• Melanoma is increasing more rapidly than any other type of cancer
• High risk groups, such as patients with familial melanoma syndrome, chronically immunosuppressed, and those who have had high sun exposure and have fair skin, should be monitored closely for cutaneous malignancy
  Early diagnosis can be life-saving because while skin cancers have a much lower rate of mortality compared with other cancers, late stage skin cancer is extremely devastating
• Risk of recurrence or metastasis depends on whether a tumor is low or high risk
• Prognosis for less invasive lesions is far better than those with greater invasion
• Skin cancer has a tremendous impact on our society. Although it is not one of the more deadly cancers, it has become one of the most costly. The total cost of Medicare expenditure on cancer management was $13 billion per year. Skin cancer is one of the top 5 most costly cancers (including lung/bronchus, prostate, colon/rectum and breast)

How can you tell if something is suspicious?
Your physician will look at your skin during a complete physical examination but it is important for you to point out things that are new or have changed. A "freckle" that has been present for a long time and "suddenly changes" is of much more concern than a darkly pigmented congenital mole that has been present since birth and has not changed. Although some skin cancers bleed, the vast majority do not. If someone in your family has had skin cancer or if you have had a significant amount of sun in your life, your physician should know. Also, people on certain medications need to know about their risk factor for skin cancer. An abundance of moles is also an independent risk factor for the development of melanoma. It is advisable to have a dermatologist perform an examination on any high risk patient.
Basic Skin Examination
In performing a skin self examination, it is important to be systematic. Start with the face: carefully examine the entire skin surface, including the scalp, ears, neck. Skin cancer occurs with high frequency on the scalp and ears for men. A thorough skin examination includes the genital and mouth surfaces

1. Actinic keratosis is a pre-malignant lesion which can often be mistaken for dry flaky skin. Patients with many of these have a higher tendency to develop non-melanoma skin cancer
2. Basal cell carcinoma occurs in many forms and types. Typically, it is a pearly lesion that occurs on sun exposed skin. The majority have very faint blood vessels on the skin surface
3. Squamous cell carcinoma can be flaky, like the actinic keratosis, but usually has more substance to the tumor

1. Freckles tend to occur on lightly pigmented individuals and are an indication of significant sun exposure. They tend to be very bland and small in size. Any freckle that is unusual in shape, size, or varied in pigment color should be closely evaluated
2. Benign moles (nevi) are extremely common and include lesions that have non-variegated color and border. Any benign nevus can change to become a more serious malignant nevus or melanoma, so careful examination by your doctor is necessary

1. An atypical mole is a possible concern and should be followed by a dermatologist
2. There are many forms of melanoma. A safe guideline for primary care physicians is to use the ABCD criteria: A: Asymmetry B: Borders- are they irregular? C: Color-is it strange or multicolored? D: Diameter- is the diameter increasing or large in size? If a lesion meets any of the ABCD criteria, further evaluation is warranted
   
   A: Asymmetry
   B: Borders- are they irregular?
   C: Color-is it strange or multicolored?
   D: Diameter- is the diameter increasing or large in size?
   If a lesion meets any of the ABCD criteria, further evaluation is warranted

• Sun Avoidance: It is important to educate patients regarding the harm the sun can cause. Generally, it is best to avoid direct sunlight from the hours of 10 a.m. to 2 p.m.
• Sun Protective Clothing: There are several lines of clothing that are effective at blocking the damaging rays of the sun. This is particularly advisable for those who enjoy several hours of outdoor activities daily. Many clothing lines offer lightweight and breathable fabrics that have SPF up to 50.
  Some examples found online are:
  www.solumbra.com
  www.sunstoppers.com
  www.sundayafternoons.com
  www.tilley.com
  www.coolibar.com
  www.sunsolutionsclothing.com
  www.radicool.msp-direct.com & www.traseusa.com
• Sunscreen: There are several types of sunscreen. The most effective sunscreens block both the A and B types of ultraviolet light

What are sunscreens and how do they work?
Sunscreens are chemical agents that prevent the sun's ultraviolet radiation from reaching the skin. Two types of ultraviolet radiation, UVA and UVB, cause damage to the skin. Until recently, most sunscreens have only blocked UVB, however a number of UVA blocking products are now available. When applied regularly, and skin cancers. They work by either absorbing or reflecting ultraviolet radiation, thereby preventing damage to the skin.

