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Welcome to Skinside Out, where Science Meets Beauty. In this episode, hosts Dr. Zain, Heather, and Courtney look into the critically important topic of skin cancer. They begin with shocking statistics, revealing that one in five Americans will be diagnosed with skin cancer by the age of 70.
With May being Skin Cancer Awareness Month and Melanoma Monday, the conversation highlights the different types of skin cancer—basal cell carcinoma, squamous cell carcinoma, and melanoma. They discuss the features, causes, risk factors, pathogenesis of these cancers, and how they are diagnosed.
Emphasis is placed on self-exams, awareness, and early detection to prevent the disease's progression. The episode also covers real-life cases and the significance of regular skin checks and proper sun protection. Don't miss out on this informative episode—your skin health could depend on it!
With May being Skin Cancer Awareness Month and Melanoma Monday, the conversation highlights the different types of skin cancer—basal cell carcinoma, squamous cell carcinoma, and melanoma. They discuss the features, causes, risk factors, pathogenesis of these cancers, and how they are diagnosed.
Emphasis is placed on self-exams, awareness, and early detection to prevent the disease's progression. The episode also covers real-life cases and the significance of regular skin checks and proper sun protection. Don't miss out on this informative episode—your skin health could depend on it!
00:00 Introduction to Skin Side Out
00:35 Understanding Skin Cancer
01:09 Types of Skin Cancer
02:04 Basal Cell Carcinoma: The Most Common Skin Cancer
02:46 Identifying Basal Cell Carcinoma
07:42 Causes and Risk Factors of Basal Cell Carcinoma
15:13 Squamous Cell Carcinoma: The Second Most Common Skin Cancer
15:33 Features and Causes of Squamous Cell Carcinoma
20:32 The Importance of Early Detection
21:05 Understanding Squamous Cell Carcinoma
21:30 Identifying High-Risk Squamous Cells
21:52 When to Seek Medical Advice
22:13 Introduction to Melanoma
22:52 Recognizing Melanoma Warning Signs
23:20 The ABCDs of Melanoma
24:12 The Role of Experts in Melanoma Detection
24:39 Personal Stories of Melanoma Detection
26:21 Rare and Hidden Melanomas
31:12 The Genetics of Melanoma
33:04 Atypical Moles and Their Risks
36:15 Diagnosing and Treating Melanoma
39:29 Other Rare Skin Cancers
40:15 Final Thoughts and Prevention Tips
Creators and Guests
Host
Host
What is Skinside Out?
Welcome to Skinside Out, where science meets beauty, the ultimate dermatology podcast! Dive deep into the fascinating world of skin health with expert insights, evidence-based discussions, and myth-busting truths. Each episode explores the medical, cosmetic, and surgical aspects of dermatology, while keeping you informed about trending skincare topics. Whether you’re a skincare enthusiast, medical professional, or just curious about how to achieve your best skin, Skinside Out is your go-to resource for staying informed and inspired.
09 Skinside Out
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[00:00:00]
Dr. Zain Husain, MD: Welcome to Skin Side Out where Science Meets Beauty. I'm your host, Dr.
Zane with Heather and Courtney. Did you know that one in five Americans will be diagnosed with skin cancer before the age of 70?
Heather Murray, PA-C: Hmm. I can believe it.
Dr. Zain Husain, MD: Yeah, it's pretty, it's pretty common, especially we have a skewed perception in our office, you know, seeing dermatology patients. So we see a lot of skin cancer, but that's pretty mind blowing.
Joe Woolworth: Mm-hmm .
Dr. Zain Husain, MD: Um, so with May being Skin Cancer Awareness month, and today's actually Melanoma Monday, I think it'd really appropriate [00:01:00] to talk about skin cancer, what causes it, and just some basic facts, um, so that people are aware of this, you know, common disease.
Heather Murray, PA-C: Yeah. So to kind of give you an overview, we'll touch on each of the types of skin cancer.
Um, so basal cell carcinoma, you might have, we might refer it to it as basal cell, um, squamous cell carcinoma. Same. We might refer it to it as squamous cell and then malignant melanoma. Um, so we'll touch on the features of these different types of skin cancers, their etiologies, so like the causes, um, or triggers, risk factors.
We'll also touch on the pathogenesis, so how those skin cancers form, as well as how we diagnose them.
Courtney Carroll, LE: And I think it's important for people to know what to look out for so that they can be aware in between skin checks, you know, we're there to help when we see people yearly or every six months or so.
But at home you definitely wanna make sure you're doing self exams too, [00:02:00] and noticing anything new or changing and what to really be on the lookout for.
Dr. Zain Husain, MD: Yeah. So let's get into the most common type of skin cancer basal cell carcinoma. So basal cell carcinoma is the most common type of skin cancer, and fun fact, it's actually the most common cancer in humans.
Mm-hmm . Mm-hmm . Yep. Um, so it is overwhelmingly common and the good thing is, is that it is easily treatable and detectable. But you know, just to look at those stats, that's pretty incredible. And they account for 80% of non-melanoma skin cancers. So basal cells, squamous cells among a few other tumors.
This year alone, 3.6 million basal cell carcinomas will be diagnosed among Americans. Yeah, that's crazy.
