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Malignant Melanoma

The diagnosis of malignant melanoma is a life changing event. Having one melanoma puts you (and your family) at greater risk of having another one. There are ways for you to help discover new suspicious lesions before they have a chance to grow or spread.

At the time of diagnosis:

  • Make an appointment with the physician who well be performing a wide excision around the melanoma.
  • Make an appointment with your dermatologist to have a full body examination of your skin every 3 months for at least the first year.                 Some experts believe that an examination may be less frequent if your lesion is a “melanoma-in-situ”.
  • Make an appointment with your ophthalmologist to have your eyes checked for moles of the retina or iris and signs of ocular melanoma.
  • The next time you have your teeth cleaned or examined, ask the hygienist or dentist to look carefully at your gums, tongue, cheeks, and palate for pigmented lesions.
  • If you are a woman, ask your gynecologist to do a visual inspection at your next yearly exam. If it will be more than 6 months until your scheduled exam, go in early just for the pigmented lesion exam.

If your melanoma is greater than 1 mm in depth, you may be asked to see an oncologist. Your physicians will help you decide whether or not a sentinel node examination should be performed.

After the diagnosis:

  • Studies show that you are more likely to find an early melanoma if you perform monthly self skin examinations. These can be done with a mirror (or two) and good lighting. Ask your significant other to help evaluate your back and other hard to see areas. The self-examination does not take the place of a medical examination. Report any new or changing lesions that have been present for at least 2 weeks.
  • There is controversy over whether chest x-rays, blood tests, or body imaging scans can help detect metastatic disease. You and your physician will discuss this.

The sun is now officially your enemy! Choose a daily sunscreen with an SPF of 30 or greater. If you plan to be out of doors or in the car a great deal, consider going with an SPF greater than 45. Sun protection is not complete without a wide brimmed hat, long sleeves, sunglasses, and even gloves. Protective SPF clothing will add tremendous protection and peace of mind without the mess or fuss of creams and lotions.

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Rosacea is a common recurrent eruption that appears on the face or neck. It is usually seen in adults, but may be diagnosed in children. Symptoms may include episodes of facial flushing or blushing (usually after spicy foods, sun, stress or alcohol), swelling, pimples, pustules, “broken” or dilated blood vessels. The central face and nose are the most common areas of involvement.

Jimmy Durante had an extreme end stage type of rosacea, contributing to the size and shape of his distinctive nose. One third of rosacea patients also note that their eyes are red, runny, have a gritty feeling, or are sensitive to sunlight. They have “ocular rosacea”.

Treatment is aimed at avoiding trigger foods, beverages, and conditions. A diary may help you understand what your triggers are. Foods that contain tyramine, monosodium glutamate and certain spices may provoke flushing. Monosodium glutamate is a flavor-enhancer commonly used in Chinese food, fast foods, and in some frozen foods. Tyramine may be found in many cheeses (not cottage or cream cheese), yogurt, sour cream, coffee, tea, non-white vinegar, nuts, citrus, raisins, herrings, chocolate, bananas, soy sauce, vanilla, figs, avocados, and anything fermented, pickled, marinated or smoked. Nitrites are found in processed meats, bacon, pepperoni, sausage, corned beef, and smoked fish. (High intake may be associated with increased pancreatic cancer, stomach cancer and colorectal cancer rates, so it is not a bad thing to cut down on their ingestion.)

Alcoholic beverages often cause facial flushing. Initially, it may be desirable to totally avoid intake of beer, wine, bourbon, gin, vodka, and champagne. After several months, you may find that an occasional alcoholic drink is tolerated.

Emotional and physical stress may aggravate rosacea. Environments where the ambient temperature is high (including after a hot shower), unprotected UV exposure, wind and even intense visible light may cause rosacea to flare.

Treatment may include topical creams to relieve or diminish inflammation and irritation. Long term, low dose doxycycline (brand name Oracea) is a safe way to diminish formation of pimples and often will alleviate eye symptoms. Occasionally, isotretinoin (a high potency vitamin A derivative) may be recommended.

