Dermatology Services

At Dermatology & Advanced Skin Care, we hope to keep you well informed about diseases of the skin so that you can better understand your diagnosis and treatment options. This section includes information about some of the more frequently treated dermatology problems.  In addition, you can click on the links below for selected educational information sheets:

• Skin Cancer
• Melanoma
• Squamous Cell Carcinoma
• Basal Cell Carcinoma
• Atypical Moles (Dysplastic Nevi)
• Aktinic Keratosis

Acne

Acne is the term for plugged pores (blackheads and whiteheads), pimples, and even deeper lumps (cysts or nodules) that occur on the face, neck, chest, back, shoulders and even the upper arms. Acne affects most teenagers to some extent. However, the disease is not restricted to any age group; adults in their 20s - even into their 40s - can get acne. While not a life threatening condition, acne can be upsetting and disfiguring. When severe, acne can lead to serious and permanent scarring.

Acne lesions range in severity from comedones (blackheads and whiteheads) to nodules and cysts. Here is a brief definition of acne lesions:

Comedo (plural comedones) is a sebaceous follicle plugged with sebum, dead cells from inside the sebaceous follicle, tiny hairs, and sometimes bacteria. When a comedo is open, it is commonly called a blackhead because the surface of the plug in the follicle has a blackish appearance. A closed comedo is commonly called a whitehead; its appearance is that of a skin-colored or slightly inflamed "bump" in the skin.

The whitehead differs in color from the blackhead because the opening of the plugged sebaceous follicle to the skin's surface is closed or very narrow, in contrast to the distended follicular opening of the blackhead. Neither blackheads nor whiteheads should be squeezed or picked open, unless extracted by a dermatologist under sterile conditions. Tissue injured by squeezing or picking can become infected by staphylococci, streptococci and other skin bacteria.

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Rosacea

Rosacea (rose-AY-sha) is a chronic (long-term) skin disease that causes redness and swelling, primarily on the face. Other areas that can be affected are the scalp, neck, ears, chest and back. Sometimes, rosacea affects the eyes.

Those afflicted with rosacea may first notice a tendency to flush or blush easily. The condition can occur over a long period of time and often progresses to a persistent redness, pimples and visible blood vessels in the center of the face that can eventually involve the cheeks, forehead, chin and nose.

Since rosacea causes facial swelling and redness, it is easily confused with other skin conditions, such as acne and sunburn. For this reason, rosacea is known as the "great pretender," and often incorrectly referred to as "adult acne."

Who Gets Rosacea?
Rosacea affects an estimated 14 million Americans. Adults, especially those between 30 and 50 years of age who have lighter skin, blonde hair and blue eyes, are most likely to suffer from rosacea. However, rosacea can affect children and people of any skin type.

Rosacea is often passed on in families, with women being afflicted more often than their male counterparts. Men, however, often get more severe forms of rosacea. For women with rosacea, increased flushing and blushing may occur around and during menopause.

Famous rosacea sufferers include W. C. Fields and former President Bill Clinton, both often captured on film with the classic mid-face redness and bumpiness of rosacea. These classic signs of rosacea are often misidentified as 78 percent of Americans, according to a Gallup survey, do not know that rosacea exists.

Psychological Effects
Some believe the social and emotional effects of rosacea are worse than the physical symptoms. In one survey, nearly 70 percent of rosacea patients said it lowered their self-confidence and self-esteem. Forty-one percent said the condition caused them to avoid public contact or cancel social engagements.

Causes
While the precise cause of rosacea remains a mystery, researchers believe that heredity and environmental factors are to blame. One explanation is that something causes the blood vessels to swell. The result, these scientists believe, is the flushing and redness characteristic of rosacea.

Another theory is that a mite called Demodex folliculorum, which lives in hair follicles, could be a cause of rosacea. The belief is that the mites clog oil glands, which leads to the inflammation seen in rosacea. Others believe that a bacterium called Helicobacter pylori, which causes intestinal infection, might be a cause.

The immune system also has been implicated as playing a role in rosacea's development.

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Skin Cancer

The following information has been provided by the Skin Cancer Foundation.

