Actinic Keratoses	Skin Cancer	Annual Skin Cancer Exams
Mole Management and Melanoma	Liver Spots	Rhinophyma
Mohs Cancer Surgery	Clavus (“corn”)Cryosurgery	Scar Management

Actinic Keratoses and Skin Cancer

Actinic keratoses (AK’s) are common, precancerous lesions that are rough, red, scaly patches, crusts or sores, measuring anywhere from one-quarter to one-inch in diameter. AKs are usually found on the face, lips, scalp, neck, forearms, and back of the hands. AK’s affect more than ten million Americans, and the prevalence is highest in sunny areas or high altitude.

Individuals with fair skin, a history of cumulative sun exposure, or with poor immune systems are at greatest risk for developing AK’s. AK’s are usually found on older people because they take years to develop; however, even people in their 20s and 30s can develop AK’s. A number of therapies are available for AKs. Treatment will be more extensive if AKs have progressed to skin cancer, so they should be treated in their early precancerous state. Non-scarring methods of treatment include liquid nitrogen cryosurgery, topical chemotherapy with 5-FU cream, topical immunotherapy with imiquimod cream, laser resurfacing and chemical peels. Importantly, 50% of actinic keratoses can be slowly ablated with Hughes Dermatology’s “basic anti-photo aging regimen” (see under Cosmetic Dermatology). Actinic keratoses can progress to squamous cell carcinoma, as shown here on a finger. Since these are sun-induced, use sunscreens, wear hats and protective clothing!

Hughes Dermatology is now offering the new “AK Immunotherapy” regimen.  A brief 4 day treatment using combined 5-FU and calcipotriol cream is effective immunotherapy for actinic keratoses and squamous cell cancer prevention (JCI, 3/21/19)!

Skin Cancer

Skin cancer (basal cell cancer, squamous cell cancer and malignant melanoma) is the most common of all cancers, accounting for half of all cancers in the United States. Of the more than one million new cases of skin cancer diagnosed in the U.S. each year, 80% will be basal cell carcinoma (BCC), 16% will be squamous cell carcinoma (SCC), and 4% will be melanoma. The incidence of skin cancer in the U.S. is rising dramatically, with more than 1 million new cases of skin cancer expected to be diagnosed in the United States this year. There will be over 7,600 deaths from melanoma and 2,200 deaths from non-melanoma skin cancers, including basal cell and squamous cell carcinomas.

If caught and treated in the early stages, all types of skin cancer are treatable and in most cases, curable. Treatment methods by Dr. Philip Hughes include topical immune enhancing agents for superficial cancers (including early superficial malignant melanoma and basal cell carcinoma), cryosurgery, simple surgical excision and Mohs cancer surgery (Dr. Hughes) for facial or ill-defined or recurrent cancers. A new concept in treatment of basal cell cancer consists of traditional curettage and electrodessication followed by topical Aldara treatment which improves the cure rate and the cosmetic result. The basal cell cancer shown here was treated by Mohs cancer surgery.

Pregnancy: Using local lidocaine anesthesthia, surgical removal of skin cancer is safe during pregancy.

New: Erivedge (vismodegib, Genentech) is an oral drug for metastatic basal cell carcinoma. It targets the “hedgehog pathway” which is unique to this cancer.In addition, a potential revolution in medically-targeted skin cancer treatment is about to arrive with the development of “protein kinase inhibitors” like imatimid which is already curative for dermatofibrosarcoma protuberans, a rare skin cancer! Hughes Dermatology awaits further medical progress in this exciting field and will apply it to our patients when appropriate.

Cancer of the penis which is common in noncircumcised men can be effectively treated with liquid nitrogen cryosurgery, as reported by Dr. Philip Hughes. As opposed to the alternative of amputation of the penis, this preserves penile function, an obvious advantage to the patient. Other non-surgical alternatives include oral retinoid therapy and the topical immunomodulator, imiquimod.

Annual skin cancer exams

Patients should be examined “head to toe” annually to check for suspicious moles, pre-malignant and malignant skin tumors. A dermatoscope will be used for mole evaluation.

Mole Management and Melanoma

If a mole is abnormal according to the ABCD rule, it should be examined by Dr. Hughes with a dermatoscope. If it is irregular under the dermatoscope, it should be biopsied. Usually this can be done via a cosmetically elegant shave biopsy right at the time of the initial visit. Hughes Dermatology recommends annual whole body skin cancer checks utilizing a dermatascope in order to identify a malignant melanoma at an early and curable stage. If a mole is malignant (malignant melanoma) prompt surgical excision is done in our office surgery suite.