Intense pulsed light (IPL) treatment will often reduce the flushing and unsightly blood vessels of rosacea. Multiple treatments are necessary to get the desired result. These treatments are not covered by insurance companies as they are considered “medically unnecessary”.

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Atopic Dermatitis

Atopic dermatitis is a recurrent and chronic eczema that may present at any age. Often this is found in individuals with a family history of allergy, eczema, asthma or hay fever. Known as the “itch that rashes” instead of the “rash that itches” this condition may have intense itching preceding the skin rash. Most older patients note a prominent involvement of the skin folds of the arms and legs, eyelids, the nipples, earlobes and behind the ears. However, the eruption is at times extremely wide spread. Scratch marks, scaling, redness and crusting may be seen. The skin is very dry and may be sensitive to chemicals, fragrances, soaps, wool clothing and other additives. In most instances, the disease becomes milder with age. There is no laboratory test that will make this diagnosis.

In addition to the dry skin and itchy, scratched rash, changes may include:

  • Dark circles under the eyes
  • Areas of decreased skin pigmentation (pityriasis alba)
  • Rough, red to flesh colored bumps on the backs of the arms, things, cheeks or buttocks (keratosis pilaris)
  • Increased number or prominence of palmar lines

Helpful control measures include:

  • Luke warm (not hot) baths or showers followed immediately by a gentle cream to seal in the moisture. Vanicream is tolerated by almost everyone. If tolerated, newer generation moisturizers actuallly replace the depleted skin lipids, which helps to restore the barrier function of skin. These include CeraVe and Cetaphil Restoraderm. Atopiclair is a prescription cream which takes the restoration one step further.
  • Total avoidance of fabric softeners, drier sheets and fragrances.
  • Decreased amount of clothing detergent in the washing machine.
  • Double rinsing may also be helpful.
  • Avoidance of anything that “burns” when applied to the skin.
  • Wool irritates the skin.
  • If it seems that any food worsens the itching, avoid it. The most common offenders are soy, dairy products, legumes, eggs, wheat fish, chocolate and berries. Some acidic foods (tomatoes/citrus) may also flare the eczema.
  • Airborne allergens may be important in individual patients. These include animal dander, dust mites, pollens, and molds.
  • Maintenance of a cool, stable temperature in the home and keeping the humidity levels up near 40% may be helpful.

It is usually necessary to have the appropriate strength cortisone cream on hand for flares. They must be treated with respect. A stronger cream is used on the body, and a weaker cream is used on the face or the folds of the skin. Generally, do not apply cortisone cream on the same spot of skin for more than 14 consecutive days. It may be necessary to use ultraviolet light (UV) treatments or topical immunomodulator creams such as Protopic or Elidel. These treatments suppress the inflammation in the skin

There is good reason to support “proactive” treatment and well as “reactive” treatment. In other words, after the flared affected area is well from the daily use of cortisone or immunomodulator cream, using the same cream twice a week may prevent recurrence as soon.

Infections of any kind may cause flaring of atopic dermatitis. Sometimes a hidden focus of sinus infection, for example, can render the dermatitis resistent to treatment. Staphylococcus aureus can live on broken skin and in the nostrils, also making the skin rash hard to treat. These may necessitate treatment with an oral antibiotic.

Many patients control the frequent bacterial colonization by taking a “bleach bath” 2 or 3 times weekly. This is done by adding 2 or 3 CAPfuls (top of the bleach bottle) of chlorine bleach to a full tub of water and then soaking in the tub for 10 minutes.

Patients with chronic eczema can have poor self-esteem. They may find it difficult to interact normally with peers. Daily back massages given by a parent or spouse to an affected individual may decrease the symptoms of itching and the feeling of isolation of this disease.

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1-2% of Americans have psoriasis, a chronic skin disorder characterized by thick, red plaques of skin with silvery scales. Usually located symmetrically on elbows, knees, hands, or feet, it is also common on the scalp, at the nape of the neck, and just above the buttocks crease. It may appear at any age in either sex. Psoriasis may be an inherited disease. Stress, illness, irritation or injury to the skin, and weather change are among the recognized triggers. Psoriasis is not contagious.

