Definition
A.Skin cell changes that occur in the body that may be benign, precancerous, or cancerous.
Incidence
A.Actinic keratosis is the most common precancerous skin disorder that occurs in approximately 58 million Americans, which is an estimate because it is not commonly reported and/or often occurs without diagnosis.
B.Basal cell carcinoma (BCC) is the most common form of skin cancer, with approximately 400,000 new cases per year in the United States. It is often seen in the sixth or seventh decade of life.
C.Squamous cell carcinoma (SCC) accounts for 20% of all skin cancers, and it occurs mostly in the middle-aged and elderly populations.
D.Malignant melanoma accounts for less than 5% of all skin cancers. The median age at diagnosis is 61 years of age. The rate of new melanoma skin cases increased to 27.6 per 100,000 in 2008.
Pathogenesis
A.Actinic keratoses: A precancerous skin lesion commonly caused by damage to the skin that is the result of exposure to ultraviolet (UV) rays or tanning beds. If not treated, these skin lesions may turn into a form of skin cancer, such as SCC.
B.BCC: Skin lesions that result from abnormal cells of the basal layer of the epidermis that progress into the surrounding stroma and support the basal cell growth. UV rays (sunlight) are the major contributor to BCC. BCC is a slow-growing tumor that rarely metastasizes.
C.SCC: Abnormal cells of the epidermis penetrate the basement membrane of the epidermis and move into the dermis, producing SCC. This often begins as actinic keratosis that undergoes malignant change.
D.Malignant melanoma: Abnormal cells proliferate from the melanocyte system. Initially, the cells grow superficially and laterally into the epidermis and papillary dermis. After time, the cells begin moving into the reticular dermis and subcutaneous fat. Malignant tumors occur because of the inability of the damaged cells to protect themselves from the long-term exposure of the UV rays.
Predisposing Factors
A.Advanced age (older than age 50).
B.Median age of 40 years for malignant melanoma.
C.Exposure to UV light (sun exposure).
D.Fair complexion (blond or red hair, blue, green, or gray eyes).
E.Smokers (damaged lips).
F.Skin damaged by burns and/or chronic inflammation.
G.History of blistering sunburns before 18 years of age increases risk.
Common Complaints
A.New lesions found on the skin.
B.Ulcer/sore that does not heal.
Other Signs and Symptoms
A.Actinic keratosis (solar keratosis): Scaly, crusted lesions commonly found on sun-exposed skin areas such as the face, ears, scalp, lips, and hands that are usually rough in texture and appearance.
B.BCC: Tumors arising from the basal cell layer of the epidermis. Tumors may be seen on face and neck; may appear as an open sore, pink growth, or nodule that is greater than 1 cm that appears shiny, pearly in color with telangiectasia; center may cave in.
C.SCC: Skin lesions seen in sun-exposed areas of the skin, or skin damaged by burns or chronic inflammation; lower lip lesions common; firm, irregular papules with scaly, bleeding, friable surface like sandpaper; grows rapidly.
D.Malignant melanoma: Asymmetrical tumor of skin with irregular border, variation in color, greater than 6 mm in diameter; can metastasize to any organ.
E.Bowen’s disease (SCC in situ): Chronic, nonhealing erythemic patch with sharp, irregular borders; occurs on skin and/or the mucocutaneous tissue; resembles eczema but does not respond to steroids.
Subjective Data
A.Have the patient identify when lesion was first noted.
B.Ask the patient to describe any changes in size, color, or shape of the lesion.
C.Determine whether the patient has noted any new lesions.
D.Ascertain any family history of malignant melanoma.
E.Determine the patient’s history of skin exposure to the sun or any other UV rays.
F.Ask the patient about smoking history. If the patient smokes, ask how many packs per day.
Physical Examination
A.Inspect:
1.Examine skin for lesions.
2.Note surface, size, shape, border, color, and diameter of lesion.
3.Examine scalp and ears for lesions.
Diagnostic Tests
A.Biopsy suspicious lesions.
Differential Diagnoses
A.Actinic keratosis.
B.BCC.
C.SCC.
D.Malignant melanoma.
E.Solar lentigo.
F.Seborrheic keratosis.
G.Common nevus.
H.Leukoplakia.
Plan
A.General interventions:
1.Monitor progress/change of lesions detected.
2.Biopsy any suspicious lesions. Excise lesion with narrow margins, making sure to include all margins. If biopsy results of specimen are inadequate for accurate histologic diagnosis or staging, repeat biopsy. Include all clinical history information on the pathology report with the specimen when sending to pathology.
B. 
See Section III: Patient Teaching Guide Skin Care Assessment.
1.Educate patients regarding the importance of early identification of lesions and monthly assessment of skin. The U.S. Preventive Services Task Force (USPSTF) recommends counseling adolescents and young adults less than 24 years of age regarding reducing the amount of UV radiation exposure, especially between the hours of 10 a.m. and 3 p.m. In adults older than 24 years of age, the USPSTF did not find sufficient evidence to determine the effects of counseling these patients regarding the use of sun protection.
2.Instruct patients on monthly skin evaluation. Teach the ABCD
method of exam for changes in lesions: Asymmetry, Border, Color, and Diameter. A body map may be used to mark skin changes and monitor progress. Mark the site of the lesion on the body map, including measurements and date found. A body map may be found at www.skincancer.org/skin-cancer-information/early-detection/body-map.
C.Pharmaceutical therapy: None indicated.
Follow-Up
A.When a diagnosis is made, follow up according to diagnosis. Differentiate between benign skin
lesions and malignant melanoma. Follow-up/treatment depends on diagnosis (nonsurgical versus surgical removal for diagnosis). Surgical removal recommended for recurrent and suspicious lesions.
Consultation/Referral
A.Refer all patients to the dermatologist if skin cancer is suspected.
Individual Considerations
A.Geriatrics:
1.The elderly is at higher risk for skin cancer because of their decreased immune system as they age, as well as their cumulative chronic disease risk factors. Educate these patients regarding their risk factors and teach them how to assess the skin for lesions. Encourage frequent skin assessment and early diagnosis for improved outcomes.