RELATED: Do You Need to Wear Sunscreen Indoors? Basal Cell Carcinoma (BCC) More than four million Americans are diagnosed with BCC every year, making it the most common type of skin cancer. Basal cells are one of the three main types of cells that occur on the top layer of skin. DNA damage from sun exposure or ultraviolet (UV) radiation from indoor tanning is usually the cause of BCC. (1) “If not treated, these cancers may invade nearby tissue and cause problems such as pain, bleeding, and numbness,” says Jennifer Lucas, MD, a dermatologist and dermatologic surgeon at Cleveland Clinic in Ohio. “Typically, we’re not as worried about basal cell carcinoma moving or spreading or causing you harm to your life per se, but they will continue to grow and spread if not treated,” she says. Squamous Cell Carcinoma (SCC) Squamous cells are a type of cell found in the middle and outer layers of the skin. Squamous cell carcinoma is also usually caused by sun exposure or UV radiation from tanning beds. (2) If diagnosed early these types of skin cancer can be treated and nearly all are cured, says Farah Succaria, MD, assistant professor dermatology at Johns Hopkins University School of Medicine in Baltimore. “If untreated, they are locally invasive, aggressive, and destructive to the skin and adjacent tissues,” says Dr. Succaria. Melanoma Melanoma is the deadliest of skin cancers. It usually starts as an unusual looking mole or a new mole that’s growing or changing or getting darker. “Melanoma can be more aggressive and more likely to metastasize or spread than nonmelanoma cancers,” says Dr. Lucas. There are about 100,000 cases of melanoma a year in the United States each year. Although only about 1 percent of skin cancers are melanoma, they cause a large majority of skin cancer deaths. It’s estimated that approximately 6,850 people will die of melanoma this year. RELATED: Can Genetics Determine Risk for Melanoma Progression?
Scarring
The scar left behind after treating basal cell carcinoma or squamous cell carcinoma depends on a few things, says Lucas. “Those factors include how risky the cancer is in terms of how it’s growing, the features associated with it, if it’s aggressive or nonaggressive, as well as the part of the body it’s on. Your face and areas around your eyes, your nose, your lips, the hands and feet, the genitalia, and the front aspect of your shins are higher risk areas [for scarring],” she says. More superficial basal and squamous cell carcinomas can be treated with lasers, cryotherapy (freezing), topical creams, or photodynamic therapy. Photodynamic therapy is a treatment in which a cream is applied to the area to make the cancer cells sensitive to light prior to treatment with a special cold red light that destroys cancer cells. Melanoma is treated surgically. Treatment for this type of tumor may leave a more significant scar because it goes deeper into the skin than nonmelanoma skin cancers, and requires that a surgeon excise both the tumor and a significant portion of healthy tissue around it — a safety margin — to make sure it does not recur. “I tell my patients before surgery, ‘You’re going to leave here with what you view as a big scar, and I apologize for that, but in order for me to remove this I have to take an adequate margin,” says Lucas. “For us to close the incision for the scar to look good and not have puckering, it has to be three times as long as it is wide,” she says. “That means that if your skin cancer starts out as a centimeter, then I have to add 1 centimeter to each side for the margin, so we’re at 3 centimeters. And that has to be multiplied by 3, so it will be 9 centimeters long,” she says. “If I don’t do that, their risk of this being incompletely treated or for this coming back down the road and moving and spreading is much higher. I’m obligated, especially in invasive melanoma, to take a big margin of skin — at least a centimeter — all the way down through the fat to the top of your muscle,” she says. One potential risk of surgery is that some patients are prone to making hypertrophic scars or keloids afterward, says Succaria. Keloids are raised nodules that can form at the site of an injury. They’re made of connective tissue that continues to multiply even after the wound is filled, which creates a mound of scar tissue about the surface of the skin. A hypertrophic scar looks similar to a keloid, but they usually aren’t as big, and they may fade in time. Both are harmless and considered a cosmetic nuisance. (3) “Scars will eventually mature and look better, but they do take an entire year to do that. At that point if the appearance of the scar bothers patients there are treatment options,” says Lucas. RELATED: ‘This Is My Scar’: How One Survivor Is Fighting the Stigma of Male Breast Cancer
Hyper- or Hypopigmentation
Hyperpigmentation is caused by an excess of melanin, the brown pigment that produces normal skin color, creating patches of skin that appears darker than the color of the surrounding skin. It can affect people of any skin color. (4) Hypopigmentation is the loss of pigmentation in the skin, making those areas appear lighter than a person’s overall skin tone. Both can occur at the site of treatment, and some can be irreversible, says Succaria. “For that reason, we always recommend applying sunscreen after the scar has healed,” she says.
Tightness and Skin Texture Change
Very aggressive skin cancer may require adjuvant radiation, which is focused radiation on the tumor site, says Lucas. “An example of this would be if I removed a squamous cell cancer from a person’s ear and it’s poorly differentiated, meaning it looks bad under the microscope, and it’s growing around nerves and it went pretty deep and it’s big,” she says. In that case, after the surgery, the patient would undergo radiation of that area as well as the lymph nodes that drain that area to try to prevent a recurrence, says Lucas. “That can lead to skin feeling tighter and stiffer and changes in the blood vessels and texture of the skin that are secondary to those treatments, which can be long term changes,” she says.