New insights into the causes of psoriasis have reclassified this disease as one of inflammation that may extend to many organs, including the joints, heart, liver, and GI tract, as well as to the increased incidence of certain cancers. Psoriasis is associated with an increased risk of the metabolic syndrome (high blood pressure, abdominal obesity, high cholesterol or lipid levels, and insulin resistance leading to type 2 diabetes.) There is some early evidence suggesting that the treatment of psoriasis to decrease the inflammation may also be beneficial to these other organ systems. This is new, cutting edge information that needs to be borne out in longer, larger studies.

One study showed that smoking led to a 70% increase in incidence of psoriasis, especially in women. Alcohol intake is well known to exacerbate psoriasis. The risks of some of the associated diseases (inflammatory bowel disease, cardiovascular disease, certain cancers) are decreased when patients stop smoking.

What can you do? Losing weight, eating a well-balanced healthy diet, and exercising regularly may help your mood, decrease your risk of stroke or heart attack, and improve your psoriasis. It is reasonable to inform your primary care provider that you may have an additional risk factor for heart disease, diabetes, or arthritis. Regular monitoring of blood pressure and screening for diabetes, high triglyceride and cholesterol levels is recommended.

Multiple topical treatments have proven useful in reducing the signs and symptoms of psoriasis. These include tar, salicylic acid, calcipotriol (Vitamin D), retinoids (Vitamin A derivatives), corticosteroids, and emollients.

Ultraviolet treatments (UVB or PUVA) are usually the first recommendation in more widespread or difficult psoriasis. These treatments probably work via manipulation of the immune system in the skin. They are taken 2-3 times a week initially. The interval between treatments is increased as one sees improvement. This may result in weekly or monthly treatments. A remission period of weeks to months may be achieved in many patients after finishing an appropriate PUVA therapy. Risks may include burning, freckling, wrinkling, and an increased incidence of skin cancer years later.

Methotrexate is a chemotherapy drug that has been the “gold-standard” for treating severe psoriasis for many years. It can be used with reasonable safety as long as it is monitored appropriately for potential blood count or liver toxicity. Frequent blood tests are required early in treatment. After a cumulative dose of 1 – 1.5 grams, a liver biopsy is recommended before further treatment with methotrexate can resume.

Neoral (micronized cyclosporine) is also a great drug for helping stop severe, disabling psoriasis in its tracks. Because it can affect the kidney and lead to hypertension, it is usually used to “rescue” patients with severe disease. It can be used with relative safety for up to a year. If possible, at this time another treatment should be substituted.

Oral retinoids (Soriatane, isotretinoin) may be used in some psoriatics. These drugs are often used in combination with ultraviolet therapy. Close monitoring for Vitamin A toxicity includes monthly blood tests. Women should not get pregnant on these drugs and for a variable period after stopping these drugs. They are required to be on adequate birth control measures.

The strongest drugs against psoriasis are a new class of drugs called “biologics” (Enbrel, Humira, Stellara, Remicade) which come from living tissue. These drugs are injected into the skin, muscle or vein at different intervals. The treatments have many side effects, but are extremely effective in the skin and joint disease associated with arthritis. Patients on these drugs are at increased risk for lymphoma, multiple sclerosis, serious infection (especially tuberculosis) and congestive heart failure. One new study suggests that as one gets into the strongest biologics, risks of cardiovascular events (heart attack and stroke) may increase. As one would expect, these treatments are quite expensive. Insurance plans may not cover them.

The National Psoriasis Foundation has thousands of members who suffer from psoriasis. They maintain a website and a newsletter full of informative suggestions from fellow psoriatics. Remedies including experimental, accidental, anecdotal, and established are often featured in some detail. All patients with psoriasis should check out this organization.