Heather Murray, PA-C: Oh, so basal cell carcinoma is typically, um, this what we call feminist perley papule. So, um, if you ever hear your provider saying that, that's. Our, our kind of, [00:03:00] um, term that we're using to diagnose or rule out basal cell.
Can you break that down for us? Those are like really big words and
Dr. Zain Husain, MD: I don't dunno, think half of us even know what those mean. . Exactly.
Heather Murray, PA-C: So erythema pretty much just means red. Um, pearly means pearly, so it has this kind of shiny hue to it. And then pape is pretty much just a raised or palpable lesion.
Lesion, something that you can feel. And so that's kind of the classic basal cell. There are other types, . Or other features that you might see in a basal cell carcinoma. So there are like lanasia or arbor rising vessels. These are like little blood vessels that are being created within that skin cancer.
Um, they're, you know, the non-class looks to a basal cell, so typically like on the trunk, so like on the chest or back, you might see a different type of basal or it looks different. Sometimes they can be flat and red. They can have this kind of lighter hue around the lesion. So it's not necessarily to say that [00:04:00] every basal cell is gonna be this erythema, perley papule, but um, that is the classic.
Dr. Zain Husain, MD: What about that rolled border?
Heather Murray, PA-C: The rolled border is very common too, especially with those blood vessels involved, they tend to kind of roll over that border and kind of form over the edge. Um, so these are just things that we're looking for under magnification to either potentially diagnose or rule out.
Yeah,
Courtney Carroll, LE: I think that's why, you know, a lot of people. Think, oh, it's just a pimple. Mm-hmm . We hear that time and time again when we are doing our skin checks or checking the face, um, you know, we'll say, how long has that been there for? And that person will say, oh, it's just a pimple. Yeah. You know, but it's been there for three, four months.
Yeah. The pimple that doesn't go away is, yeah. It's a red flag. ,
Dr. Zain Husain, MD: things are supposed to heal. Yeah, our body has those mechanisms to heal, but unfortunately, cancer doesn't obey those rules. And, you know, typically just sticks around, grows, um, gets irritated, bleeds. All those [00:05:00] things are warning signs.
Courtney Carroll, LE: Yeah, so basal cells, um, typically we see a lot of them on the face.
Um, you know, ears can be included, neck extremities that have been hit by sun. So arms, legs, um, you know, hands, really anywhere that you've had sun exposure. But there is also that genetic component to those basal cells as well. So sometimes they do come up in areas that don't get any sun exposure.
Mm-hmm . Um, my old practice had a patient a few years back who, . He was of Middle Eastern descent and he had complained about a skin tag, um, on his, um, you know, anal area and we kind of assumed it was a skin tag. But my doctor said, okay, let's just take it off. It's bothering you. Sure enough, we gave it to the pathologist.
It came back as a basal cell carcinoma. So that's just goes to show it doesn't matter if that area's had sun or not, it still can. Show up in these places.
Dr. Zain Husain, MD: Yeah. I remember finding a basal cell in someone's belly button and they just thought it was something that [00:06:00] was stuck there. Just couldn't get it out.
Heather Murray, PA-C: I actually had a guy once who had a basal cell in his tattoo and he had it for years because it was this shark tattoo and he really liked it. Didn't want to, you know, potentially ruin that shark tattoo. It ended up working out where the, the surgery was able to just kind of . Mold the shark a little bit differently.
Yeah. But I think some people are a little bit more cautious Yeah. When it's in a tattoo and they don't wanna ruin that tattoo. And
Dr. Zain Husain, MD: that also reminds me of a case that I had, um, this guy had this amazing eagle on his back as a tattoo. Literally there was like this basil cell in the eagle's eye .
Joe Woolworth: Oh wow.
Dr. Zain Husain, MD: And it's clearly basil cell. And he was just so freaked out about me manipulating that tattoo. But we were able to cut it out. Um, we did moss to. At least preserve as much of the tattoo as possible. Yeah,
Joe Woolworth: oh
Dr. Zain Husain, MD: yeah. And we [00:07:00] reconstruct in a way that it, you know, the eagle looked great, you know, it got a little bit more of an edge with a little, maybe a little wink instead of
Courtney Carroll, LE: two eyes
As someone tattooed, I definitely would. Be so mindful and a little freaked. I would wanna make sure it's as small . Yeah,
Heather Murray, PA-C: well that's why I'm afraid to get tattoos because I don't wanna have a skin cancer . That's why , that's
Courtney Carroll, LE: why . But yeah, you know, typically it is. Um, and it's funny talking about tattoos.
'cause I do feel like people who have tattoos tend to be a little better on their sunscreen use because they want to preserve the color of the tattoo. And so I know for me it's . Kind of that dual function where, okay, I wanna preserve the tattoo and I also don't wanna get skin cancer . Yeah.
Dr. Zain Husain, MD: All right. So let's talk about, um, what causes basal cell?
I think we touched upon it already.
Heather Murray, PA-C: Yeah. So I think Courtney mentioned it briefly. The most common, um, cause of basal cell is that long-term chronic UV or ultraviolet, um, radiation exposure. Um, these are, you know, the classic . [00:08:00] Being out in the sun for years and years on end is the most common cause.
