Benign Skin Growths and Spots

During my dermatology elective, I encountered countless patients who were concerned about growths on their skin that were, in fact, harmless and very common. There are thousands of lesions that can appear on the skin, but here I will discuss a few of of the most commonly seen benign skin spots and growths. I will also discuss what kind of changes to be cautious of when examining growths and moles. When in doubt, consult with your dermatologist.

Brown Spots

1.freckles-boy-flickr-NoSpareTime Freckles (“Ephelides”): these small, flat light-brown spots are small, multiple, and irregularly shaped. They appear in childhood, darken during the summer months, and lighten during the winter months (waxing and waning in response to sun exposure). They are due to a local, superficial accumulation of melanin, the protein the gives pigment to our skin and protects us from the sun. They are more common in lighter-skinned individuals who sunburn more easily. Sometimes these fade with age. The best way to avoid new freckles is by good sunprotection.

2. “Solar lentigos” (aka liver spots, age spots, or sun spots): these brown spots appear similar to freckles, but have sharper margins and sometimes stand alone. They can be found on the backs of hands, the shoulders, and the head and neck of adults. They are caused by sun damage acquired over time, but their appearance is persistent (they do not darken or lighten with the sun, or with time). They are due not only to a local accumulation of melanin, but also to a local increase in the cells that produce melanin (“melanocytes”). Some consider them to be flat versions of seborrheic keratoses (see below). Though not harmful, they can be treated for cosmetic reasons with freezing (“cryosurgery”), chemical peels, or certain lasers.

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3. Café-au-lait spots: these light-brown “macules” (flat, smaller than 0.5cm) and “patches” (flat, greater than 0.5cm) appear within the first year of life. They are due to a local increase in melanin. If a child has greater than 5 café-au-lait spots >1.5cm, they should be tested for syndromes such as neurofibromatosis.

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3. Junctional nevi: these darker brown, sharply bordered, flat lesions are a type of mole (“nevi” = mole). Moles have specific features under the microscope. They do not need to be removed unless there are features concerning for melanoma (see the ABCDE rules below). Removal is by cutting them out (“excision”); be mindful that excisions leave scars.

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*There are many types of flat and elevated moles. Some have more pigment, and some are skin-colored. We will discuss at the end how to monitor moles.

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Signs of Wisdom – seen more commonly in people age 30+

1. Seborrheic Keratoses (SKs): sometimes referred to as barnacles, these light tan to dark brown waxy growths appear to be “stuck on” to the skin, as if they could be peeled off with your fingernail. They have a rough, warty surface, and they can grow up to 1” (2.5cm) in width. SKs are caused by skin cells from the top layer of the epidermis (“keratinocytes” in the “stratum corneum”) sticking together. Some think they may be related to sun exposure. There is no need to remove these growths, as they are completely harmless, but if they become irritated or cosmetically undesirable, they can be removed by freezing (“cryotherapy”), burning with an electric current (“electrocautery”), or scraping.

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2. Skin Tags: these smooth, fleshy growths hang on to the skin by a little stalk. These are commonly acquired in areas of friction. Though they are harmless, if irritated or undesired they can be removed by snipping with scissors or freezing.

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3. Cherry angiomas: the cherry-red raised round bumps (“papules”). They often start out flat and become dome-shaped. They are caused by an abnormal growth within capillaries, the smallest blood vessels. In the rare case that the patient desires removal, they can be burned off with electrocautery or zapped with a laser.

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Monitoring moles and other growths and spots:

One of the most important rules of thumb in screening for melanoma is the ugly duckling sign: spotting the mole or growth that does not look like the others. A lesion is often not concerning if you have others that look like it on your body.

Monitor your moles by following the ABCDEs. The most important of these is E – EVOLVING—if you notice any change in your moles, or any appearance of new moles, mention this to your dermatologist during your check-up. [*Make note that even benign moles can grow. Not all change is melanoma.]

A – ASYMMETRY: if your mole has become uneven or asymmetric, have it looked it.
B – BORDER: benign moles have nice, regular borders. Dangerous moles have irregular borders.
C – COLOR: benign moles usually have only one color. Dangerous moles can have two or more.
D – DIAMETER: benign moles are usually smaller than a pencil eraser (<6mm).
E – EVOLVING: changes in your moles or the appearance of new moles should prompt examination.

