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What do Eyes Have to do With It?

You might not think of an eye exam as part of your annual skin check visit to the dermatologist, but there are several serious conditions, including cancers of the eyelids, that can be easily missed without a thorough examination. Your annual skin check should include a visualization of the upper and lower eyelids for tumors, assessment of hair distribution along the lash line to check for alopecia, as well as evaluation of eye symptoms, such as eye irritation or a gritty sensation, which can be associated with skin conditions like rosacea.

If a suspicious skin growth is found on or near the eyelid region, a biopsy should be performed to determine the type of lesion present. The most common malignant growths of the eye area are basal cell carcinoma and squamous cell carcinoma. Other less common types of eyelid cancers are sebaceous carcinoma, Merkel cell carcinoma, and intraocular melanoma. Risk factors for eyelid skin cancers include fair skin (blue eyes and red or blonde hair), immunosuppression, and history of previous radiation to the face.

Types of eyelid skin cancers

Basal Cell Carcinoma (BCC): The eyelid skin is extremely vulnerable to damage from the sun’s ultraviolet rays, making non-melanoma skin cancers, like BCC, quite common. While BCCs rarely spread to the bloodstream, they can grow large and cause disfigurement and sometimes even loss of the eye; this necessitates prompt removal with Mohs surgery, which is sometimes performed in consultation with an oculoplastic surgeon. To prevent BCCs of the eyelids, I recommend that you wear UV blocking sunglasses and don a hat — the wider the brim the better. And of course, always wear sunscreen. Stick Sunscreens for sensitive skin are generally well-tolerated around the eyes.

Squamous Cell Carcinoma (SCC): SCCs make up a smaller portion of eyelid cancers, but have a slightly higher risk of metastasis than BCCs. Prevention and treatment of eyelid SCC is similar to BCC.

Melanoma: Intraocular melanoma is the most common type of cancer that can develop within the eye in adults, yet it is still very rare. It can be found in the back of the eye in the pigmented layer of the eyeball, known as the uvea. This area is not visible to eye doctors during a regular eye exam, therefore it is crucial for individuals with a personal or strong family history of melanoma to undergo yearly dilated eye exams with an ophthalmologist. It is unclear how intraocular melanoma develops, although there are individuals who are genetically predisposed. Anyone with light hair and eye color is at a higher risk of developing eye melanoma, as are welders — either through increased occupational ultraviolet radiation exposure or other environmental causes. Melanoma is a serious diagnosis due to its ability to spread to the bloodstream and other organs. Treatment of intraocular melanoma may include surgery, radiation, and chemotherapy.

Bottom line: Check your eyelids for new growths and protect your eyes from UV exposure. Your eyes are not impervious to skin cancer!

 

 

 

References

Bain, J. (September 25, 2018). Focus on Eyelid Skin Cancers: Early Detection and Treatment. The Skin Cancer Foundation. Available online at: https://www.skincancer.org/blog/eyelid-skin-cancers/

Katella, K. (July 24, 2018). For Eye Cancer, Exams are Crucial. Yale Medicine. Available online at: https://www.yalemedicine.org/stories/eye-cancer-prevention/

Mayo Clinic Staff (September 18, 2018). Eye Melanoma. Available online at: https://www.mayoclinic.org/diseases-conditions/eye-melanoma/diagnosis-treatment/drc-20372376.

Choosing the Right Sunscreen

I love France! The food, the wine and …  the sunscreen! This week I’m writing about two of my favorite topics in one blog post: Sun Protection and the South of France!

The weather report from the outside world to us office-dwellers is that it’s been wonderful out there: sunny and not as humid as a typical Washington summer. That helps explain why I am being asked constantly for a recommendation for the best sunscreen. There is of course another reason for needing guidance: there are so many sunscreen options available. Standing in the aisle at CVS trying to pick the right one hasn’t been made any easier with the recent headline: “Sunscreen enters bloodstream after just one day of use, study says…”

That health alert was but a blip in the news cycle, but it was important and I am glad that my patients are still asking about it. The study, published in the medical journal JAMA, showed that four sunscreens when applied in maximal use scenarios (four times daily, on 75% of the body) resulted in measurable amounts of the chemical sunscreen agent passing through the skin to the bloodstream. It sounds alarming, but the study stopped short of looking at the health impact of the discovery and thus additional studies are underway. It’s important to note that all of the chemicals identified in the study are FDA-approved and have been in use for many years, without showing any harm. Likewise, there is strong evidence that regular sunscreen use helps reduce the risk of cancer and premature skin aging, so there is no justification for abandoning sun-safe behavior.

So, what should we slather on in the meantime?

Getting to that answer involves a quick look at the science behind how sunscreens work. There are two general classes of sun protection agents that differ in their method of action. SunSCREENS are those that rely on active chemical agents (with names like oxybenzone) that absorb harmful UV radiation and release its latent energy as heat on the skin surface. This was the class included in the study.