SPF, or sun protection factor, is a measure of a sunscreens' ability to prevent UVB from reaching the skin. In practical terms, one SPF is the amount of time a person can spend in the sun before developing a sunburn. Each increased SPF level increases the time that an individual can spend in the sun by one SPF. As an example, by applying an SPF 15 sunscreen, an individual who would get a sunburn in 10 minutes without any sunscreen, can spend 150 minutes in the sun without getting burned.

We recommend daily use of sunscreen, applied to all exposed areas of skin, for anyone over the age of 6 months, regardless of their skin type and likely sun exposure. Even those who work inside are exposed to ultraviolet radiation for brief times throughout the day. Also, UVA is not blocked by most windows. For children under 6 months of age, most doctors advise clothing and shade as the primary means of protection from the sun. For children in the age group, sunscreens should only be applied in cases of prolonged exposure and should be applied sparingly only to exposed areas of skin.

The answer depends on how much sun exposure one is anticipating. In all cases we recommend a broad spectrum sunscreen, which means it blocks both UVA and UVB. Most sunscreen agents block either UVA or UVB and therefore must be combined in order to get broad spectrum protection. In the United States there are a large number of sunscreens available as spray-on products and lotions.

The only single broad spectrum agents available in the U.S. are titanium oxide and zinc oxide. Both products, depending on the formulation, tend to leave a white film residue on the skin, which limits their popularity. Newer sunscreen agents such as Mexoryl and Tinosorb are available internationally in a variety of sunscreens. These are single agents (though often combined with other sunscreen agents) with broad spectrum protection, and excellent cosmetic appeal, but neither has been approved in the United States. Many make-up products and moisturizers have a sunscreen (usually SPF 15 or greater) already in them, and this is sufficient for people that spend little time in the direct sun. For people that work outside or spend significant time outdoors, we recommend a sunscreen that is broad spectrum, at least a SPF 15, and "water-resistant" or waterproof." The "water-resistant" and "waterproof" products are also less likely to drip into the eyes,which makes them ideal for people wearing a sunscreen on hot days or while they are perspiring. Sunscreens used regularly on the face should be non-comedogenic (which means they will not clog the pores) because products not designed for the face can actually cause or worsen acne.

People who will be sweating heavily or spending time immersed in water should use "water-resistant" or "waterproof" sunscreens, but even these must be reapplied (see directions on bottle for specific time suggestions). Sunscreens are only one part of protecting yourself from the sun; consistent use of sunglasses, wide-brimmed hats, long-sleeves and pants, umbrellas, and other sources of shade are critical behaviors to obtain more complete sun protection.

The tests done to determine a sunscreen's SPF require 1 oz to be applied over the entire body. Most studies show that people apply only half to a quarter of that amount, which means the actual SPF they have on their body is lower than expected. During a long day at the beach one person should use essentially 1/2 to 1/4 of a standard 8oz bottle. Sunscreens should be applied 15 to 30 minutes before sun exposure.

Because some sunscreens are actually broken down by the sun and/or washed off by sweat/water, the SPF of sunscreens decreases with time and reapplication of a sunscreen is critical. There are no studies that show the best schedule but every 2 to 3 hours is probably adequate if one is not immersed in water or sweating profusely.

• Wearing sunscreen can cause vitamin D deficiency. Fortunately this is not true. For patients that are still concerned about vitamin D deficiency there are excellent dietary supplements available.
• If it's cold or cloudy outside, I don't need sunscreen. This also is not true. Up to 40% of the sun's ultraviolet radiation reaches sea level even on a completely cloudy day. This misconception often leads to the most serious sunburns, because people spend all day outdoors with no protection from the sun.