what's up everyone we're back I'm Dr sha Dr Maxfield welcome back to our Channel Dr Lee where we talk about all things skin care but also some hardcore Dermatology stuff and today we got a request from an Instagram live we went on Instagram live on Dr Maxfield Channel go make sure you follow him and we asked the question what do you all want to hear about today so today we're going to be talking about a question that came out of the chat which is what is skin cancer and how do you identify skin cancer so this video will be our skin cancer video right and this is a very important topic hopefully this serves as a nice point of reference for people and if you're watching this now and in the future because we're going to talk about some of the most common skin cancers how they occur what to do if you get them and some of the basics about what we do to take care of them because it's a lot more than you'd think sometimes this is skin cancer here we go here we go skin cancer I personally had skin cancer we maybe have mentioned it in YouTube videos before early in my Dermatology residency I noticed that I had a pink bump that was growing on my chest and I never really had anything like it it didn't go away it wasn't getting any bigger and it actually itched a little bit it was like a little bit like I noticed it was there and then suddenly it started to become a little bit unlike the rest of my skin meaning that it when it would get irritated it would actually start to bleed a little bit so I was like this is kind of weird let's go get it checked out I showed it to Dr Maxfield said it was nothing and uh I just went on with my when end up happening was I showed it uh to some of my colleagues around and I had suspicions that it was skin cancer but I couldn't like really see closely based on the location they looked at it with the dermatoscope and they said actually we're not sure but we're going to biopsy it they biopsy it it comes back and it ends up being a basil cell skin cancer so let's form a hierarchy first there are three main types of skin cancer that you hear a lot about now with recent headlines Merkel cell carcinoma is also something people are talking about more frequently let's focus on the top three because those are the ones that most of you will encounter either in your own lives or you'll have a friend or a family member that develops one of these in their lifetime so the three main causes of skin cancer are basil cell skin cancer Squam cell skin cancer and then melanoma skin cancer basil cell being the least severe Squam cell being the second least or middle severe or more severe and then melanoma being the most severe and that's also the same order in which they occur so basil cells are most common and melanoma is the least common those are your common skin Cancers and what causes these so there's always a complex combination of genetics and environment the major contributing factor is the sun like our bodies have a LoveHate relationship with our entire environment and the Sun is no exception sun has UV rays UVB is the predominant wavelength that contributes to skin cancer the DNA of our skin cells are the perfect chromophor so to speak that's the word we use to say that that's the structure that absorbs that wavelength most effectively and efficiently your DNA absorbs UVB it actually causes changes in the DNA over time your body tries to repair that but but eventually it all adds up until it can't anymore and then you have a skin cancer it's multifactorial some wart types can cause quamis so skin cancers but the sun is the major cause the way that skin cancer or any cancer Works in general is almost like a I don't want to say like a video game but in the sense that you develop skills in your video game with time as you level up essentially so the first insult to your DNA could be that your skin didn't replicate the way that it was supposed to then the Sun hits the DNA damages it further and it basically gets to the point where your body can't keep this abnormal cell in check and then it starts to develop new skills with time every time it replicates it starts to level up and get more skills and those skills are not good things we don't want our skin cancer cells to develop more and more skills and it gets the ability to then eventually like Dr Maxfield said invade deeper into the skin get larger and larger locally and then eventually spread to either the lymph nodes or all across the entire body this doesn't happen happen overnight it happens after cumulative damage essentially the thing and that's universally true about all types of cancer is that the earlier you catch it the better off that you're going to be which is why surveillance which means looking for these things before they occur or while they're very early is really important it makes a world of difference so the next part of this video we'll talk to you about those common types of skin cancers tell you what to be looking for so that you can maybe notice something early on you your loved ones then bring it to our attention sooner some doctor or dermatologist in the office so the first one we'll talk about is a basil cell skin cancer you know what they really look like two most common snares they either start out looking like a pimple that just won't go away because they're pearly they have little dilated blood vessels on them or just a non-healing scar and I think they used to call these like rodent ulcers a few Generations back but a small