Dr. Zain Husain, MD: Yeah.
Um, and other factors that can contribute, um, including a history of previous skin cancer. So these are people who have been, you know, exposed to UV light in the past. They tend to have fair skin. Um, in general, and you know, those patients who have weakened immune systems, their bodies aren't able to detect and fight off, um, you know, these tumoral cells so you know, they can develop skin cancer as well.
And also there's a unique, um, genetic syndrome called Gorlin syndrome or basal cell Nevis syndrome. And I actually had a patient with this. Um, he was this young guy. It was just had like 20 or 30 basal cells already. I'm like, this is so weird. Like, you know, have you ever gotten this checked out? And he is like, no, I just keep getting them.
Then I knew some of the other features of basal cell Neeva syndrome. I'm like, Hey, did you ever get these, like Joss that by any chance? It's a lot of dental work. Like yeah, I got them all the time and like, you know, just kind of piecing all [00:09:00] the piece of the puzzle together. And, you know, we made the diagnosis of Gorlin Syndrome and the nice thing is, is that like.
He's aware that he is going to be in for a lot of potential future skin cancers, getting screened regularly, having low threshold to biopsy. So that really helped him. And he's just a young guy. He is like, he wasn't even 30 yet.
Heather Murray, PA-C: That's really interesting. I had a patient once that had. At least five basal cells on his scalp.
Now this was at my previous practice and mm-hmm . I was kind of, you know, transitioning to moving back to North Carolina, but, um, pretty much had to have most of his scalp kind of reconstructed and grafted. And so I'd be curious to see kind of where he is today and if that was, you know, a possibility. Yeah.
And it's cool '
Dr. Zain Husain, MD: cause we actually know the, the reason of that genetic mutation mm-hmm . And like the sonic hedgehog patch pathway that we learned about, and there's medication that actually targeted and actually can be very effective for [00:10:00] reducing the incidence of basal cell carcinoma.
Courtney Carroll, LE: We had a patient on the one of scents that you had mentioned, because again, a young guy and just completely covered with these basal cells and it's, you're nonstop cutting.
So
Heather Murray, PA-C: yeah, so that hedgehog pathway, um, is pretty much responsible. So it's a, um, . Gene pathway that's responsible for tissue homeostasis, um, stem cell maintenance, as well as tissue and cellular growth. And so when you have that mutation, um, which is common for basal cells, that creates that growth and the tumor tumor formation.
Dr. Zain Husain, MD: Yeah, it's a pretty cool pathway and I loved learning about it for, for boards 'cause they love asking questions about it. Mm-hmm . They
Heather Murray, PA-C: really do. Yeah. So you might hear some of those medications be called hedgehog inhibitors. .
Dr. Zain Husain, MD: That's cute. It's like, it's literally named after Sonic the Hedgehog. . Yeah. .
Courtney Carroll, LE: Um, the nice thing about basal cell carcinomas are that typically these are gonna be slow growing skin cancers, so they don't tend to [00:11:00] metastasize.
Like something, um, like a squamous cell mite or definitely, you know, more at risk with melanomas. So they're typically slow growing, easily treated pretty localized. So those are all good things when you're dealing with cancer. Yeah.
Dr. Zain Husain, MD: The problem is when you neglect them. Yes. Unfortunately, we see those patients who.
Know, like leave these growths like unchecked. Um, you know, those nursing home patients, unfortunately who were neglected mm-hmm . Um, and these things can grow and cause a lot of local devastation Oh yeah. To tissue. Yeah. Um, I've had, you know, I remember a patient with this fungating tumor, um, on her eyelid and it literally like ate away her orbit, her eyeball and everything.
And it was just horrific and . It could have been easily treated had it been detected. Earlier and treated appropriately so.
Courtney Carroll, LE: Yeah. Yeah. We had a gentleman who unfortunately just had really terrible white coat syndrome and by the time he had come in, the basal cell [00:12:00] essentially had taken over his whole nose.
And at that point, you know, all we can do is refer out, but that surgery, um, had he come in, you know, when it had first began Yeah. Um, would've been a lot smaller and easier.
Dr. Zain Husain, MD: Yeah. And you know, it can affect. Structures deep in the skin, nerves can lead to nerve pain paralysis. Mm-hmm . Um, it can migrate down to bone.
Um, so. It's not something you want to just let go. Um, it can be treated. Um, but like you mentioned, like it rarely metastasize, but there are rare instances mm-hmm . Where it does metastasize. Yeah. So just be mindful of that. Oh, you know, it's just a basal cell I hear from patients. Um, but, you know, sometimes, you know, it can be devastating.
Courtney Carroll, LE: Yeah. And to segue into how . We test for those basal cells. Um, kind of just going back to that white coat syndrome, it's actually a really easy procedure that, um, is done to test for those cells. So a skin biopsy is typically what, um, your provider [00:13:00] will do for you if they see a spot that looks suspicious for any skin cancer.
And the process for that is relatively easy. The area is locally numbed, usually with lidocaine, um, you know, or some other numbing agent. If you have allergies to lidocaine, then at that point your provider will just shave off that top layer of the, um, lesion. And then we send that off to the pathologist.
