Melanoma: The Most Severe Skin Cancer

Melanoma stands out as a particularly dangerous type of "skin cancer". It originates within "melanocytes", the cells responsible for producing melanin, the pigment that dictates our skin's coloration. While other forms, like basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), are more prevalent, "melanoma poses the greatest threat" due to its rapid growth potential and its propensity to spread (metastasize) to distant body parts if treatment is delayed.

Causes and Risk Factors

Primary Contributing Factors:

1. Ultraviolet (UV) Radiation

   Sunlight and the use of tanning beds expose skin cells to damaging UV radiation, which can lead to uncontrolled cellular proliferation.

2. Genetic Predisposition

   Certain genetic mutations, including those in genes such as BRAF, NRAS, and CDKN2A, can act as triggers for melanoma development.

Risk Factors :

1.  Skin and Hair Characteristics

   Individuals with fair skin, light-colored hair, and light eyes have a reduced amount of "melanin''. This lack of protection makes them more vulnerable to UV-induced harm.

2.  Frequent Incidents of Sunburn

    A documented history of experiencing ''blistering sunburns'', particularly during childhood, is strongly linked to an elevated risk.

3.  Excessive UV Exposure

  Prolonged exposure to the sun's rays, the use of tanning beds, or extended outdoor work without adequate protection heightens melanoma risk.

4.  Presence of Numerous Moles

   Having a large number of moles—specifically, "over 50–100 moles", or the presence of "atypical or dysplastic moles"—is correlated with a greater risk.

5.  Family History of Melanoma

  A close relative diagnosed with melanoma can "double" a person's likelihood of developing the condition.

6.  Compromised Immune Function

  People who are living with "HIV/AIDS", those who have received organ transplants, or who are taking certain medications face an augmented risk.

7.  Advanced Age

  Though it can affect individuals of any age, the probability of developing melanoma **increases with age. 

However, it is also one of the more prevalent cancers in ''young adults'' (especially women under 30).

8.  Prior Skin Cancer Diagnosis

 A history of ''melanoma or other skin cancers'' indicates a higher susceptibility to subsequent occurrences

Identifying Melanoma: The ABCDE Guidelines

Melanomas frequently initiate as an atypical mole or a dark spot on the skin. Applying the ABCDE rule allows individuals to identify early warning signs:

| Feature | Description|

 A - Asymmetry: The mole's halves do not correspond in shape. 

 B - Border: The mole's edges appear irregular, notched, or indistinct. 

 C - Color :The lesion displays a variation in colors, encompassing shades     of brown, black, red, white, or blue.

 D - Diameter : The spot has a diameter exceeding 6 mm (about the size of   a pencil eraser), but can be smaller. 

 E - Evolving : Observe changes in the mole's size, shape, or color over time.

Additional Indicators of Concern:

*   A new mole that deviates from the appearance of others.

*   A skin lesion exhibiting bleeding or crusting that does not heal.

*   A mole that causes itching, discomfort, or tenderness.

*   Presence of dark streaks underneath the fingernails (which could be indicative of subungual melanoma).

Melanoma Subtypes:

1. Superficial Spreading Melanoma (SSM) – Most Common (Approximately 70%)

*   Its growth pattern is horizontal along the skin surface prior to deeper penetration.

*   Most often found on the trunk in men and legs in women.

2. Nodular Melanoma (Around 15-20%) – Generally the Most  Aggressive Characterized by vertical growth, quickly infiltrating the deeper layers of the skin.

*   Frequently appears as a darkly pigmented, raised nodule that may bleed.

3. Lentigo Maligna Melanoma (About 10-15%)

*   Typically slow-growing and found in older individuals, often on sun-damaged skin, particularly on the face, neck, and hands.

4. Acral Lentiginous Melanoma (About 5-10%) – More Common in People with Darker Skin Tones

*   It usually appears on the palms, soles, or beneath the nails.

*   Not related to UV exposure; this variant is more common in the ''African, Asian, and Hispanic'' populations.

5. Mucosal Melanoma (About 1-2%)

*   Develops in mucous membranes, such as the mouth, nose, genitals, and anus.

*   Can be difficult to detect and often diagnosed at an advanced stage.

6. Ocular Melanoma (Approximately 1%):

*   Forms in the eye (uvea or retina), possibly causing vision-related difficulties.

