JDD Special Focus

Skin Cancer Articles

Stay up-to-date on new clinical findings in Skin Cancer.  View the latest articles, case reports, supplements, Podcast episodes and more!



Impact of a 31-gene Expression Profiling Test for Cutaneous Melanoma on Dermatologists’ Clinical Management Decision 

Aaron S. Farberg MD, Alex M. Glazer MD, Richard White MS, and Darrell S. Rigel MD MS

Following a diagnosis of cutaneous malignant melanoma (CMM), patients are often guided for subsequent management by their dermatologist and national guideline recommendations.1,2 Based upon staging classification for CMM, guidelines recommend diagnostic tests and additional evaluation which may provide defined treatment protocols, surveillance, and follow-up. Unfortunately, these recommendations are often similar across several tumor stages in part because of the inability to precisely stratify different risk groups that may have markedly different outcomes.


A Randomized Trial of Broad Area ALA–PDT for Field Cancerization Mitigation in High-Risk Patients 

Daniel Piacquadio , Anna Houlihan , Mary Beth Ferdon , James E. Berg , Stuart L. Marcus

Actinic keratoses (AKs) are precancerous, dysplastic epidermal lesions with potential for progression to squamous cell carcinoma (SCC). A study by Criscione et al1 revealed that in a high-risk population (≥2 keratinocyte carcinomas in previous 5 years), approximately 65% of all primary SCCs arose in lesions previously diagnosed as AKs. Furthermore, it demonstrated that the risk of malignant progression of AKs to primary SCC increases over time (0.6% at 1 year and 2.6% at 4 years).1 Cellular damage and atypia seen histologically in AKs are similar to those of surrounding nonlesional skin,2,3 suggesting that skin surrounding AKs may have an increased risk of skin cancer.


Multiple Primary Melanomas Occurring Around the Same Time: A Review of Terminology and Implications 

Shawn Shih , Christina Dai , Terri Shih , Amor Khachemoune

Multiple primary melanomas (MPMs) have been reported to occur in 2-10% of melanoma patients. This study conducted a review of the literature to elucidate the definitions of terminology used to describe MPMs that were diagnosed in close temporal proximity as well as explore common risk factors. Terminology found in the literature included “concurrent”, “simultaneous” and “synchronous” with varying definitions that ranged from 0-6 months between diagnoses of the first and subsequent melanomas. Eight cases are described in chronological order, and the incidence of MPMs diagnosed around the same time were reported as 22-39%. Nevus spilus was identified as a potential risk factor for MPMs. This study highlights that MPMs are not uncommon, and clinicians should remain aware that MPMs can be diagnosed at or around the same time, warranting thorough skin exams.


The Influence of Supportive Oncodermatology Interventions on Patient Quality of Life: A Cross-Sectional Survey 

Leora Aizman , Kamaria Nelson , Andrew D. Sparks , Adam J. Friedman

Supportive oncodermatology is a growing field that provides treatment and preventive care to oncology patients who experience dermatologic adverse events (dAEs) secondary to cytotoxic and targeted cancer treatments. Novel cancer therapies that impede the proliferation of cancer cells often target other rapidly proliferating organ systems and can lead to unfavorable skin, hair, and nail alterations. The most commonly documented dAEs include papulopustular rash, xerosis, pruritus, nail changes, chemotherapy-induced alopecia, and hand-foot skin reaction.1,2 Persistent dermatologic side effects may be disabling and are associated with negative psychosocial effects affecting patient confidence and functionality.3-6 Further, over 50% of cancer patients experience an interruption in therapy secondary to dAEs.7 With an estimated 1.8 million new cancer diagnoses made in 2019,8 all patients receiving anticancer therapy may be vulnerable to dAEs and the consequent impacts on wellness and treatment adherence.