Facts about Skin Cancer

• More than 1.3 million skin cancers are diagnosed yearly in the United States.
• One in 5 Americans and one in 3 Caucasians will develop skin cancer in the course of a lifetime.
• More than 90 percent of all skin cancers are caused by sun exposure, yet fewer than 33 percent of adults, adolescents, and children routinely use sun protection.
• A person's risk for skin cancer doubles if he or she has had five or more sunburns.

Risk Factors Associated with Skin Cancer

• Sun Exposure
  Sunlight is responsible for over 90 percent of all skin cancers. Working primarily outdoors, living in an area that gets a lot of high intensity sunlight, spending time in tanning booths all increase your exposure to UV rays and thus increase your risk for developing skin cancer. Blistering sunburns in early childhood increase risk, but cumulative exposure also is a factor.
• Skin Type
  Fair-skinned individuals who sunburn easily have a higher incidence of skin cancer than dark-skinned individuals.
• Moles
  There are two kinds of moles that a person can have: normal moles - the small brown blemishes, growths, or "beauty marks" that appear in the first few decades of life in almost everyone - and atypical moles, known as dysplastic nevi. Regardless of type, the more moles you have, the greater your risk for melanoma.
• Previous Skin Cancer
  If you have had a skin cancer of any type, it increases your risk of developing another one.
• Family History
  If your mother, father, siblings, or children have had a melanoma, you are in a melanoma-prone family. Each person with a first-degree relative diagnosed with melanoma has a 50 percent greater chance of developing the disease than people who do not have a family history. If the cancer occurred in a grandmother, grandfather, aunt, uncle, niece or nephew, there is still an increase in risk, although it is not as great.
• Reduced Immunity
  People with weakened immune systems due to excessive unprotected sun exposure, chemotherapy, or those with certain illnesses such as HIV are more likely to develop skin cancer.

Types of Skin Cancer

Basal Cell Carcinoma (BCC)
Basal Cell Carcinoma (BCC) is the most common form of cancer, with more than 800,000 new cases estimated in the US each year. Basal cells are cells that line the deepest layer of the epidermis. An abnormal growth - a tumor - of this layer is known as Basal Cell Carcinoma. Basal Cell Carcinoma can usually be diagnosed with a simple biopsy and is fairly easy to treat when detected early. However, 5 to 10 percent of BCCs can be resistant to treatment or locally aggressive, eating away at the skin around then, sometimes even into bone and cartilage. When not treated quickly, they can be difficult to eliminate. Fortunately, however, this is a cancer that has an extremely low rate of metastasis, and although it can result in scars and disfigurement, it is not usually life-threatening. The sun is responsible for over 90 percent of all skin cancers, including BCC, and chronic overexposure to the sun is the cause for most cases of Basal Cell Carcinoma. BCCs - the tumors themselves - occur most frequently on the face, ears, neck, scalp, shoulders, and back.

Warning Signs
The five most typical characteristics of Basal Cell Carcinoma are shown below. Frequently, two or more features are present in one tumor. In addition, BCC sometimes resembles non-cancerous skin conditions such as psoriasis or eczema. As us if you are unsure about a lesion or sore.

An Open Sore that bleeds, oozes, or crusts and remains open for three or more weeks. A persistent, non-healing sore is a very common sign of an early Basal Cell Carcinoma (BCC).



A Reddish Patch or irritated area, frequently occurring on the chest, shoulders, arms, or legs. Sometimes the patch crusts. It may also itch or hurt. At other times, it persists with no noticeable discomfort.



A Shiny Bump or nodule that is pearly or translucent and is often pink, red, or white. The bump can also be tan, black, or brown, especially in dark-haired people, and can be confused with a mole.



A Pink Growth with a slightly elevated rolled border and a crusted indentation in the center. As the growth slowly enlarges, tiny blood vessels may develop on the surface.



A Scar-like Area which is white, yellow or waxy, and often has poorly defined borders. The skin itself appears shiny and taut. This warning sign can indicate the presence of an aggressive tumor.