SunBLOCKS work entirely differently. They employ extremely fine-grained minerals, zinc oxide and titanium dioxide, to provide a physical barrier at the skin surface. These inert minerals reflect or scatter the radiation, preventing the rays from ever reaching the skin. In days past, they were the magic in the greasy white paint lifeguards smeared on their noses. Today, these minerals have been refined and formulated in to sheer creams, lotions and sprays that are invisible when worked in to the skin and pleasant to the touch.

Okay, let’s talk about France! 

American dermatologists and others interested in the topic have known for years that you can buy a much wider array of UV-stopping products in Europe. Why is that? This answer requires a brief look at government regulation. European consumer product rules are focused on the accuracy of manufacturers’ claims, which in the case of sunscreens and blocks is about their ability to stop or absorb UV rays. In the US, the Food and Drug Administration assesses manufacturers’ claims of efficacy. However, the FDA is concerned with potential toxicity of the same chemicals within the human body and environment, thus setting a higher bar of regulation. Meeting the FDA’s testing requirements takes considerable time for which many European manufacturers do not have the appetite. Several European brands have cleared this high bar, though, bringing a few sunscreen formulations to the US that have been used in Europe for years. In the meantime, there are many more choices available throughout Europe.

All this explains why on a recent sunny weekend in the south of France an American dermatologist (moi) was SLOWLY browsing a wide array of sun screen products in a charming pharmacy. Even for me, the process was daunting!

So at last, my best sun protection product advice: when reading a product label, be it in France or CVS, use sunblocks that rely on zinc oxide or titanium dioxide and have an SPF 30 or higher. These active ingredients have not been found to cross in to the blood stream, they are non-toxic, they stop UVA and UVB from reaching your skin and some formulations have become so sheer that you don’t even notice you have them on. These “physical” sunblocks are widely available. For years, my office has only carried sunscreens that have fewer chemicals and rely on non-reactive ingredients. If you are heading to the south of France or the south side of your neighborhood pool, you can pick them up on your next visit, or call and we can ship to you.

Early Detection Just Got VERY High Tech

FotoFinder Automated Total Body Mapping Studio

“Early detection” is something I talk about a lot.  That is for good reason: skin cancer is not only the most common form of cancer in the United States, it is also the most curable – that is, IF it is detected early.  This is why I talk just as much about the importance of regular full body exams.

May is Skin Cancer Awareness Month, so this is an especially good time to mention a powerful new early detection tool I’ve just added to my practice:  FotoFinder.  This breakthrough technology is truly one of the most impactful medical devices I have seen in my career.

FotoFinder combines the very best photographic equipment and German robotic engineering in a way that superbly augments the dermatology professional during full body exams.

Here’s how it works: The computer-controlled machine captures highly detailed photographs of the entire skin surface and merges them into a comprehensive Total Body Map.  It then employs artificial intelligence to meticulously compare current skin conditions to earlier “baseline” images.  If it “sees” new moles, or even minute changes in existing moles, it automatically flags them for detailed follow up by the professional.  The mapping and analysis process take just 20 minutes.  It is amazing technology that will greatly advance early detection of skin cancer.

Baseline: FotoFinder Total Body Map

Follow Up: Updated Body Map, with moles highlighted for further examination

When I saw this sophisticated device in action, I knew immediately I need to bring this to our patients.  The Dermatologic Surgery Center of Washington is the first and only practice in the Washington, DC region to install this significant advancement in the science of early detection.

Since we installed the system in January, I am often asked who should consider FotoFinder early detection technology?  If you can answer yes to any of these questions, I recommend we discuss if FotoFinder is right for you:

  • Do you have a history of melanoma or other skin cancer?
  • Do you have a family history of skin cancer?
  • Do you have many moles – more than 50?
  • Do you have large moles – 2 inches in diameter or larger?
  • Do you see changes in a mole or have new moles?
  • Do you have a history of a severe, blistering sunburn as a child or adolescent?
  • Do you have very light skin?
  • Are you exposed to strong sunlight on a regular basis?

Skin Cancer Awareness Month is a great time to make an appointment with one of our talented dermatology professionals for your next full body exam – and create your baseline Total Body Map with FotoFinder.

Click here to make an appointment online or call us at 301-652-8081.

 

All the photos used are courtesy: FotoFinder Systems, Inc.

Immunotherapy for Melanoma

Melanoma is by far the deadliest skin cancer but recent advances in cancer treatment have significantly improved the prognosis.  More than one million Americans are living with melanoma. It is estimated that 91,270 invasive melanoma cases will be diagnosed in 2018, with invasive melanoma projected to become the fifth most common cancer in men and the sixth most common cancer in women in 2018.[1]

Melanoma is more likely than most cancers to spread to the brain, and once it gets there, fewer than 20 percent of patients survive within one year with traditional treatments.[2]  However, newer options utilizing the body’s own immune system hold promise for helping patients with advanced-stage melanoma.  You may have read about the recent Nobel Prize winner, Jim Allison from MD Anderson Cancer Center.  His discoveries laid the ground-work for a life-saving new treatment for melanoma.