Melanoma: Staging and Prognosis

Melanoma Stages

Melanoma's progression is staged based on tumor thickness, the presence of ulceration, and the extent of spread:

| Stage | Description | 5-Year Survival Rate

| Stage 0 (In Situ)| Confined to the outermost skin layer. | >99%               

| Stage I | Tumor is relatively small, with no evidence of spread. | 90-95% |

| Stage II | Thicker tumor that may present ulceration. | 60-80% |

| Stage III | Spread to adjacent lymph nodes. | 40-60% |

| Stage IV| Melanoma has metastasized to distant organs (lungs, liver, brain). | 15-20%              |

''Early detection dramatically improves outcomes''. Catching melanoma at ''Stage 0 or I'' generally offers a high likelihood of cure!

Diagnostic Procedures

1.  Skin Examination

    *   A dermatologist examines any suspicious moles using a dermatoscope. 

2.  Biopsy (Skin Sample Analysis)

    *   Excisional Biopsy: The complete mole is removed.

    *   Punch Biopsy: A deeper sample of the skin is obtained.

3.  **Sentinel Lymph Node Biopsy (SLNB)**

    *   If the melanoma is found to be thick, nearby lymph nodes undergo testing to determine if cancer has spread.

4.  Imaging Tests (In Advanced Cases)

    *   CT, MRI, or PET scans are utilized to ascertain any signs of metastasis.

Melanoma Treatment Protocols:

Treatment strategies hinge on the specific stage of the melanoma.

1. Surgical Intervention (The Cornerstone of Treatment)

*   Wide Local Excision: This entails removing the tumor, along with a surrounding margin of healthy tissue.

*   Lymph Node Dissection: If the melanoma has spread to the nearby lymph nodes, surgical removal is performed.

2. Immunotherapy (For Advanced Stages)

*   Checkpoint Inhibitors (they help stimulate the immune system to fight cancer):

    *   Keytruda (Pembrolizumab)

    *   Opdivo (Nivolumab)

    *   Yervoy (Ipilimumab)

3. Targeted Therapies (For Melanomas with BRAF Mutations)

*   BRAF and MEK inhibitors (these block the growth-signaling pathways in cancer cells):

    *   Zelboraf (Vemurafenib)

    *   Tafinlar (Dabrafenib)

    *   Mekinist (Trametinib)

4. Radiation Therapy

*   Radiation is used in instances when surgical excision is not viable, or post-surgery to eradicate any remaining cancer cells.

5. Chemotherapy (Less Frequently Employed)

*   Administered when other treatments are not effective.

Prevention Best Practices:

✔ Sunscreen Application (SPF 30 or higher daily, reapply every 2 hours).

✔ Tanning Bed Avoidance (tanning beds elevate melanoma risk by about 75%).

✔ Protective Clothing(hats, sunglasses, and clothes with UPF ratings).

✔ Minimizing Sun Exposure (especially between 10 AM and 4 PM).

✔ Monthly Skin Self-Checks (use the ABCDE guidelines).

✔ Yearly Dermatologist Visits (or earlier, if you detect any changes).

Key Takeaways:

*  Melanoma represents the deadliest form of skin cancer, but offers a high degree of treatability with early detection.

*  Familiarize yourself with the ABCDE indicators and conduct routine skin examinations.

* Protect yourself from UV exposure

prevention is the most crucial measure!

In the event that you observe and concerning moles, consult a dermatologist without delay!

Basal cell carcinoma (BCC)

 Basal cell carcinoma (BCC) is the most common type of skin cancer and originates from basal cells (small, round cells) in the lower part of the epidermis (outermost layer of the skin) Although BCC grows slowly and rarely spreads to other parts of the body, if left untreated it can cause significant damage to surrounding tissue.

 Causes and risk factors:

 Main causes:

 Ultraviolet (UV) light: damages the DNA of skin cells. 

 Risk factors:

1. White skin: people with fair skin, blonde or red hair, blue or green eyes are at higher risk.
2. Age: more common in older people, but young people can also get the disease if they have high sun exposure. 
3. Gender: more common in men: slightly more common in men than in women. 
4. Geographical factors: living in sunnier areas or at higher altitudes increases the risk.
5. Family history: genetic predisposition may play a role. Arsenic exposure: occupational exposure increases the risk.
6. Radiotherapy: previous treatment for other diseases increases susceptibility.
7. Immunosuppression: HIV/AIDS and drug treatment (e.g. after organ transplantation) may increase the risk. 

