Healthcare Pros
The latest on prevention, diagnosis and treatments to save your skin
Learn about new medical advances for your skin and eyes from these Southwest Florida doctors.
It is an exciting time to be a dermatologist. Developments and advances in the prevention, diagnosis and treatment of dermatologic diseases in general and skin cancer in particular are springing forth after years of slow going. Melanoma has perhaps benefited most from this combination of bench research and clinical advances, stemming from the understanding of how this killer develops at the cellular level. I would like to present the most important developments at each level of intervention.
PREVENTION Sun avoidance, broad spectrum sunscreen use, protective clothing and eyewear are the mainstay of melanoma prevention, beginning in youth and proceeding throughout life. Sunlight is not your friend, and sun-damaged skin is neither “healthy” nor “attractive,” but it is in fact deleterious to your health.
The vitamin D myth is slowly being debunked as it is readily available through dietary measures and as studies have shown that 15 minutes of sunlight two times a week to forearm skin is all that is required to convert all the vitamin D needed by the human body into its active form. The complete role of vitamin D in cancer prevention is as yet unclear and an area of ongoing research.
Polypodium leucotomas (a fern extract) has been shown to exhibit sunscreen and cancer protective effects when taken orally and shows real promise as an important tool in cancer prevention.
The American Academy of Dermatology (AAD) has taken a very active role in grassroots public education and at the state legislative levels regarding the harmful effects of phototherapy at tanning salons; well-controlled study has shown that even a single indoor tanning session may increase an individual’s risk for melanoma by 20 percent.
Familial melanoma is a relatively rare presentation of the disease. This was initially identified in families with multiple moles and exhibiting concerning features out of which an increased number of melanomas arose (the atypical mole syndrome). From that bedside observation, bench research answered the origin of this phenomenon by identifying a genetic mutation found in many of these patients (the CDKFN2A [p16] gene); that determination led to a blood test to screen for this aberration in patients with two or more first-degree relatives having melanoma. Knowledge of the presence of a mutated gene may then be an impetus for more stringent photo-protection measures and closer surveillance of the affected individual.
DIAGNOSIS By far, the most important predictor of melanoma survival is early detection. Again, the AAD’s efforts in dermatologist-performed melanoma screening clinics—Melanoma Monday in May (always the first Monday of the month, which was May 4) and Spot the Spot programs—have increased awareness and resulted in earlier diagnosis.
Self-examination is very important, especially if one engages in at-risk solar behavior, and knowing your “A-B-C-D-E’s” is important but does rely on the patient ability to identify features that occasionally only a dermatologist can discern (a number of benign lesions may exhibit these features). The level of patient concern and observance of regression (the lesion spontaneously getting smaller and going away) are also important.
However, studies have shown that the general public can readily identify three key features: 1) Is it new? 2) Is it changing? 3) Is it an ugly duckling (the ugly duckling sign refers to a growth
The evolution of targeted therapies in melanoma management has been a recent, exploding development that has provided hope both for the patient afflicted with melanoma and for the ultimate goal, a definitive “cure.”
that appears distinctly different in comparison to other growths on the skin)? “Skin selfies” or photography taken at home and put up every month on the computer screen can be very helpful in detecting these three features. If any of these features listed above are suspect, see your physician.
The dermatologist is the expert for your skin, hair and nails, and the individual most qualified to render judgment on a growth’s concerning features or lack thereof. When doubt exists regarding a lesion’s intentions, biopsy may be obtained so that the correct
diagnosis is reached. However, in this effort at the bedside there have been consequent advances as well. Dermoscopy, utilizing the principle of diascopy with magnification and illumination, has become a de facto subspecialty of dermatology and the trained physician is able to identify features concerning for melanoma with routine use of this device. Total body photography in the office aids us in surveillance of the concerning signs listed above.
For nevi (moles) that have exhibited worrisome features, the use of confocal microscopy and computer analysis of visible and near infrared scans (a non-invasive device recently approved in the United States) show promise in increasing diagnosis sensitivity and specificity. A newly reported noninvasive technology, that of tape stripping to harvest cells from pigmented lesions (epidermal genetic information retrieval), can be used to detect melanoma accurately by assessment of a 17-gene biomarker panel.
TREATMENT I vividly recall, during my years in medical school, scoffing at my molecular biology professor’s assertion that monoclonal antibody techniques were going to revolutionize cancer therapy in the future, just as I did when my girlfriend asserted (while playing on her brand-new Commodore 64) that we would all someday own and be dependent upon computers in the home. I was, needless to say, epically incorrect on both accounts.
The evolution of targeted therapies in melanoma management has been a recent, exploding development that has provided hope both for the patient afflicted with melanoma and for the ultimate goal, a definitive “cure.” Bench study has again provided the impetus for these clinical developments, identifying multiple, critical pathways, important checkpoints and potential targets critical to the initiation and propagatiion of melanoma cancer cells. Designation, identification, and targeting of BRAF, CKIT, RAS, PD-1, PD-L1, CTLA-4 and MEK cancer promoters have given rise to dabrafenib, vemurafenib, trametinib, nilotinib, imatinib, ipilimumab and a slew of other monoclonal therapies in the pipeline; these agents show specificity to killing cancer cells while tending to minimize side effects in comparison to traditional chemotherapy agents.
There is conclusive evidence that these agents may work synergistically, resulting in improved disease-free and survival durations, and yes, even long-lasting remission, or “cure.” Vaccine therapies and agents aimed at inducing apoptosis (programmed cell death of malignant cells) also have promise.
Our excitement amidst these remarkable developments needs to be translated into public awareness and outreach programs, the sooner the better. Your risk of melanoma at some point in your lifetime is 1 in 30, which translates into more than 10 million cases of melanoma in the U.S. at some point in their lives for the population living today. One’s risk of a second melanoma after the first is doubled (1 in 15) and the incidence in states near the equator is higher, particularly with sun-seeking behavior.
We are in the midst of a true melanoma epidemic. Few if any will be untouched by this killer, be it you, one whom you love, or a friend. Awareness should logically lead to action: Be sun smart, protect yourself and your loved ones, and see your dermatologist sooner rather than later if there is concern regarding a growth on your skin.