The most important things to remember:

  • You are not alone.
  • You did not cause this.
  • Psoriasis is not contagious.
  • Psoriasis is not CURABLE, but the symptoms are very CONTROLLABLE.
  • Much exciting research is being done in this field.
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Evaluate your melanoma risk


Evaluating your risk of developing malignant melanoma

The relative risk of a person developing melanoma depends on certain characteristics. If you have a relative risk of “1”, that means you are not at increased risk of developing melanoma. Check your relative risk by examining the list below.

Risk Factor                                                                                                                      Relative Risk

  1. History of sunburn or excessive sunlight (natural or artificial) exposure 2-3
  2. Prior history of non melanoma skin cancer (basal cell or squamous cell) 2-3
  3. Fair skin 4
  4. Red hair/ Blue eyes 2
  5. Number of moles on your body:

11 – 25 moles                                                  1.6

26 – 50 moles                                                   4.4

51-100 moles                                                    5.4

Over 100 moles                                                9.8

  1. Number of atypical, dysplastic or unusual moles

1-5 atypical moles                                           3.8

Over 6 atypical moles                                      6.3


These risks may not be strictly additive. In other words, a patient who has fair skin and blue eyes may not have a relative risk of “6”. However, it is obvious that people with multiple risk factors will have a much higher risk of developing malignant melanoma than someone who has none of the risk factors.

It is also well recognized that individuals who have a history of melanoma in a first degree relative (parent, uncle, aunt, or sibling) are much more likely to develop melanoma than someone who is not related to an individual with melanoma. It is also known that certain people carry a gene or group of genes related to the development of melanoma.

It is obvious from the above list of risk factors that most of them are beyond our control. We can not pick our parents, change our eye color or relive our childhood years. But we have a great deal of control about our future sun exposure. Practicing “safe sun” allows us to enjoy the best skin future possible for our skin.

“Safe Sun” is an active process. This includes the normal precautions of avoiding intense direct sun, tanning beds, burns and tans. It involves wearing hats with a 3 inch brim or wider to protect our ears, neck and nose. Long sleeves and long pants protect arms and legs better than any lotion can.

Remembering to apply a sun protective factor (SPF) of 25 or better to our face, neck and chest will also prevent wrinkles, sun spots (age spots) and discoloration. Don’t forget to protect your lips!   Sunglasses that wrap around provide important protection of the retina, iris, eyelids and the skin around the eye.

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Food and Melanoma

A frequent question asked by patients who have had melanoma or are at increased risk of melanoma is “What can I do or eat to decrease my risk of this deadly disease?” Strict sun avoidance, use of hats, sunglasses, sun protective clothing and frequent skin exams are obvious choices. The effect of foods and supplements are just starting to be studied. Very few human studies have been completed.

Polyunsaturated fatty acids seem to protect against ultraviolet (UV) damage. Daily tea consumption, shellfish, vegetables and fish were found to have protective benefits against melanoma. The “Mediterranean diet” (lots of fish and vegetables) also has preventive effects against melanoma.

Grape seed proanthocyanidins (GSPs) are found in high concentrations in grapes and reduce photoaging and inhibit growth of UV induced tumors.

Green tea orally or topically decreases oxidative stress and decreases the number and size of UV induced tumors.

Resveratrol is found in peanuts, fruits, grape skins, mulberries, and red wine. It protects against sunburn damage. It has antiproliferative effects against melanoma cells.

Lycopene (a carotene found in red carrots, papyas, watermelons and tomatoes) is the most effective carotene at reducing oxidative stress and seems to increase the skin’s defense against UV damage.

Compounds which have been studied but not yet found to have significant data in reduction of human melanoma include rosmarinic acid (found in rosemary), selenium, Vitamin D and Vitamin E. The studies on Vitamin D are mixed, with some showing lower melanoma incidence and improved prognosis and others showing no clear relationship with melanoma risk.

The take home: diet probably has an important role to play in the prevention or the development of many diseases, including melanoma. Future studies should clarify this and help guide us as to dietary changes and recommendations. For now, a diet that includes fish, vegetables, grapes, tea, peanuts and tomatoes sounds like a good start.