Immunotherapy works by harnessing the body’s own immune system to recognize and destroy cancer cells more effectively. Within our immune system, there are regulatory molecules called immune checkpoints, which work to keep the immune system in a balanced state (homeostasis). Tumors from cancers like melanoma take advantage of this regulatory mechanism to avoid being eliminated by the immune system. [3]

A specific group of immunotherapy drugs, called checkpoint inhibitors, work by inhibiting these immune checkpoints to release the brakes and unleash a much stronger immune response to the tumor. While these drugs do not help everyone, they have demonstrated excellent results thus far and are an important part of the initial treatment plan for patients with advanced melanoma.

 

 

[1] American Academy of Dermatology. Skin Cancer; Incidence Rates. Available online at: https://www.aad.org/media/stats/conditions/skin-cancer.
[2] Grady, Denise (Aug 22, 2018). Immunotherapy Drugs Slow Skin Cancer That Has Spread To The Brain. The New York Times; A16.
[3] Grady, Denise (Aug 22, 2018). Immunotherapy Drugs Slow Skin Cancer That Has Spread To The Brain. The New York Times; A16.

melanoma

Amelanotic Melanoma: Symptoms, Causes, Treatment

melanomaA patient recently came to the office concerned about a new dark mole on her leg. During her full body skin examination, I noticed a pink bump on her back.  I asked her about it and she said it was a bug bite that was taking a long time to heal.  Because of the appearance of the lesion when I examined it with a dermatoscope, I recommended a biopsy. Unfortunately, the pink spot on her back turned out to be a melanoma. The mole on her leg was benign.

 

Most patients are concerned when they spot a new dark mole, but it’s not widely recognized that melanoma can present as a pink or colorless skin lesion. Amelanotic melanoma is a serious form of skin cancer where the cells do not make melanin or pigment. It is responsible for approximately 2-20% of melanoma cases1. Because of their lack of color, diagnosis of this type of melanoma may be delayed until it reaches an advanced stage.

Symptoms

One of the most obvious symptoms of amelanotic melanoma is the sudden appearance of a red, pink, or skin-colored spot on your body where it wasn’t before. Melanomas also grow and may change shape, becoming a larger bump over time. Amelanotic melanoma may not present with the classic ABCD criteria (Asymmetry, Border Irregularity, Color variation, and Large Diameter) that are typically associated with melanoma warning signs. Expanding the ABCD warning signs to include the 3 Rs (Red, Raised, Recent change) may help in the early detection of amelanotic melanoma2. It is also estimated that about 25% of melanomas of the nail are amelanotic, so checking your nails should be a regular part of self-skin examinations. It is important to note that melanoma may present differently in individuals of color, therefore regular self-skin examinations are essential in the early detection of these skin cancers.

Causes

Melanoma occurs when the DNA in your skin cells becomes damaged, which can cause the cells to grow out of control and become cancerous. Exposure to the sun for long periods of time can damage your skin cells and increase your risk for melanoma. This risk is increased in patients with fairer skin, individuals of European descent, those with many moles (especially 50 or more), a family history of melanoma, and patients with a weakened immune system from an existing condition3. The use of tanning beds has also been associated with an increased risk for melanoma and should be avoided4.

Treatment

The most common treatment for melanoma is surgical removal.  However, melanoma can spread to the lymph nodes, necessitating the removal of one or more nodes. Advanced melanoma may need to be treated with chemotherapy and/or radiation. Biological therapy (or drugs that aid your immune system in killing cancer cells) as well as targeted therapy (medications that weaken cancer cells) are other common melanoma therapies. Patients with a history of a previous melanoma are 4 times more likely than the general population to develop a subsequent invasive melanoma, therefore full body skin examinations should be performed by a dermatologist every 3 months after a melanoma diagnosis.

 

References:
1.         Thomas, N.E., Kricker, A., & Waxweiler, W. Comparison of Clinicopathologic Features and Survival of Histopathologically Amelanotic and Pigmented Melanomas: A Population-Based Study. JAMA Dermatol. 2014;150(12):1306-1314. doi:10.1001/jamadermatol.2014.1348
2.         Kim, S.J., Park, H.J., Lee, J.Y., Cho, B.K., A Case of Subungual Melanoma. Ann Dermatol. 2008 Mar; 20(1): 26–28. Published online 2008 Mar 31. doi:  10.5021/ad.2008.20.1.26
3.         American Cancer Society. Risk Factors for Melanoma Skin Cancer. Available online at: https://www.cancer.org/cancer/melanoma-skin-cancer/causes-risks-prevention/risk-factors.html
4.         American Academy of Dermatology. Indoor Tanning. Available online at: https://www.aad.org/media/stats/prevention-and-care