Symptoms :

1. Pearl-like or waxy bumps: usually develop on sun-exposed areas such as the face, neck and ears. Blood vessels may be visible.
2. Flat, scaly patches: More likely to appear on the back and chest. 
3. Non-healing sores: bleed, ooze or crust over and do not heal completely.
4. Scar-like areas: white, yellow or waxy, often with indistinct borders.
5. Dark lesions: rarely have melanoma-like pigmentation.

 Types of basal cell carcinoma:

• Nodular BCC: the most common type. Occurs as pearly, dome-shaped nodules with visible blood vessels. 
• Superficial BCC: usually appears as flat scaly plaques on the trunk. It may resemble eczema or psoriasis.
•  Sclerosing BCC: appears as scar-like, whitish areas. It is more aggressive and can be difficult to treat.
•  Pigmented BCC: contains melanin and can be brown, blue or black in color. It is often confused with melanoma.
•  Basal squamous cell carcinoma: Rare hybrid form with features of both basal cell carcinoma and squamous cell carcinoma. The risk of metastasis is slightly higher. 

Diagnosis :

1. Physical examination: the dermatologist examines the skin and records the size, shape and texture of the lesion.
2.  Dermatoscopy: a hand-held device (dermatoscope) is used to more clearly identify skin structures. 

• Skin biopsy: shave biopsy: removal of the superficial layer of the lesion.
•  Punch biopsy: a small cylindrical sample is taken. 
• Extraction biopsy: if small, the entire lesion is removed.

   3. Histopathology: The biopsy sample is examined under a microscope to confirm that it is BCC. 

Treatment options 

The choice of treatment depends on the size, location and type of BCC and the general condition of the patient.

1.Surgical options :

• Excisional surgery: the lesion is excised and healthy tissue is left intact.
• Mohs micrographic surgery: 
•  best for high-risk areas (face, ears, hands).  
•  The tumor is removed layer by layer and observed under a microscope until the cancer cells disappear. 

  Curettage and electrocautery:

• the tumour is scraped out and then cauterized to destroy the remaining cells.
•  Suitable for small, low-risk BCC.

2. Non-surgical option:

cryotherapy:

• freezing the lesion with liquid nitrogen. 
• Effective for small, superficial BCCs. 

Local treatment: 

imiquimod cream: 

• boosts the immune response to attack cancer cells.

 5-fluorouracil (5-FU): 

• chemotherapy cream that destroys cancer cells.

 Photodynamic therapy (PDT):

• uses light-sensitive drugs activated by laser light to kill cancer cells.
•  Suitable for superficial BCC. 

3. Radiotherapy: 

• used when tumors are large, recur or surgery is not an option.
•  Targeted radiation is given to destroy cancer cells.

 4. Targeted therapy: 

hedgehog pathway inhibitors (for advanced BCC): 

vismodegib (Elivedge) and sonidegib (Odomzo): 

• Oral drugs that inhibit signaling pathways important for BCC growth. 
• It is used when surgery or radiotherapy is not possible.

 Prognosis and follow-up :

Prognosis: Good if treated early. The cure rate for small, localized BCCs is over 95%. 

Risk of recurrence: Higher in patients with a history of BCC. Regular skin checks (every 6-12 months) are recommended after treatment.

 Long-term management Sun protection: comprehensive sun protection, protective clothing, avoidance of peak UV hours. Self-examination for new lesions or skin changes. 

Prevention tips :

Sunscreen:

•  use sunscreen with SPF 30 or higher every day, even on cloudy days. 
• Wear a wide-brimmed hat, sunglasses and long-sleeved clothing.

 Avoid tanning beds: 

• UV radiation from tanning beds significantly increases the risk of skin cancer. 
• Regular skin checks: do monthly self-checks and see a dermatologist once a year.

 Healthy lifestyle: 

• avoid smoking and excessive alcohol consumption.
•  Eat a balanced diet high in antioxidants.

 Key points :

• Early diagnosis and treatment of basal cell carcinoma is important to prevent extensive tissue damage and improve prognosis. 
• Sun protection and regular dermatologic check-ups can significantly reduce the risk of BCC.

Lupus

 Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease in which the immune system attacks healthy tissue, causing inflammation and damage to various organs and tissues. Lupus affects the skin, joints, kidneys, heart, lungs, brain, and blood cells. It is a complex condition with varying severity, and its cause is not fully understood. 

Types of Lupus

1. Systemic Lupus Erythematosus (SLE): -

•  The most common and severe form of the disease. 
•  It affects multiple organ systems, including the skin, kidneys, and central nervous system. 

2. Cutaneous lupus erythematosus: - 

• Primarily affects the skin

         Types include: 

•      Discoid lupus erythematosus (DLE):  may cause scarring.

