Promoting Skin Care Detection in the Wound Clinic

Outpatient wound care providers can play a significant role in helping patients spot the signs of skin cancer through proper assessment and referral. This article will educate clinicians on symptoms to be concerned about and offer tips to share with patients regarding self-examination. 

The most common risk factor for both non-melanoma and melanoma skin cancer is chronic ultraviolet (UV) light exposure. UV light directly causes alterations in the DNA of cells at the surface of the skin, and if these alterations are not repaired, or the affected cells are killed, then cancer may develop. Because the damage caused by UV exposure is cumulative, patients who have lived or worked in settings with chronic sun exposure, or those who have used indoor tanning devices, are at increased risk for developing skin cancer. Thus, risk increases with age. While all patients are subject to the risks of chronic UV light exposure, patients living with chronic wounds are at additional risk for the development of skin cancer and for a missed diagnosis of skin cancer.

Patients in the chronic wound care setting have two other major considerations to keep in mind during the course of their wound care. First, skin cancer, particularly when advanced or neglected, can mimic the appearance of a chronic wound. Both primary skin cancers and internal cancers that are metastatic to the skin may mimic a chronic wound. These lesions can appear as pearly or keratotic papules (or plaques) in earlier stages, but may also clinically present as ulcerated or frankly necrotic wounds, or as plaques or nodules that are very similar in appearance to granulation tissue. Practitioners should consider a skin biopsy for patients who have a chronic wound where the cause of such wound is not firmly established. Further, a wound appearing at a postsurgical site for an internal malignancy, such as in a mastectomy incision, should generate suspicion for a recurrence of the previously treated internal malignancy at the surgical site. A biopsy should be considered in this setting as well.

Another consideration in the chronic wound population is the fact that non-melanoma skin cancer, particularly squamous cell carcinoma (SCC), can occur in skin that has been subject to chronic inflammation. The chronic inflammation may be caused by chronic inflammatory conditions, such as lichen planus or lichen sclerosus, or it can be the product of chronic nonhealing wounds of any etiology. The prototypical example of this is Marjolin’s ulcer, which represents malignant degeneration into SCC of an old scar or ulcer. Classically, a Marjolin’s ulcer occurs many years following a thermal burn wound, but can also occur in scars from venous ulcers, pressure ulcers, and sites where osteomyelitis has been present. A Marjolin’s ulcer can present as a firm mass of granulation tissue with or without purulence.^1-5 

COMMON TYPES OF SKIN CANCER⁶

Skin cancer is an abnormal growth of cells and most often develops on areas exposed to UV rays. Those with lighter skin who sunburn easily have a higher risk of skin cancer, but skin cancer is well known to affect people of all skin types. When assessing the overall health of the patient’s skin, wound care providers should be mindful of the four most common skin cancer types. Note that some wounds exhibit typical clinical signs of cancer, such as a raised border, ulceration, and friability, but many do not.¹

Actinic Keratoses (AK)

These dry, scaly patches or spots are actually precancerous growths and are more likely to develop on sun-exposed areas. Also referred to as “solar keratosis,” AKs form when the skin is badly damaged by UV rays from the sun or indoor tanning.⁷ Most people will develop more than one AK, and those who have multiple AKs will likely continue to develop them for life and should be under a dermatologist’s care.⁷ Left untreated, many AKs will spontaneously regress by the action of the immune system, but AKs may also develop into SCC. By seeing a dermatologist for routine checkups, AKs can be treated with a variety of treatments, including topically applied agents, photochemical treatments, or cryodestruction with liquid nitrogen, before they become skin cancer. Further, educating patients about sun-safe behaviors and the use of sunscreen (sun protection factor ≥ 30) can reduce the formation of these precancerous lesions. Most people see their first AKs after age 40, and they typically form on the head, neck, hands, and forearms.

What to look for: Dry, scaly patches with a rough texture that are often better palpated than seen (Figure 1, Copyright of the AAD). 

Basal cell carcinoma (BCC)

The most common type of skin cancer, BCC affects millions of people each year.8 Especially common on the face and often forming on the nose, this skin cancer also frequently develops on the head, neck, or back of the hands, but can appear on any part of the body, including the trunk, legs, and arms.⁸ Treatment is important because BCC left untreated can be a mutilating process that grows both in width and depth, destroying the structures it invades. A slow-growing cancer, BCC rarely metastasizes (spreads) to other parts of the body. It frequently develops in fair skin, yet can occur in darker skin.⁸ People who use tanning beds develop skin cancer, including BCC, more frequently and earlier in life.⁸ Early diagnosis and treatment for BCC is important because lesions caught in the early stages of development can be treated with minimal long-term impact on the patient. This is particularly true for facial BCC, where early lesions can be treated with a tissue-conserving procedure known as Mohs micrographic surgery. Left untreated, BCC can also invade surrounding tissue and grow into nerves and bones, causing damage and disfigurement.

What to look for: Flesh-colored or pink, firm papules with a pearly quality. More advanced lesions will ulcerate or bleed easily. Often confused with a pimple in early stages (Figure 2, Copyright of the AAD). 