non-healing sore or a pimple that just doesn't go away on a sun damaged area is highly indicative of a basil cell especially if you have a dilated blood vessel that's fairly prominent across it they really can look like anything even basil cells can be pck pigmented to some degrees I often see pigmented basil cell carcinomas that a lot of people would think would be a melanoma but as soon as a dermatologist looks at it you know right away this is a pigmented basil cell skin cancer invariably like Dr Maxfield is saying about really pretty much all forms of cancer is almost always going to be caused by the sun now if you have a lighter skin tone you're uh you know Fitzpatrick type one and you have freckles and red hair you're going to be higher risk of developing these forms of skin cancer that being said I am not any of those things and I developed a basil cell skin cancer the good thing about basil cell skin cancer is that it's the least aggressive so once you identify it it's easy to treat usually most of the time as long as it's not too advanced and it's not in a very tricky location but we usually just treat these with a myriad of different types of treatments and we'll talk a little bit about how to treat these at the end and we'll talk about how I ended up treating mine now let's talk about the next type of skin cancer which is the second most common cause of skin cancer which is squamous cell skin cancer right and this this type of skin cancer starts out with a precursor so just like colon cancer where you get these little Pops that have the potential to perhaps invade deep continue down that cancerous route you have these things called actinic keratoses these are firm fixed little scaly bumps again on a sun damaged background that just don't go away and those eventually over time accumulate mutations accumulate cancerous cells you see it under the microscope just goes from like a layer thick full thickness to invasive into the skin then you have your Squam cell skin cancer again you're looking for nonhealing sore or something thick and scaly that's fairly firm and they can even be a bit tender when they get thicker and cause pressure or even invade a local nerve now these ones like Dr sha mentioned they are a little more aggressive than basal cells and meaning that they have a higher risk of metastasis or spreading throughout the body especially on the lips and the ears those do have a metastasis rate of up to 15% over the course of your lifetime that is something that's very important to take care of and again the earlier you catch it the much easier it's going to be to take care of it right so what do you look for with this like Dr Maxfield said red flaky bleeding bump that's not healing and if you've ever seen a dermatologist and you're over the age of let's say 45 and they froze something and didn't explain really much what they were freezing what most likely they were freezing was something called an actinic keratosis which is that precursor Legion that he mentioned earlier and the reason why we freeze these or the reason why we treat these or the reason why we try to prevent these actinic keratoses is because they're left untreated eventually over time not tomorrow again these are things that have to develop a skill set to basically invade deeper and get bigger eventually these actinic keratoses turn into scamac cell skin cancers and we try to treat them before they get to that point right and so while the sun is the major contributing cause for these HPV virus is another cause of squil skin cancer there are lung Squam skin cancers there's head and neck squal skin cancers there's some from smoking there's some from twing tobac that occur in the mouth so it's actually a type of skin cancer that has many different causes and all those behave very differently we're focusing on just the skin portion of the Squam cell skin cancer here so now let's talk about the least common and most aggressive form of skin cancer and there's been quite a lot of public education on this form of skin cancer because it's a little bit easier to identify than the other two that we talked about that are a little bit more non-descript and can just simply look like a pimple this is a melanoma skin cancer so melanoma is very aggressive it originates from m ocytes which are the pigment producing cells of our skin so we have little cells called melanocytes they produce melanin and that's what gives us pigment that's what gives us Satan eventually they develop some type of abnormality in them and then they start to grow abnormally and then what you end up getting is usually and this is scary to say that it's not always the case but usually you end up with a brown spot or a black spot that starts to look abnormal and the main way to identify this is the ABCD e of melanoma and we'll talk a little bit about that next but just bear in mind that you can also have melanomas that are what we call amelanotic meaning that they actually don't have pigment in them which is scary for dermatologists because they're hard to identify and often go missed but just so just so you know not every melanoma is actually going to be pigmented right um for those that are that's what we're trying to equip you to find so a stands for asymmetry b stands for irregular borders C is multiple different colors like three or more colors D is diameter 6 mm or a pencil eraser size e is one of the most important ones and that's evolving meaning that it's changing over time and our