Squamous cell carcinoma (SCC)
Squamous cell carcinoma (SCC) is the second most common form of skin cancer, with over 200,000 new cases per year estimated in the United States. Squamous cells are cells that compose most of the epidermis. An abnormal growth of these cells is known as a squamous cell carcinoma.

Most SCCs are not serious. When identified early and treated promptly, the future is bright. However, if overlooked, they are harder to treat and can cause disfigurement. While 96 to 97 percent of SCCs are localized, the small percentage of remaining cases can spread to other parts of the body, and the results are often fatal.

Like all skin cancers, chronic overexposure to the sun is the primary cause of nearly all cases of squamous cell carcinoma. Tumors appear most frequently on the face, neck, bald scalp, hands, shoulders, arms and back: all places that are exposed to the sun. The rim of the ear and the lower lip are especially vulnerable to these cancers. Squamous cell carcinomas may also occur where skin has suffered certain kinds of injury: burns, scars, long-standing sores, sites previously exposed to X-rays or certain chemicals (such as arsenic and petroleum by-products). In addition, chronic skin inflammation or medical conditions that suppress the immune system over an extended period of time may encourage development of squamous cell carcinoma.

Occasionally, squamous cell carcinoma arises spontaneously on what appears to be normal, healthy, undamaged skin. Some researchers believe that a tendency to develop this cancer may be inherited.

Warning Signs
Squamous cell tumors are thick, rough, horny and shallow when they develop. Occasionally, they will ulcerate, with a raised border and a crusted surface over a raised, pebbly, granular base. Any bump or open sore in areas of chronic inflammatory skin lesions indicates the possibility of squamous cell carcinoma, and a doctor should be consulted immediately if this is the case. Usually, the skin in these areas reveals telltale signs of sun damage, such as wrinkling, changes in pigmentation, and loss of elasticity. That is why tumors appear most frequently on sun-exposed parts of the body.

Melanoma
Melanoma is the most serious form of skin cancer. However, if it is recognized and treated early, it is nearly 100 percent curable. If it is not, the cancer can advance and spread to other parts of the body, where it becomes hard to treat and can be fatal. While it is not the most common of the skin cancers, it causes the most deaths. The American Cancer Society estimates that in 2006, there will be over 60,000 new cases of melanoma in the United States.

Melanoma is a malignant tumor that originates in melanocytes, the cells which produce the pigment melanin that colors our skin, hair, and eyes and is heavily concentrated in most moles. The majority of melanomas, therefore, are black or brown. However, melanomas occasionally stop producing pigment. When that happens, the melanomas may no longer be dark, but are skin-colored, pink, red, or purple.

Evaluating Your Moles
Moles, brown spots and growths on the skin are usually harmless - but not always. Anyone who has more than 100 moles is at greater risk for melanoma. The first signs can appear in one or more of these moles. That's why it's so important to get to know your skin very well, so you can recognize any changes in the moles on your body. Look for the ABCDEs of melanoma, and if you see one or more, make an appointment with us.

A symmetry
If you draw a line through this mole, the two halves will not match, meaning it is asymmetrical, a warning sign for melanoma.


B order
The borders of an early melanoma tend to be uneven. The edges may be scalloped or notched.

C olor
Having a variety of colors is another warning signal. A number of different shades of brown, tan or black could appear. A melanoma may also become red, white or blue.


D iameter
Melanomas usually are larger in diameter than the size of the eraser on your pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected.


E volving
Any change - in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching or crusting - points to danger.

Common moles and skin cancers do not look alike. Consult us if you are concerned!

Common Moles

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Moles

The medical term for a mole is a NEVUS (mole is Latin for "spot."). Nevi are the plural of nevus. Congenital nevi are moles present at birth; acquired nevi develop anytime later. Nevi are made up of a particular type of cell, and the name is used to distinguish them from other, similar appearing fleshy growths.

Acquired Nevi
Most moles that are acquired during life are usually less than 1/4 inch in size. Many of those that form in childhood and early adult life are now thought to be due to sun damage. Most people think of a mole as being a dark brown spot, but moles have a much wider range of appearance. They can be raised from the skin and very noticeable, or they may contain dark hairs. Having hairs in a mole does not make it more dangerous. Moles can appear anywhere on the skin, alone or grouped. They usually are brown in color and can be various sizes and shapes. Special cells that contain the pigment melanin cause the brown color.