SCC

SCC is the second most common type of skin cancer and produces approximately 700,000 new cases in the United States per year.⁹ SCC is also the most common skin cancer in African Americans.¹⁰ A cancer that tends to develop on skin that has been exposed to the sun for many years, it is likewise most frequently seen on the head, neck, and back of the hands, as well as the rim of the ear, face, chest, and back. SCCs are at least twice as frequent in men as they are in women, partly because of more time spent in the sun.¹¹ It is possible to get SCC on any part of the body, including the inside of the mouth, lips, and genitals, and, as with BCC, people who use tanning beds have a much higher risk of SCC and tend to get SCC earlier in life. SCC can grow deep into the skin, causing damage and disfigurement. Though it can also spread to other parts of the body, SCC is highly curable with early diagnosis and treatment.  Populations that are at particular risk for poorer outcomes with SCC include those who are immunosuppressed, particularly organ transplant recipients and those diagnosed with chronic lymphocytic leukemia, and patients who have or have had chronic wounds.

What to look for: In early stages, SCC most commonly looks like a firm, scaling papule. SCC and BCC patients often state that a lesion will be present and heal, but only to return again. More advanced SCC may ulcerate and become a larger, firmer plaque (Figure 3, Copyright of the AAD). 

Melanoma

Also referred to as “malignant melanoma,” this is the deadliest of the common forms of skin cancer.¹² It may develop within a mole or may appear as a new dark spot on the skin. If not detected early, it can spread quickly to other parts of the body.¹² Early diagnosis and treatment are considered crucial, according to the American Academy of Dermatology (AAD). 

What to look for: Knowing the “ABCDE” warning signs of melanoma — asymmetry, border, color, diameter, evolving — can help detect an early melanoma (Figure 4A-E, Copyright of the AAD). Consider:

• A = Asymmetry — One half is unlike the other half.
• B = Border — An irregular, scalloped, or poorly defined border.
• C = Color — Is varied from one area to another; has shades of tan, brown, or black; or is sometimes white, red, or blue.
• D = Diameter — Melanomas are usually > 6mm (the size of a pencil eraser) when diagnosed, but they can be smaller.
• E = Evolving — A mole or skin lesion that looks different from the rest or is changing in size, shape, and/or color.

A referral to a dermatologist should be made if any spots on the skin seem different from others or undergo changes, cause itching, or bleed. Also, consider spots that look like changing freckles or “age spots,” dark streaks under fingernails or toenails, bands of darker skin around a fingernail or toenail, or slowly growing patches of thick skin that look like scars. To equip patients with education materials to be read at home, suggest that they read the AAD’s Body Mole Map¹³ and How to SPOT Skin Cancer.^{™, 14}

DETECTING SKIN CANCER, SELF EXAMS¹⁵

It is estimated by the AAD that one in five Americans will develop skin cancer at some point. To best conduct a self-exam at home, patients (as well as healthcare providers) can follow certain guidelines in an attempt to promote early detection. First, one’s entire body should be examined in front of a mirror, preferably a full-body mirror. Check your body front and back, and then look at the right and left sides, with arms raised. Next, bend both elbows and look carefully at forearms, underarms, and palms. To continue, take a seat on a chair and examine the backs of the legs and feet, spaces between the toes, and the soles of the feet. Next, use a handheld mirror to view the back of the neck and scalp in a larger mirror. (Hair should be parted for a closer look.) Finally, check the back and buttocks with the handheld mirror. It is very common for patients to state that someone in their life, such as a barber or hairdresser, or a relative or an acquaintance, had told them to “get that spot looked at” months prior to their visit with a physician. A very simple way to improve skin cancer detection is to encourage patients to listen to those around them and to seek care earlier, when people comment that they have a new growth. 

References

1. Snyder RJ. Skin cancers and wounds in the geriatric population: a review. OWM. 2009. 55(4):64-76.

2. Esther RJ, Lamps L, Schwartz HS. Marjolin ulcers: secondary carcinomas in chronic wounds. J South Orthop Assoc. 1999;8(3):181–7.

3. Simmons MA, Edwards JM, Nigam A. Marjolin's ulcer presenting in the neck. J Laryngol Otol. 2000;114(12):980–2. 

4. Fitzpatrick TB, Freedberg IM. Fitzpatrick's dermatology in general medicine. 6th ed. New York, NY. McGraw-Hill;2003.

5. Phillips TJ, Salman SM, Bhawan J, Rogers GS. Burn scar carcinoma. diagnosis and management. Dermatol Surg. 1998;24(5):561–5. 

6. Types of Skin Cancer. AAD. Accessed online: www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/types-of-skin-cancer

7. Actinic Keratosis. AAD. Accessed online: www.aad.org/public/diseases/scaly-skin/actinic-keratosis

8. Basal Cell Carcinoma. AAD. Accessed online: www.aad.org/public/diseases/skin-cancer/basal-cell-carcinoma

9. Squamous Cell Carcinoma. AAD. Accessed online: www.aad.org/public/diseases/skin-cancer/squamous-cell-carcinoma

10. McCall CO, Chen SC. Squamous cell carcinoma of the legs in african americans. J Am Acad Dermatol. 2002;47(4):524-9.

11. Squamous Cell Carcinoma – Causes and Risk Factors. Skin Cancer Foundation. Accessed online: www.skincancer.org/skin-cancer-information/squamous-cell-carcinoma/scc-causes-and-risk-factors

12. Melanoma. AAD. Accessed online: www.aad.org/public/diseases/skin-cancer/melanoma

13. Body Mole Map. AAD. Accessed online: www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/detect/body-mole-map

14. Infographic: How to SPOT Skin Cancer. AAD. Accessed online: www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/detect/how-to-spot-skin-cancer

15. Detect Skin Cancer. AAD. Accessed online: www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/detect