Skin Cancer

Integumentary System: Review

• The largest organ of the body, consisting of the skin, hair, nails, and glands.

• The skin has two major layers: the epidermis (outer layer) and dermis (inner layer), with subcutaneous tissue lying beneath the dermis.

• Because the skin is visible and easily assessed, nurses can identify abnormalities early through inspection and palpation.

Integumentary System: Environmental Hazards for Skin Cancer

• Prolonged UV exposure damages the skin, causing loss of elasticity, thinning, wrinkles, and dryness. It also increases the risk of actinic keratosis, basal cell carcinoma, squamous cell carcinoma, and melanoma.

• Some medications cause photosensitivity, making the skin more sensitive to sunlight. Teach patients to use sunscreen, protective clothing, and limit sun exposure.

• Encourage monthly skin self-exams using the ABCDE rule: Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, and Evolving (changes in size, shape, or color).

Skin Cancer: ABCDE Rule

• A – Asymmetry: One half of the mole does not match the other half.

• B – Border: Edges are irregular, uneven, blurred, or poorly defined.

• C – Color: Uneven coloring or multiple shades of brown, black, red, white, or blue.

• D – Diameter: Larger than 6 mm (size of a pencil eraser), although melanomas can be smaller.

• E – Evolving: Any change in the mole's size, shape, color, or appearance, including new itching or bleeding.

Skin Cancer: Overview and Risk Factors

• The most commonly diagnosed cancer, classified as either melanoma or nonmelanoma. Skin lesions are often visible, allowing for early detection and a better prognosis.

• Risk factors include fair skin, blond or red hair, blue eyes, excessive sun exposure, outdoor occupations, indoor tanning, family or personal history, and living near the equator or at high altitudes.

• The Fitzpatrick Classification assesses skin type and sun sensitivity. People with darker skin have a lower overall risk but can develop melanoma, particularly on the palms, soles, mucous membranes, and under the nails.

Skin Cancer: Risk Factors

• Risk increases with fair skin, blond or red hair, blue eyes, excessive sun exposure, indoor tanning, outdoor occupations, family or personal history, and living near the equator or at high altitudes.

• The Fitzpatrick Classification helps determine skin type and sun sensitivity. PUVA therapy (psoralen + UVA radiation) also increases skin cancer risk.

• People with darker skin have a lower risk due to increased melanin, but still need sun protection. Melanoma may develop on the palms, soles, mucous membranes, or under the nails.

Skin Cancer: Nonmelanoma Skin Cancer

• Basal cell and squamous cell carcinomas are the most common types of skin cancer. They develop from nonmelanocyte cells and rarely cause death, but can lead to local tissue destruction and disfigurement.

• Usually occur in sun-exposed areas, including the face, head, neck, hands, and arms. UV exposure is the main risk factor.

• Squamous cell carcinoma commonly develops on the head and neck, while basal cell carcinoma can also develop in areas protected from the sun.

Skin Cancer: Actinic Keratosis

• Also called solar keratosis, it is the most common precancerous skin lesion, usually caused by prolonged sun or UV exposure, especially in older adults with fair skin.

• Typically appears as a rough, scaly, slightly red, flat or raised lesion with irregular borders and a hard, crusty surface.

• Can progress to squamous cell carcinoma, so treatment is important. Nonsurgical treatment is preferred initially, and persistent or suspicious lesions should be biopsied.

Skin Cancer: Basal Cell Carcinoma

• The most common type of skin cancer but least deadly. Develops from the basal cells of the epidermis, usually in middle-aged or older adults.

• Most commonly occurs on sun-exposed areas of the head and neck. May appear as a pearly or pigmented lesion with rolled borders and can resemble melanoma, requiring a biopsy for diagnosis.

• Rarely metastasizes, but can cause severe local tissue destruction if untreated. Treatment depends on tumor size, location, type, and history of recurrence.

Skin Cancer: Squamous Cell Carcinoma

• Develops from keratinizing epidermal cells and can be aggressive with the potential to metastasize, making it more dangerous than basal cell carcinoma if left untreated.

• Often develops from actinic keratosis (AK) or another skin lesion. Major risk factors include sun exposure and immunosuppression, especially after organ transplantation. Smoking increases the risk of SCC on the lips and mouth.

• Typically appears as a rough, scaly, or crusted lesion that may ulcerate or bleed. A biopsy is required to confirm the diagnosis.

Skin Cancer: Melanoma

• Develops from melanocytes (cells that produce melanin) and causes most skin cancer deaths. It is highly aggressive and can metastasize to any organ, including the brain and heart.

• UV radiation is the main cause, damaging DNA and causing mutations in skin cells. Both sunlight and indoor tanning increase the risk.

• Risk factors include fair skin, red or blond hair, light-colored eyes, easy freckling, family history of melanoma, immunosuppression, and dysplastic nevi (atypical moles).

Skin Cancer: Clinical Manifestations of Melanoma

• Most commonly occurs on the lower legs in women and the trunk or head in men. About 25% develop from existing moles, while others develop on previously normal skin.

• Lesions are often dark brown or black because melanoma cells continue producing melanin, although some have little or no pigment.

• Use the ABCDE rule to assess suspicious lesions. Any new or changing mole, especially changes in size, shape, or color, should be evaluated.

Skin Cancer: Melanoma — Diagnostic Studies

• Dermoscopy helps examine suspicious lesions, but a biopsy is needed to confirm melanoma. An excisional biopsy is preferred because it allows accurate measurement of tumor depth.

• Breslow thickness measures tumor depth in millimeters and is one of the most important prognostic factors. The thicker the tumor, the greater the risk of metastasis.

• Staging ranges from 0–IV and considers tumor thickness, ulceration, lymph node involvement, and metastasis. Stage 0 is confined to the epidermis, while stage IV indicates distant metastasis.

Skin Cancer: Melanoma — Treatment

• Wide surgical excision is the primary treatment, especially when diagnosed early. Stage 0 melanoma is highly curable with complete removal.

• Advanced melanoma may require immunotherapy, targeted therapy, chemotherapy, or radiation. Immunotherapy helps the immune system attack cancer cells, while targeted therapy blocks specific mutations, such as BRAF and MEK.

• Chemotherapy is generally less effective than newer treatments and is used less often. Radiation may help treat lymph node or brain metastases.

Skin Cancer: Atypical or Dysplastic Nevus

• Also called atypical moles, these are usually larger than 5 mm, with irregular borders and varying shades of color. They may resemble melanoma but have less pronounced ABCDE changes.

• Having dysplastic nevi increases the risk of developing melanoma, either within an existing mole or elsewhere on the body.

• The more atypical moles a person has, the greater their risk. Having 10 or more is associated with approximately 12 times the risk of melanoma.