Lymphedema
Sometimes when skin cancers are very deep, or if the skin is ulcerated, meaning the skin has broken down, a procedure called a sentinel lymph node biopsy may need to be performed. A sentinel lymph node is the first lymph node or group of nodes cancer cells would reach if they spread. “This lymph node is sampled to give us knowledge on whether the cancer has moved or spread,” says Lucas. If cancer is found in the lymph node or nodes, they need to be surgically removed, which can lead to lymphedema.
Wound Infection After Surgery
There is a risk of infection after skin cancer surgery, says Lucas. “While in the office or the hospital we do everything as clean and infection-free as possible, but you’re leaving the office with a fresh wound. It needs to be kept clean and protected and you need to be careful,” she says. Most surgical wound infections happen within 30 days after surgery. There may be pus draining from the wound which can be red, painful, and hot to the touch. (6) “A staph infection is probably the most common infection. Staph is found on all our skin; some people carry this in their noses and in other areas,” says Lucas. There are risk factors that increase a person’s chance of developing a surgical wound infection, including poorly controlled diabetes, an immune disorder, being overweight or obese, smoking, steroid use, or if the surgery lasted more than two hours. (6) There are ways to reduce the risk of infection after surgery, according to Lucas:
Wash hands thoroughly before performing twice-a-day wound care.Avoid performing wound care in the bathroom if possible; lots of bacteria can live in there.After cleaning the wound, keep it lubricated with something like Vaseline to keep the suture line moist.Be cautious when out and about and don’t engage in strenuous activity.
Hematoma
Hematoma is bleeding under the surface of the skin. “It forms a mass and puts pressure on the wound. If it breaks open it can cause more issues in terms of the wound healing,” says Lucas. Too much activity before the wound is healed can cause a hematoma, according to Lucas. “Patients who are on blood thinners such as clopidogrel (Plavix) or warfarin (Coumadin) are more at risk for this and need to be especially careful,” she says.
Numbness and Pain
There may be some numbness along the area where the surgery was, says Lucas. “In some cases, we may have to move a lot of skin to repair the wound and that area might not feel the same in the end,” she says. Those feelings of numbness, tingling, and pain are caused by damage to the nerves as a result of the surgery and may improve over time. (7)
Damage to the Muscles, Nerves, and Bones
If melanoma goes untreated long enough, there are instances where it may grow deeply enough to affect muscle, says Lucas. “As far as it goes down, we have to remove it; if it involves the muscle, it has to go. Sometimes skin cancers can go so deep they can even go into bone.” The temporal branch allows you to raise your eyebrows, says Lucas. “The surgeon may have to take some of those nerves to remove the cancer. In that situation, the patient may not be able to raise their eyebrow after the surgery, and that can be a permanent change,” she says. RELATED: How Is Skin Cancer Treated? Medication, Alternative and Complementary Therapies, Surgery Options, and More
Metastasis
Metastasis is when cancer cells spread from the skin to other parts of the body. Melanoma is more likely than nonmelanoma skin cancers to metastasize. A local recurrence of melanoma, in which the skin cancer returns where the tumor was surgically removed, happens less than 5 percent of the time, according to William H. Sharfman, MD, director of cutaneous oncology and clinical codirector for oncology at the Johns Hopkins Melanoma Program in Baltimore. A melanoma recurrence, in this circumstance, can look like dark or pink spots at or around the site of the excision. “The vast majority of local recurrences that we see are not because the surgeon didn’t do an adequate margin in the surgery. They did the adequate margin and yet the melanoma was able to come back because the melanoma cells must have escaped before the diagnosis was made or the surgery was done,” says Dr. Sharfman. There’s also a chance that someone could have a regional recurrence of melanoma, meaning that the melanoma will show up in the lymph nodes near the place where it started, says Sharfman. “If the melanoma is on the arm it will show up in the armpit [nodes], if it’s on the leg it will show up in the groin [nodes],” he says. Melanoma can also spread beyond the closest lymph node to almost anywhere in the body. The most common places that melanoma spreads include the skin, lymph nodes, lungs, liver, bone, and brain. (8) RELATED: Speaking Cancer: A Glossary of Formal and Informal Terms Used to Describe Cancer Tests, Treatment, Patients, and More
Anxiety and Depression
“I think anytime people hear the word ‘cancer’ it can cause anxiety, which is totally understandable,” says Lucas. People can get stressed about the treatment or the cancer itself, but they can also have anxiety about the future, she says. “They think because they need to be cautious about sun exposure that they can’t go out and enjoy their life.” Whether a person experiences depression or anxiety can depend on whether the person is predisposed to having a mood disorder, says Lucas. “A diagnosis of melanoma doesn’t have to lead to depression. The good news is most of these skin cancers we can cure and treat. Even for melanoma, if we catch it early, we can give the person a good prognosis in the end,” she says. RELATED: Boxed In Episode 1: ‘Anxiety and Depression in the Time of COVID-19’