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Sunprotection

Summer is upon us, and that means fun in the sun!  Let’s remember to be safe and smart, taking measures to prevent sunburn in the short-term, and skin cancer, premature aging, and unsightly discoloration in the long-term.

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Everyone, regardless of skin tone, is susceptible to the harmful effects of the sun’s rays. People with lighter skin types who burn easily should be especially cautious.

Ultraviolent (UV) radiation (290 to 400 nm) causes skin damage. Within that spectrum, UVB (290 to 320 nm) is responsible for sunburn (“B” for “burn”), inflammation, skin discoloration, and cancer formation. UVA (320 to 400 nm) is responsible for photoaging (“A” for “aging”), skin darkening, and possibly cancer formation.

The UV Index, on a scale of 0-11, is a forecast of how risky the sun exposure is that day, and is calculated by zipcode here or here. Read this or this to learn how to interpret the UV index.

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To protect your skin against UV radiation:

A)   Avoid the sun during peak hours: stay inside or seek shade between 11 am and 3pm. This is especially important at latitudes closer to the equator.

B)   Wear sun protective clothing:

  1. Sunglasses: Look for lenses that block 99-100% of UV rays. UV rays can lead to eye damage including cataracts, macular degeneration, photokeratitis (“sunburn of the eye”). For more: Mayo Clinic, All About Vision.
  2. Hats: especially wide-brimmed.
  3. Long-sleeve garments: Fabrics are rated on their ultraviolent protection factor (UPF).

C)   Apply sunscreen: these contain filters that reflect or absorb UV rays. They fall into two categories: organic (aka chemical), or inorganic (aka physical).

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Here are some tips for finding and using sunscreen:

1)   Look for “broad-spectrum” on the label: these protect against both UVB and UVA. Make sure it contains at least one of the following in the ingredients list: avobenzone, zinc oxide, or titanium dioxide.

2)   Look for SPF 15 or above, per the FDA (but better 30 or higher). When enough sunscreen is applied, SPF 15 will absorb about 93% of UV radiation; SP 30 will absorb 97%, and SPF 50 98%.

3)   Apply daily, even on a cloudy day. Keep your sunscreen of choice next to your toothbrush so you apply it as part of your morning routine.

4)   Look for cosmetics or lotions with SPF15+. Choosing a moisturizer or a foundation with SPF to use as your daily sunprotective product may help you stick with your sunscreen routine.

5)   Apply 15-30 minutes before going out in the sun. This allows a protective film to form on the skin.

6)   Apply sunscreen liberally before outdoor activities to all sun-exposed areas. For the average adult, this means applying 1 oz (30mL), or one shot glass full.

7)   Reapply often: at least every two hours when out in the sun. Reapply after swimming, water sports, or sweating.

8)   Look for water-resistant sunscreens for days you will be in the water. Continue to reapply, however, after each swim.

9)   If you have sensitive skin, inorganic or physical sunscreens may be best for you, as they are less irritating. These contain mineral compounds such as zinc oxide and/or titanium dioxide. These products are also preferred for use in children.

10) Find the form you are most likely to use. Sunscreens come in a variety of forms: creams (greasier, thicker), lotions (thinner), liquids, sprays, gels, roll-on sticks. Find the vehicle that works for you. The best sunscreen is the one that you will use.

Vitamin D: Some people are concerned that they will not produce enough 25-hydroxyvitamin D if they do not get enough sun. Vitamin D, however, is readily available in certain foods (milk, fortified juices, salmon) or in supplement form. Vitamin D insufficiency is a common problem, but the safest way to combat it is by taking a daily supplement.

Thanks for reading, and enjoy your summer!

-Alex

 More links: Consumer info on Sunscreens, Teacher Resources, SunSmart Australia

References:

Baron ED, Elmets CA, Corona R. Selection of sunscreen and sun-protective measures. UpToDate April 01, 2014. Accessed May 13, 2014.

Young AR, Tewari A, Dellavalle RP, Danzl DF, Corona R. Sunburn. UpToDate May 01, 2014. Accessed May 13, 2014.

HPV: Could It Happen To You?

This article was originally published by The Cornell Daily Sun on February 14, 2014. Some changes have been made to this version.