Facial moles are probably determined before a person is born. Some may not appear until later in life, but moles that appear after age 50 should be regarded with suspicion. Moles may darken, which can happen after exposure to the sun, pregnancy and sometimes during therapy with certain steroid drugs. There is little risk of melanoma cancer developing in these moles.

Atypical moles (dysplastic nevi or Clarks nevi)
An estimated one out of every ten Americans has at least one atypical mole. These moles are larger than common moles, with borders that are irregular and poorly defined. Atypical moles also vary in color, ranging from tan to dark brown shades on a pink background. They have irregular borders that may include notches. They may fade into surrounding skin and include a flat portion level with the skin. These are some of the features that one sees when looking at a melanoma. When a pathologist looks at an atypical mole under the microscope, it has features that are in-between a normal mole and a melanoma.

While atypical moles are considered to be pre-cancerous (more likely to turn into melanoma than regular moles), not everyone who has atypical moles gets melanoma. In fact, most moles -- both ordinary and atypical ones -- never become cancerous. Thus, the removal of all atypical nevi is unnecessary. In fact, half of the melanomas found on people with atypical moles arise from normal skin and not an atypical mole.

Congenital nevi
Only a few babies, about one in hundred, are born with a mole, the congenital nevus. These can vary in size from being less than 1/4 inch to covering almost the entire body. Large nevi can vary greatly in size, shape, color, surface texture, and hairiness. Some are reddish-tan; others are almost black. Most are shades of brown. Some have fine downy hair; many have long, thick, darker hair. Some have a permanent "goose bump" appearance.

Nevi measuring four inches (10 cm) or more at birth occur in about one in every 20,000 children. Giant congenital nevi involving much of the body surface are less common, possibly around one in every 200,000 to 500,000 births. Many people with a giant nevus will have anywhere from several to hundreds of smaller "satellite" nevi. In a very few persons with giant moles, nevus cells can also be found in the spinal cord and near the brain, a condition called neurocutaneous melanosis.

The exact risk of melanoma developing in a giant congenital nevus is not known but is thought to be at least six percent. There has not been any melanoma in the satellite nevi, and those on the arms and legs are also less dangerous in general. Small and medium sized congenital nevi have a much lower risk and are rare. Small congenital nevi rarely turn malignant before puberty. Congenital moles will grow in proportion to body growth. Their color may stay the same, lighten slowly, or darken slowly over time. Changes in growth, in color, in surface texture, pain, bleeding, or itching are all of concern. Any such changes should be evaluated medically if they last longer than a few weeks.

Treatment
Surgical excision of nevi should be done where cancer is a reasonable concern. Improving cosmetic appearance is another reason for excision, but all surgery leaves some scarring. Smaller nevi can be "shaved off". Larger ones can be cut out directly and the wound edges sewn together. Much larger nevi may be excised in stages by taking a little more out each time until the entire nevus is removed. This is called "serial excision." Cutting out very large nevi will leave behind a raw area that is too big to be sewn together and must be covered. This can be done with a split thickness skin graft from some other normal area of the body. The skin-grafted area will have varying degrees of scarring and will usually be thinner and more fragile than normal skin.

There have been several reported cases of melanoma developing underneath a skin graft from nevus cells left behind. Occasionally, thickened scars called keloids may appear. Laser treatment, chemical peels and dermabrasion, also destroy nevus cells before they can be checked for cancer under a microscope. They also leave nevus cells behind and the pigment often seems to reappear.

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Warts

Warts are caused by the human papilloma virus (HPV). There are several different types of warts. Warts can grow anywhere on the body but are most common on the hands. It is estimated one in twenty school children have warts.

Planter warts are ingrown in the feet and are also known as verrucas. Mosaic warts are tiny and can spread all over the sole of the foot. Common warts have a raised surface with a cauliflower-like head. If the wart is touched or scratched the virus can spread to another area of skin. However, it can take up to one year for a new wart to appear.