Topical Fluorouracil Therapy for Residual Superficial Basal Cell Carcinoma Following Mohs Micrographic Surgery 

Hannah Pederson , Cecil Jordan Staples , Chad Housewright

When treating invasive basal cell carcinoma (BCC) with Mohs micrographic surgery (MMS), including infiltrative and nodular subtypes, the goal is complete surgical removal of the tumor. In some cases, after several stages of MMS, residual foci of superficial BCC are noted with no dermal invasive components apparent. Some patients and surgeons have opted for halting surgery and treating residual superficial BCC with adjuvant topical fluorouracil. In this retrospective study, this treatment method is shown to be effective with a recurrence rate of BCC of 3.7% over a mean follow up of 28 months. This treatment method reduces the number of stages of MMS as the surgery is stopped was invasive BCC is removed. This can be beneficial when considering the morbidity of prolonged surgical procedures in frail, elderly patients experiencing surgical fatigue, the cost of additional stages, and the cost of advanced repairs due to enlarging defect size.


Real-World Utility of a Non-Invasive Gene Expression Test to Rule Out Primary Cutaneous Melanoma: A Large US Registry Study 

Brook Brouha , Laura K. Ferris , Maral K. Skelsey , Gary Peck , Ronald Moy , Zuxu Yao , Burkhard Jansen

Efforts to unambiguously assess and adjudicate primary melanocytic skin lesions clinically suspicious of melanoma to rule out melanoma via the existing standard of care of visual assessment and histopathology remains a challenge even for pigmented lesion experts because of inherent limitations of image recognition.1-11 Dermoscopy, confocal microscopy, or computer-aided image analysis of skin lesions can reduce some of these inherent limitations. However, these tools generally do not overcome these issues and challenges continue after biopsy decisions have been made. Histologic evaluation is again guided by image and pattern recognition. Histologic criteria to distinguish between benign and malignant are overlapping and are in nature subjective, affecting the performance of our existing mainstay of establishing diagnoses in pigmented lesion management.4

Long-Term Benefits of Daily Photo-Protection With a Broad-Spectrum Sunscreen in United States Hispanic Female Population 

Pearl Grimes , Rebat Halder , Michele Verschoore , Janet Wangari-Talbot , Kumar Pillai , Peter Foltis , Charbel Bouez , Angelike Galdi , Deena Abdelhalim , I-Chien Liao , Qian Zheng

The skin of color population has been growing significantly in the United states and globally. This requires specific dermatological attention and patient care strategies due to unique physiological conditions and clinical manifestations regarding skin of color. Concerning photoaging, although people with higher Fitzpatrick phototypes (III and above) in general have fewer visible signs of aging such as lines and wrinkles, they are more susceptible to certain pigmentary-related conditions including uneven skin tone, ashy skin and blotchiness, post-inflammatory hyper- and hypo-pigmentation, Melasma, and seborrheic keratosis. 

Long-Term Efficacy and Safety of Superficial Radiation Therapy in Subjects With Nonmelanoma Skin Cancer: A Retrospective Registry Study 

William Roth , Robert E. Beer , Vivek Iyengar , Thomas Bender , Isabelle Raymond

Nonmelanoma skin cancer (NMSC) comprises basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and numerous less common skin tumors.1 NMSCs are the commonest form of malignancy among Caucasians2 and its incidence continues to rise worldwide.3 Although Mohs surgery has traditionally been regarded as the gold-standard for treating NMSC,4 it may not be suitable for the elderly due to frailty, limited life-expectancy, and comorbidities.5-7


Hispanic Tattoo Artists Could Provide Skin Cancer Prevention via Aftercare Instructions and Social Media

Cristian D. Gonzalez MD, Adrian Pona MD, Barbara J. Walkosz PhD, Robert P. Dellavalle MD PhD MSPH

The incidence of melanoma and non-melanoma skin cancer in the Hispanic population has increased. Hispanics are more likely to present with advance-staged melanoma and worse overall prognosis. Thus, public health campaigns are necessary to target the underrepresented Hispanic population. To explore Hispanic tattoo artists’ skin cancer knowledge, sun safety recommendations, and their willingness to implement primary and secondary skin cancer prevention in their daily work routines.