So you're left with almost like a little scrape, um, a little wound that you take care of for about a week with some Aquaphor Vaseline bandage. But it's a very easy procedure. Um, takes no more than a few minutes to do mm-hmm . And most times by the time it's over, people say, oh, that was
Heather Murray, PA-C: nothing. . Yeah.
And there are some devices that we can use too, as providers to help kind of determine whether a biopsy is needed or not. So there, um, these little handheld magnifiers called Dermatoscopes, and so we use those, I use mine all the time. Mm-hmm . Especially during a full body skin check or looking at something that a patient's [00:14:00] worried about.
And that really just allows the provider to look at the lesion in different ways, look at it under different lights, um, to, to kind of see those features that erythema is pretty pape or those blood vessels, those classic features that we're looking for. Or we might look at something and you know, it doesn't really have any of those classic features.
And then that's another red flag that . Might, um, warrant a biopsy too.
Dr. Zain Husain, MD: Yeah, I mean, I feel like. Oscopy is almost becoming standard of care in dermatology. Yeah. Um, I know some of the old school docs haven't necessarily embraced it, but you know, in training when I was in residency, um, you know, oscopy was so vital.
Um, it allowed us to make educated decisions about whether we even need to biopsy rather than turning all of our patients to Swiss cheese. Yeah. We really looked at those features and Oscopy really changed the game. Um. And it gave us a little bit more of an algorithm to follow, um, based [00:15:00] on those features that we saw, um, on that.
So it, it's pretty cool. And you know, if you ever see those little fancy little magnifying glass at the dermatologist office, that's what we're using.
Heather Murray, PA-C: Yeah.
Dr. Zain Husain, MD: Yeah. All right. Well that was basal cell carcinoma. So let's transition to the second most common type of skin cancer, which is squamous cell carcinoma.
So SCC as we'll refer to as well, um, there are 1.8 million cases diagnosed in the US every year. So that's also a ton of patients. Mm-hmm . Um, so let's talk about a little bit about the features of basal cell. Yeah.
Heather Murray, PA-C: So typically it'll be a kind of firm scaly, nodule or bump. Um, not always the case, but they do tend to be pretty scaly and kind of thickened.
Um, but they can also be just flat and red. Um, they might look, um, like just a ingrown hair almost. Mm-hmm . It really kind of depends on the type of squamous cell. It could be, but that's kind of the [00:16:00] classic look to it.
Dr. Zain Husain, MD: One of my favorites is the cutaneous horn. It's like this little like crusty nail. It's just a little
Heather Murray, PA-C: vertical stick outta your face.
Dr. Zain Husain, MD: Yeah. So I mean, there's often like a little squamous cell lurking at the base of that. Um, what about our volcano?
Courtney Carroll, LE: Yeah, the like the Kas. The
Dr. Zain Husain, MD: Keratoma. That's one of my favorites. Yeah. Patients come in, um, with this rapidly enlarging nodule. Painful, painful that showed up within weeks. Yeah. Um, and they're freaking out.
And I get it.
Courtney Carroll, LE: It's incredibly fast. Very fast. So I understand their concern. It's, you go from nothing. Yeah.
Heather Murray, PA-C: I think the kas are, you know, you walk into that room and you say, that's a ka Yeah, that's a squamous cell
Dr. Zain Husain, MD: doorway diagnosis. Yeah. Yep. .
Courtney Carroll, LE: But yeah, fortunately, um, you know, unlike basal cell, I guess squa squamous cell does have a little bit higher risk of that, um, metastasizing, um, still nowhere close to like a melanoma where we are really concerned about, [00:17:00] you know, um, lymph nodes and things like that.
But that's why you definitely wanna make sure you're getting your checks and, um, getting ahead of that to make sure it does not grow into anything more than just the skin.
Dr. Zain Husain, MD: Yeah. All right, let's go into the etiology. What leads to squamous cell carcinoma?
Heather Murray, PA-C: So similar to basal cell, the most common cause is that prolonged or excessive UV exposure, especially in fair skin individuals.
Um, we see that all the time where people are like, oh, I was born in the eighties. I didn't use sunscreen. I used . Mineral oil and sine iodine. . Yeah, . So, um, luckily we are getting away from that, but that's kind of your classic risk factor.
Dr. Zain Husain, MD: But there are other risk factors, right? So we have patients who have chemical exposure such as like arsenic.
That's a pretty classic case. Um, smoking leads to higher risk of squamous cell carcinoma. Um, HPV infection. So the virus [00:18:00] that causes warts can lead to squamous cell carcinoma. Um, and then is having like a weakened immune system, like transplant patients, patients who are on chemotherapy, um, HIV, that type of thing.
So there are a lot of potential risk factors.
Heather Murray, PA-C: Yeah. Even like, um, CLL, so, um mm-hmm . Chronic, um, or. Ccc, CLL, chronic Lymphatic Leukemia. Leukemia. I see. I've seen a lot of squamous cells in those patients too.
Dr. Zain Husain, MD: And also wounds, chronic wounds. Mm-hmm . Um, can lead to squamous cell carcinoma. That constant inflammation leads to transformation of those skin cells.
And that can lead to squamous cell carcinoma.