moles do change with us like I tell younger patients especially up to mid 20s your moles do grow with you a little bit but beyond that you really shouldn't have any changing or new moles and then there's another one called The Ugly Duckling sign that's a pretty strong predictor actually and that's if you have a lot of moles you have your own pattern all your moles look alike but one stands out I I rely on that pretty heavily as well and that's a good predictor that it could be a mole a bad mole and maybe a melanoma so with these pictures hopefully that can help guide you and knowing what to look for for these right so that ugly duckling sign ends up being super helpful for both what I decide to biopsy and what I decide not to biopsy so when I first look at somebody and I see a mole that looks funny to me I look at it closely and I say wow this has some abnormal features maybe it has some asymmetry maybe it has two colors in it and then I say let me look at the rest of this person to see what does their moles normally look like they might have 20 moles that are asymmetric can have two colors in them and then I say to myself this is their signature mold they just make moles that look funny but they may have moles that all look the same and then all of a sudden they have one mold that's just blacker or it's it got more Jagged edges and then you say this is the ugly duckling and this is the one that should be biopsied but usually the ugly ducklings are the ones that your friends your family members your wife your husband is telling you this mole doesn't look good go get it checked out and you say no I'll wait till tomorrow it's fine oh the dermatologist is booked oh I have to go to my primary care this is not something to push off if you have something that looks abnormal I really I can't tell you how many times in my career and I'm early career remember patients have come in where their wives or husbands have told them you should get this checked out they blew it off and they came in finally to get this ugly duckling checked out and then it ended up being a melanoma this is almost always the story so if you have something that looks abnormal like I said that earlier you catch the better off that you are so just you know take a day take a few hours go get it checked out at least get the reassurance that it's either nothing or if it is something we can biopsy and hopefully treat it if it's early enough yeah that brings us to the treatment options and we'll lump this into Surgical and non-surgical and so for surgical options we're basically trying to destroy or remove it and for something early depending on the severity range from something called electrodesiccation and curage we basically numb it scrape it a few layers into the skin but not through the skin so this is for your early skin cancer where there's not a significant depth you're not on any sort of sensitive area if however you have invasive Roots then you're going to be doing an excision or if you have an aggressive skin cancer like a melanoma then you don't want to leave any skin behind you want to capture it all and so you'll do an exision where you cut through the skin you have to take normal appearing skin to capture the microscopic cancer cells that are in the area and then convert that into a line like or curvy linear scar for more aggressive skin cancers then we have something called Mo surgery or on high-risk locations like the face hands groin feet shins where you actually cut it out look at it under the microscope while you're there to ensure the highest possible C rate complete margin examination and then perhaps more complex closure especially useful around the face where you can't just go in a straight line so surgically those are your primary options for most of the common types of skin Cancers and we'll do a much more detailed video on Mo surgery specifically Dr Maxfield does a ton of Mo surgery in clinic and so we even show you some videos of some most surgery procedures as well so you can see what that procedure looks like cuz it is different than other skin cancer procedures now remember this because some of you are watching this video now because you've either been diagnosed with skin cancer or you're post skin cancer surgery and you're coming to this video now the procedure is always going to be bigger than the initial lesion so if you have a lesion and it's just 5 mm big you would think well why wouldn't my surgery just be that big and then they close it one like you said you have to take normal skin around it and that amount of normal skin has been determined by multiple studies we either can take a whole centimeter around the lesion sometimes 2 cenm around the legion sometimes just a half a centimeter around the legion so depending on how aggressive that initial skin cancer is that's going to determine whether or not you're going to have a very large SCAR or not and in order to close it you can't close a circle into a line so you actually have to take little triangles off the edge of it and so that's another reason why your scar might actually be a lot longer than you anticipate so I just want you to keep in mind that that's the case right and that's important consideration I would stress that to my patients because it is hard to Envision ahead of time so it's a very important thought and then after surgeries then you have radiation which is always an acceptable option this has really progressed a long way where you use superficial very