A Survey-Based Comparison of Sun Safety Practices in a Representative Cohort of the General Public Versus Attendees of a Skin Cancer Screening 

Emily C. Murphy BS, Stephanie Kao BA, Huan Wang MS, Dechang Chen PhD, Hong Nguyen MD MPH, Adam J. Friedman MD 

A large proportion of data on photoprotective practices is yielded from free skin cancer screenings. However, the sun safety practices of populations who seek these skin cancer screenings may differ from the general public. To examine differences in skin cancer prevention practices and risk factors, we surveyed pedestrians at six locations in Washington, DC (public group, n=285) and attendees of a free skin cancer screening (screening group, n=144) using an IRB-approved survey. The screening group was older and included more individuals with fair skin than the public group. Respondents from the screening group were significantly more likely to always wear sunscreen, always seeks shade, and always or sometimes wear sun-protective clothing than the public group (P<0.05). To examine whether younger and non-white participants, who were less likely to attend our free screening, have different practices and risk factors than older and white participants, respectively, we compared survey answers for all participants by age and race.

Non-Invasive Buccal Swab Gene Testing for Skin Cancer Risk 

Lauren Moy MD, Alexis B. Lyons MD, William Fox MS, Marcie A. Glicksman PhD, Ronald Moy MD, Rebecca Tung MD

It is well known ultraviolet (UV) light and DNA damage can lead to skin cancer. This occurs when epidermal keratinocytes are exposed to UV radiation, forming dimers and oxygen radicals that alter the structure of nucleotides. When these defects are not repaired, DNA replication is altered leading to mutations in p53 and PTCH tumor suppressor gene1 and ultimately tumor development.2 Major DNA repair defects can give rise to cancer-prone phenotypes. This phenomenon is illustrated in xeroderma pigmentosum, a disease with mutated repair genes that predispose patients to extreme UV sensitivity and 2,000-fold risk of NMSC and other malignancies.3 However, aside from rare syndromes, the variants in DNA repair genes for the general population and the association with cancer risk is not yet well understood.

Skin Cancer Epidemiology and Sun Protection Behaviors Among Native Americans 

Melody Maarouf MHS,  Shannon W. Zullo BS, Timothy DeCapite MD, Vivian Y. Shi MD

The latest 2010 United States Census indicates that 2.9 million people identify as Native American (NA). Forty-one percent live in the Western states (Arizona, California, Colorado, Montana, Nevada, New Mexico, Alaska, Hawaii, Idaho, Oregon, Utah, Washington, Wyoming).1 Despite the prevalence of NA residing in these UV-intense geographic regions, there is very limited data on skin cancer in this population.In the last 20 years, only 11 publications have mentioned NA sun protection behavior and skin cancer prevalence. Herein, we aim to fill the knowledge gap on skin cancer epidemiology and sun protection behaviors in NA.

Dual Immunostaining With SOX10 and AE1/AE3 to Confirm Perineural Invasion on Mohs Sections 

Matthew R. Donaldson MD and L. Arthur Weber MD

Perineural invasion (PNI) is associated with high risk keratinocyte carcinomas. Identification of PNI during Mohs surgery is important for staging and post-adjuvant treatment decisions but can be challenging. To confirm or exclude PNI suspected on hematoxylin and eosin sections, we performed immunohistochemical double staining on Mohs frozen sections. Neural marker SOX10 and pan-cytokeratin marker AE1/AE3 were combined in a simultaneous assay using species-specific (mouse and rabbit) antibodies and horseradish peroxidase and alkaline phosphatase detection systems. Of 23 Mohs cases with suspected PNI, 18 were confirmed to have definitive nerve involvement by tumor using double staining. Double staining frozen tissue is feasible and can be beneficial for real time confirmation of PNI during Mohs.

Is It Time to Rethink What Thickness Really Means as a Prognostic Indicator in Melanoma? Ten Questions We Should Be Asking Ourselves 

Marc L. Frost MD, Katherine Hrynewycz MD, C. William Hanke MD

Tumor thickness has been a key tool for prognosis of melanoma. However, with the advent of gene expression profile (GEP) assays for melanoma and the discovery of multiple melanoma subtypes, it is time to reassess how we view tumor thickness as a prognostic indicator.Herein we present ten questions for consideration by the shrewd practitioner when considering prognostic factors of melanoma.