Moles that are irregular in color and shape or bigger than a pencil erasor should be promptly biopsied (a malignant melanoma is shown here)! News: In addition to prompt surgical excision, Aldara (imiquimod, a topical immune modulator) is used as adjunctive treatment post-operatively to destroy any residual malignant cells that may have been left behind. Another newly popular technique, originally done by Dr. Fred Mohs in the 1950’s, involves the application of Mohs paste to the melanoma site (after the biopsy but before the final excision). This is an immunostimulant that produces an increased survival rate. Brand new therapies for metastatic melanoma include enhancing immune activation with Ipilimumab (“Yervoy,” FDA approved March 2011) or Nivolumab, or using “targetted therapy” with BRAF and MEK kinase inhibitors in appropriate patients.

The latest good news about melanoma prevention is that long-term use of daily aspirin may prevent melanoma. MSNBC(6/23, Carroll) reported, “An aspirin a day may keep melanoma at bay,” according to a new study. “After scrutinizing the medical records of 1,000 people, an international team of researchers have determined that the risk of melanoma was cut by almost half when people took a daily dose of aspirin for at least five years.” Interestingly, “there was also a hint that other NSAIDs, such as ibuprofen (marketed as Advil and Motrin) and naproxen (Aleve), might reduce melanoma risk if taken regularly over a long period of time.” Multiple additional studies confirm these agents produce “chemoprevention” of melanoma and squamous cell carcinoma. The major investigator was from Harvard’s Dept. of Dermatology.

In The Melanoma Letter, spring 2016, nicotinamide 500mgm/day offers promise as a chemoprotective option for nonmelanoma skin cancers in high risk patients and for melanoma chemoprevention. Nicotinamide reduces UV immunosuppression.

Liver Spots

“Age spots” or “liver spots” are flat, brown areas representing seborrheic keratoses or lentigos. They have nothing to do with the liver – they are inherited and usually appear on the face, hands, back and feet. They are generally harmless but are unsightly. The important thing is that they may mimic melanoma and therefore may require evaluation. Hughes Dermatology evaluates these with a dermatoscope, a special device that can usually identify the harmless ones and therefore often prevent a surgical biopsy prior to treatment. Commercial “fade” creams will not make lentigines disappear, but effective prescription medications(including alpha-hydroxyacids, retinoids), chemical peels, liquid nitrogen cryosurgery and surgical resurfacing treatments are available.

Dermoscopy can differentiate a seborrheic keratosis from a melanoma.

New: Our Candela V-Beam Perfecta is an alternative treatment that eradicates non-elevated brown spots (lentigos or “liver spots”) without the blistering asociated with liquid nitrogen cryosurgery.

Electrosurgery of Rhinophyma

Electrosurgery is the gold standard for remodeling rhinophyma. Earlier stages of rhinophyma are treated with the erbium:YAG laser. All these procedures are done in the office surgical suite. Dr. Hughes has had many years of experience successfully treating this malady.

Electrosurgical Sculpting

MOHS Cancer Surgery

Mohs surgery is microscopically controlled surgery, done by Dr. Philip Hughes, that is a highly effective treatment for certain types of skin cancer, with a cure rate of up to 99% for basal cell cancer. Since the Mohs procedure is micrographically controlled, it provides the most precise method for removal of the cancerous tissue, while sparing healthy tissue. For this reason, Mohs surgery results in a smaller surgical defect and an improved cosmetic result compared to other methods of skin cancer treatment. The Mohs procedure is recommended for skin cancer removal in anatomic areas where maximum preservation of healthy tissue is desirable for cosmetic and functional purposes (the face, eyelids, ears, lips, fingers and genital areas), for lesions that have recurred following prior treatment, or for lesions in anatomic areas which have the greatest likelihood of recurrence eg., the angle of the nose).

Mohs surgery requires special training both in frozen section microscopic interpretation and in the surgical technique for excising the cancer and then repairing the defect in a cosmetically elegant manner. This is done in Hughes Dermatology’s office surgical suite.

The American Society for Mohs Surgery is a non-profit professional medical society of over 700 dermatologists, pathologists, and Mohs technicians. Founded in 1990, the ASMS is dedicated to the highest quality patient care and education relative to Mohs surgery as a specialized surgical treatment for skin cancer. Dr. Hughes is a Fellow of the American Society for Mohs Surgery and was a speaker at the annual ASMS meeting in 2004. Consult with Dr. Hughes today to see if your cancer is best treated by Mohs surgery.

Clavus (“corn”)Cryosurgery

These aggravating lesions are successfully treated and cured with the Spiller cryosurgical method. Contact Dr. Hughes for the solution to this painful disabling condition.

Scar Management

Major theme: Successful scar management requires early intervention. Whether the patient has a grooved traumatic or surgical scar or an elevated hypertrophic scar, corrective measures should be carried out at one month post-scarring event. These include resurfacing (ablative laser, dermabrasion or 90% TCA) for grooved scars and pulsed dye laser or topical or intralesional steroids for red elevated scars. Treatment is inexpensive. This contrasts with the old obsolete advice of waiting a year to “see what happens.” Scars are common. If patients are aware of this urgency, they will benefit from early scar management.

The picture on the left demonstrates acne scarring treatment using Erbium: YAG laser resurfacing. The picture on the right was taken 10 weeks later.