A 25 year-old woman comes to clinic for her routine Papanicolau (Pap) smear during my ob-gyn rotation. A few days later she receives a phone call from the gynecology resident. “Your Pap smear results were abnormal,” the doctor told her, “and we would like to take a biopsy of your cervix, which we do under an exam called a colposcopy.” She is told that this abnormality was caused by a strain of the human papillomavirus (HPV), the same virus family that causes common warts.

“HPV?” she asks, “isn’t that a sexually transmitted infection?”

“It is, in fact it is the most common STI in the US.”

“I didn’t think that I was at risk for HPV… I have not had many partners… and we almost always use protection… and I think maybe I was vaccinated… Does this mean I’m going to get cancer?”

The patient expressed a flurry of questions. She was quite surprised and distressed. She did not know that she could be among the 20 million Americans, male and female, aged 15-49 currently infected with HPV. Seventy-four percent of those infections occur in the 15-24 age group.

Nearly all sexually active people will become infected with one of the many strains of HPV at some point in their lives; half become infected within three years of becoming sexually active. Some strains are high-risk, or potentially cancer-causing, and some are low-risk, or wart-causing. Most HPV infections will not cause symptoms or problems, and they will become undetectable within 6-24 months. Among women with high-risk HPV infection of the cervix, the infection will be persistent in 10%, putting the patient at risk of developing dysplasia, or precancer, that, if left untreated, could progress to cancer. Cervical cancer is currently the third most common cancer in women, and 99.7% of cervical cancer is caused by HPV. Both males and females, regardless of sexual orientation, are susceptible to developing dysplasias and cancers of the anogenital region. HPV has also been associated with head and neck cancers and some skin cancers. Looking at cancer as a whole, approximately 5% of all cancers in men and 10% of all cancers in women are caused by HPV.

There is no cure for HPV infection. The best strategies are prevention and early detection. Vaccination with Gardasil or Cervarix can prevent infection with HPV types 16 and 18, which are responsible for 70% of cervical cancer. Gardasil also provides protection against HPV types 6 and 11 which cause anogenital warts. Gardasil has been approved for use in both females and males ages 9 to 26, and is ideally given before the start of sexual activity (i.e. before exposure to HPV), so it is commonly administered prepubertally (eg. age 11-12). Even if you are already sexually active, vaccination is recommended. On the other hand, even if you plan to abstain and become monogamous for life, if your partner has ever had another sexual partner, you could still be at risk for acquiring HPV. Furthermore, HPV can be transmitted by genital contact besides intercourse. Vaccination should be a consideration for all young people, because everyone who will eventually become sexually active will most likely be exposed to at least one strain of this ubiquitous virus.

Because vaccination does not cover all strains of HPV, regular Pap smears are recommended in women aged 21 and over regardless of vaccination status. With a Pap smear your doctor can collect a sample of cells from the cervix and upper vagina to analyze under the microscope. This test can detect precancerous cells, prompting further intervention in order to diagnose dysplasia and prevent the progression to cancer.

So, what are some ways to protect yourself against HPV?

1. Get vaccinated if you are under 26, regardless of gender, sexual orientation, and sexual activity. Then,

2. Get Pap smears regularly if you are a female, starting at age 21. Your doctor will let you know how frequently you should be screened. Currently most women with a negative Pap smear at age 21 only need screening once every three years.

3. Use condoms consistently. Condom use reduces the risk of HPV infection and disease progression. Condoms are not, however, a perfect protection against HPV. Condom use is important to prevent against other STIs including HIV and chlamydia, two infections that have serious consequences in their own right, and that make HPV more likely to remain persistent.

4. Consider your number of partners: HPV prevalence increases nearly linearly with increasing number of lifetime partners, despite condom use. Furthermore, infection with multiple high-risk HPV types increases the risk of high-grade precancerous lesions.

5. Don’t smoke: Smoking is a risk factor for persistent infections.

If, after taking appropriate precautions, you find yourself with an HPV-related concern as the patient described did, remember that:

1) You are not alone. The volume of patients seeking care for HPV-related concerns, particularly cervical dysplasia, is quite large. On my ob-gyn rotation, four afternoons per week were dedicated to cervical dysplasia: one to Pap smears and three to colposcopy. I have also seen patients presenting to dermatology for genital warts and for HPV-related skin cancers and precancers of the penis.

2) About 90% of infections become undetectable without further intervention. Therefore, your infection will most likely not remain persistent, and you will most likely not develop an HPV-related cancer. Make healthy choices for your body and mind, and live your life.

References: