggest the contrary. My goal is not to overlook the importance of these fields, but to bring attention to the one that’s often “overlooked.”

For instance, what’s the first thing your cardiologist sees? You got it - your skin (even if you wear your heart on your sleeve).

And what about the rheumatologist? Although it would be convenient, these docs certainly don’t have X-ray vision.

How many urologists do you see walking around their office making diagnoses by looking at a cup of urine?

The gastroenterologist? Needs no explanation.

And the oncologist… are you really going to accept a diagnosis of cancer without a biopsy? If an oncologist is giving you a confident diagnosis of cancer by looking at your skin, you probably don’t have very long to live (this does not apply to skin cancer).

Last I checked, hematologists can’t diagnose leukemia by looking at blood.

Although there are many exceptions to the rule, the dermatologist often only needs to look at you to make a diagnosis. A picture, in this case, is worth a thousand words. Or perhaps only one or two? (Depends which textbook you use).

I hope you learn something by reading this, even if it is merely the existence of a specialty called dermatology.

The Rules

Before I officially start blogging about skin, I want to set forth some basics.

1) I don’t like typos, but the keyboard’s not perfect.
Spellchecker and I have become good friends over the years, but when it’s midnight and I have to rise before 7am, please forgive me if there are some things here and there that defy the laws of grammar and spelling.

2) Personal patient information will not be revealed here.
I may write about my experiences with certain diagnoses and loosely people with those diagnoses that I have encountered over the years, but this retelling will not in any way be traceable to an identifiable person. In fact, details will be altered to ensure protection of personal patient information.

3) Personal patient photos will not appear here.
The photos taken in clinic stay in clinic. If you think it looks like you, it’s not. Photos that appear on this site are borrowed from the public internet and teaching references. I’ve been seeing patients for over 5 years now. If I saw (at a minimum) 30 patients a day, 5 days a week, 12 months out of the year, that would amount to over 30,000 patients seen – so rest assured that if you think you’re the only one in the world who has it, you’re probably wrong.
















4) I am not your doctor.
Don’t ask me about your skin. If you have a question about your rash, ask the physician listed on your insurance card. This blog is not in any way intended to give personalized medical advice or act as a definitive source of medical information. Do not use it to convince yourself you’re dying. Do not use it to convince yourself you’re healthy.

What is this blog about?

If you’re thinking ‘skin,’ well, you’re not wrong (obviously). I might carry that theory further and suggest that its birth is a reaction to opinions, anecdotes, comments in passing by colleagues (you know who you are), students, professors, and (not least) primetime television (if you don’t know what I’m talking about, YouTube “Seinfeld” or “Grey’s Anatomy” and “Dermatology”).

I’d like to, therefore, in part, dispel some of the myths about this superficial organ (the only thing superficial about it, is its relation to other organs – after all, how many other organs can you see in the mirror?), and hopefully muster *some* appreciation for what I think is one of the most important tools in expression, judgement, and ((gasp)) cultivating good health.

I might have to attribute part of my motivation in writing this to the film Julie & Julia. No, I don’t quite plan to choose a textbook about skin and blog about a different diagnosis every day until I’ve exhausted the contents (have you ever seen one of those books?! Good. Now buy it, and [if you have any money left], try to backpack with it through the Peruvian highlands). That might result in more posts than days I have left to live (no, I might not be exaggerating). I do, however, hope to give my readers some skinsight (pun intended) into my world of dermatology, and why it might actually be important, and even (be seated for this one) *intellectually challenging* (translation: interesting).