Superficial Radiation Therapy: A Viable Nonsurgical Option for Treating Basal and Squamous Cell Carcinoma of the Lower Extremities 

William I. Roth MD, Michael Shelling MD, Keren Fishman

Superficial radiation therapy (SRT) is a nonsurgical method of treating basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) lesions on the lower extremities of older individuals that might otherwise suffer complications or prolonged healing following surgical intervention. Objective: The goal of this study was to evaluate the effectiveness of SRT for treating BCC and SCC lesions on the lower extremities of elderly patients in an outpatient clinic setting. Methods and Materials: A retrospective review was performed using data from consecutive patients with BCC and SCC on their lower extremities and were treated with SRT.


Skin Cancer Prevention: A Review of Current Oral Options Complementary to Sunscreens 

Marie Stoddard MD, Alexis B. Lyons MD, Ronald L. Moy MD

The incidence of non-melanoma skin cancer (NMSC) is dramatically increasing worldwide, despite the increased use of improved sunscreens. In 2014, the Surgeon General estimated that 2.2 to 5.0 million people are treated annually for NMSC.1-3 For decades, recommendations for sun protection have remained insufficient; subsequently, the numbers of newly diagnosed skin cancers continue to rise, and there is a need for additional preventative measures beyond sunscreens. The objective of this article is to review current oral prescription medications as well as supplements that may play an important role in skin cancer prevention.


Cosmetic Versus Medicine: How Does Your Country Define Sunscreen? 

Elissa Tong BMed, Gayle Fischer OAM FACD MD, Saxon D. Smith MBChB MHL PhD GAICD FACD

Skin cancer (melanoma and non-melanoma) is the most commonly diagnosed cancer in the United States,1,2 with melanoma being responsible for over 9000 US deaths annually. Melanoma is the 3rd most diagnosed cancer in Australians,3 and non-melanoma skin cancer is the most common cause of Australian cancer-related hospitalizations, representing a major health-care cost burden.4 Primary and secondary skin cancer prevention is globally inadequate,5 with only 3 in 10 American adults using sun protection routinely.6Internet purchasing of sunscreen products is possible for consumers worldwide. However, countries have unique sunscreen regulations. Sunscreen products purchased internationally may not meet standards required by the consumer’s respective local regulation. This can create confusion for consumers who do not understand the differing international regulations.

Facial Basal Cell Carcinoma in Patients Younger Than 40 

Ardeshir Edward Nadimi MD, Yizhao Zhou MS, Jaeil Ahn PhD, and Ali Hendi MD,

The incidence of basal cell carcinoma in the population younger than 40 years is rising, and a majority of basal cell carcinomas occur on the head and neck. Our objective was to determine whether basal cell carcinomas in the population younger than 40 years occur more frequently at the forehead and its subunits (forehead proper, temple, suprabrow, and glabella). Methods: We performed a retrospective case review of 4,337 basal cell carcinomas in 3,223 patients treated with Mohs micrographic surgery. Results: Patients younger than 40 showed 2.2 fold increased odds of developing BCC at the forehead. Being younger than 40 was associated with more than 2.5 times higher odds of developing BCC at the forehead proper and 2.0 times higher likelihood of developing BCC at the temple. Females were associated with 3.8 fold higher odds of developing BCC at the glabella; however, they were less likely to develop BCC at the temple. Discussion: There may be underlying differences in the pathogenesis and natural history of basal cell carcinoma in the younger population, and between males and females; alternatively, lifestyle factors may also play a role.

Demographic and Tumor Characteristics of Patients Younger Than 50 Years With Nonmelanoma Skin Cancer Referred for Mohs Micrographic Surgery 

Nicola A. Quatrano MD, Euphemia W. Mu MD, David E. Orbuch MD, Adele Haimovic MD, Roy G. Geronemus MD, and Jeremy A. Brauer MD

Nonmelanoma skin cancer (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), is the most common malignancy in Caucasian populations worldwide. However, because NMSC are typically not reported to national and state registries, the exact incidence rates are unknown and are likely underestimated. In the United States, it is estimated that over 5.4 million cases of NMSC are treated in more than 3.3 million people annually and that the incidence is increasing each year.