Courtney Carroll, LE: And I think to speak on that, that's why sometimes patients tend to disregard those new lesions. They say, oh, well this was a, a cut that I had, it's just not healing well. Or, you know, and those are those red flags again, that were looking for. Um, yes, it might have started as like a little cut or wound, [00:19:00] but it provides that environment for that squamous cell to grow.
Yeah.
Dr. Zain Husain, MD: So similar to Basal Cell Carcinoma, we have a well-known genetic pathway that leads to the squamous cells. Can you tell us a little bit more about that, Heather?
Heather Murray, PA-C: Yeah, so most commonly, um, there's this TP 53 suppressor gene, and that when that gets, um, mutated, it can lead to the squamous cells. So this, um, TP 53 is responsible for regulating, um, cell growth, cell repair and survival.
And so when you have that mutation, a tumor is likely to form.
Dr. Zain Husain, MD: Yeah. And I dunno if you've, um. If you've seen or heard about the permitting dimers that form from the UV damage. Um, so that's literally happening on the molecular level. And what's really cool, 'cause we can actually see how that's translating into these genetic mutations leading to the skin cancer, which is really cool because we actually see the precursor, which is the [00:20:00] nin keratosis.
Mm-hmm . Also known as precancerous, which can evolve with increasing mutations to actually form the tumor. So it's really interesting, um, to see that whole, like transformation happen.
Heather Murray, PA-C: Yeah. Um, yeah. With kind of going off of that, with those AKs, the actinic keratosis, some of them will develop into squamous cells, not all of them.
Mm-hmm . And that's why we definitely want to treat them versus letting them go and potentially turning into that squamous cell or basal.
Dr. Zain Husain, MD: because you never know when they're gonna transform. Yeah. Mm-hmm . That's the scary thing.
Courtney Carroll, LE: Yeah. And as mentioned before, you know, it can go into the deeper layers of the skin and you know, that's why it's funny, I feel like I have definitely, even in this last week, heard of several stories of people's, um, parents who have had squamous cell that has metastasized.
We had that patient earlier today. Her father had passed away from that, unfortunately. Um, many years back. And I think as we get better at detecting and spreading awareness [00:21:00] less people are having that happen because we're able to catch things earlier. Yeah. So, um, you know, to reiterate that too is the biopsy, um, just like we explained for the basal cell, is typically how we'll catch those squamous cells.
So that's why the skin exams are so important, especially if you have that family history or that personal history.
Heather Murray, PA-C: Yeah. Yeah. And with that, um, dermatoscope just, um, allowing your provider to use that tool to see, um, certain features, to know if it's a risk or not.
Dr. Zain Husain, MD: Exactly. And you know, not all squamous cells are the same, right?
So there are squamous cells that are more aggressive than others. Typically, those that are found on the head and neck. On mucosal surfaces such as the lips, also the tips, um, like your ears. Um, so they have higher risk, um, of potentially metastasizing. So, um, you know, that's something to take note of.
Courtney Carroll, LE: A good rule of thumb that I've always heard my providers go by is if it's not healing within.
That four week mark mm-hmm . Once you hit that fourth, fifth week, [00:22:00] if that spot is still there, okay, maybe you think it's just a pimple or just a, a cut. You banged your hand on something. Um, but at that fourth week, if it's still there, you should go get it checked out with your provider. Yeah.
Dr. Zain Husain, MD: All right. So now that we've talked about the non-melanoma skin cancers, we're gonna move on to the Biggie.
Melanoma. So, melanoma, um, as you may have heard, is the most deadly form of skin cancer. I. Um, and like basal cell and squamous cell, it arrives from a different cell type. So they come from melanocytes, which are the cells that produce pigment. Um, and an estimated 212,200 Americans are estimated to be diagnosed with melanoma this year.
Wow.
Joe Woolworth: Um,
Dr. Zain Husain, MD: so that is a pretty staggering number. And, you know, with the highest rate of fatalities with a skin cancer, um, that's scary.
Heather Murray, PA-C: Yeah, and this is typically gonna be in a new or a changing mole. Um, about [00:23:00] 70% of melanoma show up in a new mole, whereas 30% of melanomas are in an existing mole. That is changing, and I think that is why it's so important to.
You know, take photos of your skin if you have a lot of moles. You know, it's sometimes hard. I have a lot of moles on my arms, and I think it's hard sometimes to be like, oh, have I had that? Or is that new? And so, um, we kind of look for these, um, red flags or warning signs, and we typically call them the ABC ds.
And so a stands for asymmetry. So if you were to cut the lesion in half, is it the same on the left versus the right or top versus bottom? Um, B is borders. So if it has kind of irregular or kind of wonky borders, that could be a red flag. C stands for color, so this gets a little finicky because you can have a benign and a normal mole that has two different colors, but if it has more than two colors, that could be a red flag for sure.
Um, D stands for diameter, so anything [00:24:00] more than six millimeters, which is the size of a pencil eraser. And E is evolution. So something that is new or changing. Sometimes they can be itchy or ulcerated or bleed, and that could be a red flag too.
Dr. Zain Husain, MD: Yeah. And just to note, um, the ABCDs are just a rough guide, right?
For the lay person. There are a lot of other features we are looking at when we're examining your skin. And even though like, it may not be completely symmetric or they may be different colors, it may not even be a pigmented lesion. It might be just a, a benign growth. So, um, you know, take it with a grain of salt.