Warts are no threat to health and do not lead to any illness, however, they can cause embarrassment and are painful in some cases.

How are warts removed?
Warts can be removed by several different methods, or they can also go away of their own accord. Fifty percent of childhood warts disappear within six months and 90 percent within two years. However, they may last up to seven years in adults. Some warts do not respond to treatment, even if another wart on the same person is easily removed. However, often they will eventually disappear spontaneously in time. Planter warts (verrucas) may take longer to disappear and removal may be recommended for these. Warts on the face may also require professional advice.

Treatments for Wart removal

Cryotherapy (Freezing)
Liquid nitrogen is used to freeze the wart. The treatment is repeated at one to two week intervals. This method has a 70 percent success rate, and limited scarring.

Electrosurgery
The wart is scraped away and then burned by diathermy or cautery using a needle heated with electricity. This works in most cases. However, 20 percent of warts can return within a few months, and a repeat treatment is sometimes required. The wound may take up to six weeks to heal and can leave a scar.

Excision
Cutting out the wart is generally not recommended because the incision leaves a scar and is not any more effective than other methods. The wart virus can extend through the scar and cause a bigger area of warty skin.

Laser
A carbon dioxide laser is used to destroy warts. This is mainly used for multiple planter warts. Repeat treatments are likely to be necessary.

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Actinic Keratosis

Actinic keratoses are rough, reddish patches or warty growths which appear on sun-exposed areas of the body. These growths have an estimated five to ten percent chance of turning into skin cancer called squamous cell carcinoma. Actinic keratoses that have been rough, red, irritated or tender can be destroyed by several methods. The most common method is cryosurgery (freezing). This involves liquid nitrogen which freezes skin cells causing them to die and peel off. Cryosurgery will usually destroy the precancerous actinic keratoses, but may also damage some of the surrounding skin tissue. A blister may form which may heal with some whitening of the skin and mild scarring.

Photodynamic treatment is another newer treatment used with topical Aminolevulinic Acid (5-ALA). This method involves light activation of a photosensitizer to generate highly reactive oxygen intermediaries, which ultimately cause tissue injury and necrosis. 5-ALA is applied locally and it then passes through the abnormal keratin overlying the lesion and is metabolized by the underlying cells to photosensitizing concentrations of porphyrins. The patient will be asked to return to the office within 14 to 18 hours for exposure to photoactivation of the 5-ALA in the form of a (usually blue light but sometimes a proprietary red) artificial light source for approximately 17 minutes. The patient will experience erythema, severe burning, pain and dying of the actinic keratotic lesion. Healing usually occurs in 10-14 days. However, some lesions may not respond and a second treatment session may be required after 8 weeks.

Other methods are chemical peeling agents and, rarely, removal by excision.

How should I care for the treated areas?
Wash areas gently twice daily and apply bacitracin or vaseline to prevent crusting. Cortisone creams may be applied the first day of treatment to reduce stinging. If treated areas develop tenderness or yellowish-infected drainage, please call the office.

What Happens After Treatment?
Often treated areas look "worse" before they look better. The area may swell or blister, can be red for days, then scale or crust and heal over one to four weeks. Wounds heal much faster if cared for as described above. Be sure to treat a blister with bacitracin or vaseline and band-aid or telfa pad until well healed.

By one month after treatment the areas should be pink and smooth. If an area still persists with rough crusting or tenderness, it may need to be retreated or biopsied. Please make a follow-up appointment. If the treated area heals with any evidence of a thickening scar after three to six weeks please call the office for follow-up care.

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Eczema

There are a variety of types of eczema as well as causes. Eczema is associated with very dry, itchy skin. It can become red and bleed, particularly if the area becomes broken from scratching. Eczema is not contagious and can be treated. Mild cases can usually be treated with topical remedies and a mild skin care routine. More advanced cases may require oral medications.

Eczema
Atopic dermatitis, also called atopic eczema, is the name given to a stubborn, itchy rash that occurs in certain persons with sensitive or irritable skin. Eczema is common in infants and young children, and may disappear before adulthood. Eczema may clear for years, only to reappear later, often o