Dermatologist Practices During Total Body Skin Examinations: A Survey Study 

Evan A. Rieder MD, Euphemia W. Mu MD, Jenny Wang BS, David E. Cohen MD, Darrell S. Rigel MD, and Mary L. Stevenson MD

Though screening for skin cancer is an essential practice in dermatology, limited data are published on dermatologists’ total body skin examination (TBSE) behaviors. We surveyed 6500 dermatologists on their TBSE practices, including questions about less commonly examined body sites. We found varied TBSE practices among all dermatologists and discrepancies in examinations between dermatologists of opposite genders.


Podcast Episodes

Going On, Not Off, the Reservation: Identifying Gaps in Sun Protection Perceptions and Use in Native Americans

Skin cancer doesn’t discriminate. We hear that evidenced-based media-friendly line often nowadays to highlight the importance of sun protection in all skin types. But are we really getting that message everywhere it needs to be? Definitely not. Dr. Vivian Shi’s most recent study published in the June 2019 edition of JDD highlights clear shortcomings in the Native American communities in Arizona. Tune in to hear how this study came to light, what unique concerns and issues impede proper sun protection in this group, and tricks to get even a nonbeliever on a photoprotective regimen that he or she can realistically stay on.

How Do You Celebrate the Birthday Suit: Variations in Skin Cancer Screening Practices Among Dermatologist

In this edition of the JDD podcast “Ask the Investigator,” host Dr. Adam Friedman from the GW School of Medicine and Health Sciences is joined by Dr. Evan Rieder, Assistant Professor of Dermatology at NYU Langone Medical Center and one of the few dermatologists double board certified in dermatology and psychiatry in the U.S., to discuss his recent study entitled “Dermatologist Practices During Total Body Skin Examinations: A Survey Study.” Do we all do it the same? Are we all checking every nook and cranny? Do we need better standardization for our greatest weapon to enable early and life saving skin cancer detection? Call me crazy, but this is pretty…..preeeetty… pretty important (as Larry David would say).


Learning Objectives: Upon completion of this enduring activity, participants should be able to discuss the efficacy and safety of different topicals indicated for topic dermatitis, and the unique approaches to managing this complex yet extremely common conditions.


Case Reports

Basal Cell Carcinoma in the Nasal Vestibule

Basal cell carcinomas (BCC) arise from DNA damage to cells of the basal layer of the epidermis and most commonly in areas of the skin exposed to sunlight or ultraviolet radiation. BCC is the most common skin cancer seen in humans with over 4.3 million cases reported in the United States and is responsible for 3-10% of all cancers annually. We report what we believe to be the first case of this very prevalent skin cancer arising in the nasal vestibule. The lesion was treated with Mohs micrographic surgery and required three stages to obtain histological clearance. Given the location of the tumor, Mohs surgery was chosen due to the procedure’s effectiveness for achieving the highest cure rate with the lowest incidence of tumor recurrence and for preserving as much adjacent healthy tissue as possible

Combination Topical Chemotherapy for the Treatment of an Invasive Cutaneous Squamous Cell Carcinoma

Standard of care for squamous cell carcinoma (SCC) is usually surgical, with either excision or Mohs micrographic surgery. However, surgery may not be ideal for elderly patients with numerous lesions, who are poor surgical candidates or who refuse surgery. Topical 5-fluorouracil (5-FU) and imiquimod have been studied off-label as monotherapies in the treatment of SCC in situ with promising results. However, long-term tumor-free survival rates are still less than with surgical management.


Recurrent Squamous Cell Carcinoma Arising Within a Linear Porokeratosis

Here we report a case of linear porokeratosis with recurrent malignant degeneration to squamous cell carcinoma (SCC) recurring six years after excision of initial SCC. A 79-year-old woman presented with a friable tumor located within a longstanding lesion on her posterior thigh. Six years prior, she was diagnosed with SCC arising within the same lesion, which had been surgically excised with negative margins. Physical examination revealed a 3.5 x 2.7 cm friable tumor on the left proximal posterior thigh.



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