Yeah. And then see your experts, um, for full evaluation.
Courtney Carroll, LE: Yeah. Um, I know. We've seen quite a few of just those, um, melanomas that look almost just like a freckle. Mm-hmm . And something just speaks to, it's scary. It's, it's incredibly scary. Yeah. Because just there's something that, you know, you guys are so used to seeing nor what's normal.
And so if something's standing out, even if it's just so slight and you end up biopsying and that comes back as melanoma, sometimes we [00:25:00] just look at those pictures and I'm just stunned at. How did you guys find that? , you know, the
Dr. Zain Husain, MD: scariest ones? The a metic melanomas? Yeah. Those are the melanomas that don't have pigment.
They kind of just look like a pink little pape or just barely anything. Um, I remember, um, having a patient in New Jersey who had one in like I guess an arm that had a tattoo, and I just saw it. It just didn't look right. I just had that. I know there was just something about it, it, otherwise, in most patients I would've just kind of glanced over.
It just looks like another, like, you know, growth. But there was just something about it. We biopsy, it came back as a, you know, a metic melanoma and that scared me. , she was a nurse herself and, but I'm glad that I had biopsied. There was just something about it. And you know, to this day she actually sees me in my North Carolina office.
She sees me, um, every six months for her skin check. She relocated to South Carolina, so she makes the trip out to see us and she's so sweet, so grateful.
Heather Murray, PA-C: Yeah. The PA I used to work with, um, [00:26:00] she had biopsied this melanoma on the foot and we were looking back at the photos and mm-hmm . Every provider in the office was like.
What made you Yeah. Biopsy that and she said, I had a measurement of it from last year and it changed one millimeter. So I, I had this gut instinct that it needed to be biopsied and, um, good things she did.
Courtney Carroll, LE: Yeah. And to speak on that, um, you know, those areas are. Scary when you think about melanomas. So palms of the hands.
Mm-hmm. Bottom of the feet. I mean, that's how Bob Marley died. Mm-hmm. Um, from his melanoma on the bottom of the foot. So those are ones that you definitely wanna pay extra attention to, but they can also, you know, be on the, the extremity. So, um, trunk arms, legs, and on face unfortunately too.
Dr. Zain Husain, MD: Yeah. And I always remind my patients like.
You know, see your dentist, see your eye doctor, because melanomas can arise inside the oral mucosa. Um, and in the eyes. The eyes. I had a patient who had ocular melanoma. Yeah. Um, [00:27:00] and you know, that is just crazy. Yeah. Um, because we can't detect it as dermatologists because we don't have the specialized equipment to really assess it.
Um, and just another crazy site that you can get this this is actually my dad. He had melanoma insight too, of his large intestine. His colon. Wow. Wow. And they found it on colonoscopy. So the GI doctor was doing the colonoscopy, saw this dark patch, um, and decided to biopsy it. And, you know, lo and behold, it came back as melanoma in insight two.
First of all, who would've ever thought it would be, you know, inside your gut and your colon second, like we don't really fit the stereotype for melanomas, usually fair skinned individuals, but it can happen in skin of color. Um, and yeah, it was pretty crazy. And you know, it's so rare, um, that we went to several centers.
We start off at Memorial [00:28:00] Sloan Kettering, um, in New York City 'cause we live close by and, you know, they were. They were recommending doing a really invasive procedure with like, you know, colectomy, ostomy, all that stuff. And my dad just, you know, he was not, he was not for it. And we got a second opinion up at Mass General at Harvard and, you know, his surgical oncologist decided to, you know, do a more conservative approach, do like a small, little like excision and watch and, you know, periodically.
Reassess the area, and that's what he did. And you know, that was when I was a first year dermatology resident. I was back in 2012, so it's been 13 years. Um, and thankfully he is doing great. Um, has not had any issues, but, but who would've thought?
Courtney Carroll, LE: Yeah. So what does Insight two mean for those who don't know?
Dr. Zain Husain, MD: Yeah, so that's a great question. So Insight two means that the skin cancer has not [00:29:00] invaded into the second layer of the skin. So we have the epidermis on the top, which is the most superficial layer. Then you have the dermis and then the subcutaneous tissue. So it has not penetrated the basement membrane going into the dermis, which is a good thing.
That means it was caught earlier. Um, and that we can usually surgically, you know, treat it, um, without having to do any more invasive procedures such as sentel, lymph node biopsy, or other treatments.
Heather Murray, PA-C: Yeah. So we'll kind of touch on, um, etiology or the causes. So, um, kind of similar but a little different.
It's definitely that . Chronic, um, intermittent sun exposure, or particularly with melanomas, it's the sunburn. Mm-hmm . So having five or more sunburns actually doubles your risk for melanoma, which is crazy to me because I was that teenager that wanted to be tan. My poor mom was, did you ever get
Dr. Zain Husain, MD: tan ?
Heather Murray, PA-C: No , it was always a burn.
Which scares, which is why it scares me so much. Yeah. My poor mom, I hope she's not listening [00:30:00] right now, but, um, she was always like, you have your sunscreen on, right? And I'm like, yep.