•    Subacute cutaneous lupus erythematosus: red, scaly  lesions, sensitive to sunlight; 

3. Drug-induced lupus: 

       

•  caused by certain drugs (hydralazine, procainamide, isoniazid, etc.).
•  Symptoms resolve when the drug is discontinued.

 4. Neonatal lupus: - 

• Rare disease that affects newborns of mothers with lupus. 
•  May cause skin rash, liver damage, congenital heart block.

 Causes: - 

 The exact cause of lupus is unknown, but is thought to be the result of a combination of genetic, environmental, and hormonal factors. 

• Risk Factors - Gender More common in females (90% of cases). 
• Age: 15-45 years most common. 
• Ethnicity: More common in African Americans
• Heredity: Family history of lupus and other autoimmune diseases. 
• Environmental factors: 

1. sunlight (u.v light)
2. Infections (e.g., Epstein-Barr virus).  
3. Certain medications. 

•  Hormones: estrogen may be involved. 

 Symptoms:

 Symptoms of lupus are variable, with flare-ups and remissions.

 Common symptoms include:

 1. General Symptoms - 

• Fatigue. 
• Fever. 
• Weight loss or gain;

 2. Skin and hair -

• Erythema Butterfly red rash across cheeks and nose;
• Photosensitivity (photosensitivity). 
• Discoid (round, scaly) rash. 
• Hair thinning or alopecia.

 3.Joints and muscles: -

•  Joint pain, swelling (arthritis), especially morning stiffness. 

4. Kidneys: - 

• Lupus nephritis: inflammation of the kidneys that causes protein in the urine, swelling, and high blood pressure. 

5. Heart and lungs: -

•  Pleurisy (chest pain when breathing).
•  Pericarditis (inflammation around the heart).

 6. Nervous System: -

• Headaches, confusion, memory loss. 
•  Seizures or strokes

 7. Hematologic and Immune System: - 

• Anemia. 
• Low platelet or white blood cell counts.
• Increased risk of blood clots. 

 Diagnosis:

 Lupus can be difficult to diagnose because the symptoms are similar to those of other diseases. Diagnosis is based on a combination of the following: 

1. History and physical examination; 

2. Clinical examination: - 

• Antinuclear antibody (ANA) test: detects autoantibodies. 
•  Anti-dsDNA and anti-Smith's antibodies: specific by lupus. 
•  Complement levels (C3, C4): often low during disease activity.
•   Urinalysis: detects renal involvement; 

3. Imaging: - chest x-ray or echocardiography to look for heart or lung involvement;

4. Biopsy: - renal biopsy to evaluate for lupus nephritis;

 Treatment :

There is no cure for lupus, but treatment is aimed at controlling symptoms, preventing flare-ups, and reducing organ damage.

1. Medication - 

• Nonsteroidal anti-inflammatory drugs (NSAIDs): for joint pain and inflammation.
• Antimalarial drugs (e.g., hydroxychloroquine): reduce skin and joint symptoms and prevent flare-ups. 
• Corticosteroids(e.g., prednisone): Used for severe inflammation.
• Immunosuppressants(e.g., methotrexate, azathioprine): suppress the immune system. 
• Biologic therapies (e.g., belimumab, rituximab): target specific immune pathways 

2. Improve lifestyle habits: - 

•   Avoid sun exposure and use sunscreen and protective clothing. 
•  Exercise regularly to reduce joint pain and fatigue. 
•  Manage stress to prevent flare-ups. -
•  Maintain a healthy diet to maintain general health.

 3.Treatment of Organ Complications: - 

• Dialysis or kidney transplantation for severe lupus nephritis. 
•  Use blood thinners for blood clotting disorders.

Complications:

1. Organ damage: - permanent damage to kidneys, heart, lungs, or brain

2. Infections: - due to compromised immune system or immunosuppressive therapy

3. Cardiovascular disease: - increased risk of heart attack or stroke 

4.Pregnancy complications: - increased risk of miscarriage, preeclampsia, or premature delivery.

 Prognosis - 

• Mild to moderate: Most people can manage lupus effectively with treatment and lifestyle adjustments. 
• Severe cases: Aggressive treatment and regular follow-up are necessary if organ involvement is present.  
• Advances in treatment have improved lupus survival and quality of life.

    Living with lupus:

•   Establish a strong support system, including health care providers, family members, and support groups. 
• Identify symptoms and triggers and address flare-ups. 
• Stay informed about the latest research and treatments.