localized radiation I know you had a lot of experience with this up at for Dermatology and it's again a very cosmetically appreciable treatment and very effective for a lot of different types of skin cancer if however the skin cancer is very aggressive and it has metastasize you have lymph node involvement other options like immunotherapy or chemotherapy on board and these are not the same thing so chemotherapy is basically it's like a nuke you drop just something very destructive into your body you wipe out a lot of different things and hopefully the skin cancer is a bystander that also gets hit there is some selectivity in it so I don't want you to think this is like thoughtless destruction because they all do have different mechanisms that are more targeted towards different things but it is more like an overarching theme to just damage a lot of things cancer in general gets attacked to immunotherapy has revolutionized the cancer world and it can afford miraculous cures although it's not the rule it's still the exception but there are a lot of different immunotherapy treatments now we wrote a paper on one of them earlier on and it turns on your immune system so that your immune system can attack the cancer and there are again multiple different options Gene selective targeted treatments but different things that a select person might need for an advanced skin cancer as well we've gotten very specific with these treatments now you can specifically treat the root mutation that is causing basil cell skin cancer when you have very aggressive basil cell skin cancers that have either metastasized or have gotten locally very very large I think that's beyond the scope of this video right now but ultimately these are like the range of your treatments you also have your topical chemotherapeutic agents as well so we have topical F floreros cell some people refer to it as aidex skin cancer is already a little bit challenging to to treat at that point now it's sometimes indicated for people that have very superficial skin cancers but for the most part this is going to be used for people that have that tinic keratosis we were talking about so people use it as a field treatment to get rid of all that damage without individually trying to remove those one by one now this type of treatment ends up causing a big red reaction on the face but what it does is it targets those skin cells that are already abnormal and on their way to skin cancer the other topical option that we have is a really good option for those basil cell skin cancers especially when they're superficial something called the mamod it's an immunomodulator that also boosts your immune system locally to help to destroy skin cancer cells so we have some topical options we have some surgical options and then we also have some chemotherapeutic and immunotherapeutic options for cancers nowadays the main thing is if you have something abnormal you definitely want to get it checked out as soon as possible and when you see us if we're also suspicious about it the next step is always to do a biopsy of the lesion biopsy is when we take a scraping of the lesion and we send it off to the lab for analysis that's not a surgery at that point that's us just getting a sample so we can know what the next step is whether it's going to be surgery immunotherapy chemotherapy or nothing at all so just a brief mention because we do know that this is like very relevant just with recent events and Jimmy Buffett is Merkel cell carcinoma this is one of many rare skin cancers so we talked about the common three this is not all of them skin cancers is a huge collection of different types of cancers there unfortunately are hundreds most of them are pretty rare thank Merkel cell carcinoma something a dermatologist may see a handful of times in their lifetime I've unfortunately diagnosed a patient with one as well but Merkel cell carcinoma is contributed by The Sun Also a virus polyoma virus end point is DNA damage they can be particularly locally aggressive they can also be widespread the reason that this is a hard one to Counsel on is there's not a classic clinical appearance and we can't tell you exactly what to look for with this one yeah so this is another one that can just simply look like a pimple I it can be red it can be skin colored um again it's just something that wasn't there before and that usually suddenly appeared and usually you'll notice it before anybody else notices it um and every time I've biopsied Merl cell carcinoma which has only been a few times I didn't suspect it was going to be Merle cell carcinoma and really nobody else did we do have a dermatologist we worked with um that could for some reason pick out a Merkel cell which is very unusual to even have that in your differential but it is something that that's aggressive that can spread rapidly I think the main thing is not to lose sleep over something like this but that if you just have something adnormal get it checked out and then we'll confirm the diagnosis for you so hopefully this collection of diagnosis options treatments is going to be helpful for you um so whether you're wondering if you have a skin cancer or you have one and wondering what's going to happen this can hopefully provide you some guidance um but we greatly appreciate you just being a part of this with us here today and thank you for asking us to make this video hopefully you find this helpful and we'll see you all in the next video we'll see you next time