Dr. Zain Husain, MD: Mm-hmm . And
Heather Murray, PA-C: of course I put like tanning oil s pf five on. Oh my God. And then I You're a bad girl.
Joe Woolworth: Well,
Heather Murray, PA-C: I,
Dr. Zain Husain, MD: who would've thought, Hey, at least
Heather Murray, PA-C: I didn't go to a tanning bed, but I was, I even had my worst sunburn.
Was right before senior year, um, spring break, , and me and like 10 other friends were going to Cabo. Oh. So of course I'm like purple. I'm like blistering on my shoulders, and then I'm in Cabo the next week, . So it was horrible. So my risk of melanoma is probably very high. Well, I feel like
Courtney Carroll, LE: I had the opposite experience as a child where.
I was like begging my mom to put more sunscreen on me. So good for you. Good for you. Because I would burn all the time. And my mom has that nice Italian complexion. She has the beautiful olive skin, and so that's what I wanted. She would use the baby oil and iodine and just say, oh, you're fine. But meanwhile, I would be at the beach completely burnt in the restaurants like
Freezing because you get that burn [00:31:00] trying to shower like, oh gosh, you know? So now the tables have turned tremendously where I'm the one, you know, mothering my mother. Make sure you put sunscreen on. . .
Dr. Zain Husain, MD: Yeah. So we talked about some of the pathogenesis, um, or the gene mutations and squamous cell basal cell.
What do we know about melanoma?
Heather Murray, PA-C: So melanoma is typically a mutation in the BAF gene, um, which is activates a signaling pathway and kind of promotes that tumor growth. So you might hear, I mean, your provider might not get it into the nitty and gritty when talking about it, but the BRAF gene mutation is typical with melanoma.
Yeah.
Dr. Zain Husain, MD: But there are other genes that are, um, you know, potentially mutated in melanoma, but that is a pretty common one.
Courtney Carroll, LE: Yeah. Um, and you know, as mentioned, melanoma definitely, um, is more aggressive than your basal cell and your squamous cell carcinomas. So, um, that's [00:32:00] why like Dr. Sain had mentioned earlier about, um, sometimes there will be additional testing to see if it has, um, spread to lymph nodes.
Um, and they'll usually stage it, um, which, you know, the pathologist will send to us. So we're able to see exactly kind of where that lies.
Heather Murray, PA-C: Yeah. And because that, um, melanoma arises from the mutation in the melanocytes, so the cells that are forming that melanin, um, I kind of. Anybody technically could get melanoma, but it's definitely more likely in your fair skin individuals.
And I like to kind of describe it to, um, like my darker skin types or um, skin of color patients that their skin or their melanocytes kind of act as umbrellas and so it has that extra melanin in it to help protect. Whereas us, like fair skin individuals don't have that umbrella. So our skin is just kind of, you know.
Baking out in the sun pretty much and getting that risk of [00:33:00] the mutation.
Dr. Zain Husain, MD: Yeah. Um, I also wanted to touch on. Atypical moles and what that means. Um, so Courtney, can you tell us a little bit about what atypical moles are, how we grade them, and how are they different than melanoma?
Courtney Carroll, LE: Yeah, so, um, occasionally you'll go get your skin exam and um, have a biopsy done.
And your provider might be worried about me melanoma, but they might also mention about just atypical moles, or you might hear the word dysplastic. Um, nevi or nevus, which is just another word for mole. These moles have these atypical cells that when the pathologist is looking at them, they can see the severity of these.
So they kind of grade them by mild, moderate, and severe. Um, and that just shows essentially. How, again, how rapidly those cells are changing. They do have the potential of turning into melanoma down the road. It does not mean that it's a melanoma right then and there, but because of that potential, and especially in the ones that have that moderate [00:34:00] ayia, um, or the severe ayia, you do want to remove that mole so it doesn't even have that chance to turn into melanoma.
Um, I actually had a, a dysplastic mole with severe ayia removed, um, right on my arm and . You know, we went in and took a couple millimeters around the area and surgically excised it. But people who get those atypical cells are atypical moles. Typically I feel tend to get a couple or a few, I mean, . When providers are looking at your moles, um, your moles might look different than other people's moles.
Mm-hmm . What's typical for you is not typical for everyone. So they're able to get a good layout and see what's your typical mole. And ones that look a little bit off are the ones that they're gonna say, Hey, let's biopsy that. So they're kind of these in between moles that still show that ayia that you wanna have removed, but they're not quite melanoma yet.
Dr. Zain Husain, MD: Yeah. And I like that you pointed out that, you know, people may have really funky looking moles, but they're [00:35:00] normal for them. That's their signature kind of mole. Mm-hmm . So some people are just, you know, oh my God, those all my moles look really weird. Mm-hmm . Um, do I have to take them mo off? I'm like, no, because that's just how your genetics plays a role into that.
And just how you just produce moles, um, is just a pattern that we see. So it's all taken into context. Mm-hmm .
Courtney Carroll, LE: Yeah. Sometimes like, you know, I'll notice you guys go back. Um, you know, there's a spot maybe on the back that you're unsure about. Mm-hmm . But you continue checking, let's see what that normal mole looks like.
Let's get a good mean. And then going back to it to say, okay, maybe we do need to take that off. Or, okay. That is your typical mole.
Heather Murray, PA-C: Yeah. I do that a lot. 'cause sometimes I tend to look at the back. That's one of the first places that I look and . There's a lot of, you know, you might look at this, what looks like an abnormal mole, but then you, as you go through, like you were saying, and you, you're like, oh, well this might be your typical mole.
Dr. Zain Husain, MD: Yeah. Do you use your dermatoscope when you're [00:36:00] looking at moles?
Heather Murray, PA-C: I do. I always do. I probably use it on every mole that I see. Yeah. I'll vouch for her for that. . .
Dr. Zain Husain, MD: That's why you're always running behind . No, that's good. It's a great tool that you can use. And then how do we typically diagnose it?
Courtney Carroll, LE: Same way.
Biopsy. Mm-hmm . Um, you know, clinical evaluation with the Dermatoscope. Um, again, taking into context all of the different moles someone has. And then, um, being able to biopsy again, usually through that shave removal. Sending that off to the pathologist and at that point they're able to, um, do additional tests if they need to stage it.
Yeah.
Heather Murray, PA-C: I think the biggest difference between pathology of a melanoma versus other, um, skin cancers is that, um, breslow depth that they're looking for. So that is something that the pathologist will, um, document on because we wanna see how deep into the skin is that melanoma.
Dr. Zain Husain, MD: Yeah. And that will. Gauge how severe, um, [00:37:00] you know, that melanoma is and what the next steps are staging, whether we need to do imaging and what type of treatments, um, whether we need to, you know, do
Immunotherapy, radiation, chemotherapy. So a lot of that hinges just based on, you know, getting that slo depth and just making sure that you biopsy it correctly so you can get that information. 'cause if you transect it or go through the mole and don't get the full depth, you don't get the full picture.
Mm-hmm .
Heather Murray, PA-C: Right?
Dr. Zain Husain, MD: Um, yeah, so the nice thing about melanoma, if there is anything Yeah. , um, is that if you catch it early, . Um, you can have over a 99% five year survival, which is insane. The problem is when you, you know, don't detect it early enough and it spreads to the lymph nodes, your survival drops down to like 75% and if it spreads to distant organs, um, with metastasis, you're looking at [00:38:00] 35% survival rate and that is pretty grim.
However, with the new immunotherapies and other like treatment advances that we have, people are living longer, but still, like, you don't want to get to that point, right? You want to detect these earlier and treat them surgically and just, you know, eliminate that risk.
Courtney Carroll, LE: Yeah, I know. Um, I don't know if there's any real housewives.
Fans that listen. But, um, one of the housewives Teddy Mellencamp is struggling with that right now, where she did have that melanoma metastasized and it did metastasize to the brain. And she had a few tumors, um, which fortunately they were able to take out. I think she said four. Um, and so she's struggling with that right now, and it's just incredibly sad.
She's young, she's in her forties. Um, you know, she has two or three kids. And, um, her story's just been really interesting to follow along with. And I, you know, think she's using her platform really well and encouraging people to get those early skin checks and don't put it off. And, um, if you notice anything new or changing or weird, just, you know, [00:39:00] go ahead and get it checked.
Dr. Zain Husain, MD: Yeah. Melanoma is actually a pretty common cause of death in younger individuals. Mm-hmm . Because. Unfortunately, we're seeing it more and more common, um, in younger folks. And, you know, I've seen a teenager with melanoma.
Joe Woolworth: Mm-hmm .
Dr. Zain Husain, MD: Um, and I just feel like it's probably due to like better detection, but also like, you know, people are tanning, you know, people are doing those kind of risky behaviors that can lead to increased risk of melanoma.
Mm-hmm . So I think that we have talked about melanoma quite a bit, but I also wanted to point out that there are other type of skin cancers, not just basal cell, squamous cell and melanoma. Um, there are rare tumors. There is DFSP or dermato fibrosis or coma protuberance say that 10 times fast. Um, um, sebaceous carcinoma.
There's puo carcinomas, . There's a lot of different types of rare skin types, which Merkel cell. Exactly. Merkel cell, which can be very deadly. [00:40:00] Um, which we may touch upon in a future podcast. But for all intents and purposes, I think focusing on these three, um, is important because these are the ones that you may come across, um, you know, and in real life.
Mm-hmm . Yeah. , so I think this discussion on these different types of skin cancers has been. Really important to get the word out.
Um, you know, especially among young, younger individuals, what to look out for so that they can keep themselves safe and healthy.
Heather Murray, PA-C: Yeah. And just a reminder to get your yearly skin check. Mm-hmm . If you haven't already, um, wear your sunscreen, which we'll actually touch on at our next episode. Mm-hmm . Um, and just, you know, if you're worried about something, just to have a provider take a look.
Courtney Carroll, LE: Yeah,
Heather Murray, PA-C: the
Courtney Carroll, LE: biopsies really are not that bad and you would much rather have a small biopsy than, you know, lead to something much worse, like a big surgery or things like that. So.
Dr. Zain Husain, MD: Okay. Well, thanks for joining us on this episode. Hopefully you liked it. Please like and subscribe and until [00:41:00] next time, skin side.
Joe Woolworth: Ouch. Ouch.