DermHelpCentral

Skin Cancer Screening

These are the recommendations of the National Guidelines Clearinghouse taskforce on skin cancer screenings:

Very limited evidence was available to inform the following recommendations on screening. No prospective studies have evaluated the impact of screening on survival, quality of life, or morbidity from treatment for skin cancer nor are there data on the adverse effects of screening for skin cancer. As experts in the treatment and epidemiology of skin cancer, the guideline panel members were aware that some individuals are at increased risk for skin cancer because of personal characteristics or history. They reviewed key papers on risk and identified groups of patients who might be expected to benefit from increased surveillance for skin cancer. Separate recommendations are offered for two groups at increased risk (very high risk and high risk) and the general population.

Very high risk of skin cancer

• Individuals with any of the following risk factors have a very high risk of skin cancer (approximately 10 or more times the risk of the general population):
  • On immunosuppressive therapy after organ transplantation
  • A personal history of skin cancer
  • Two or more first-degree relatives with melanoma
  • More than 100 nevi in total or 5+ atypical nevi
  • Have received more than 250 treatments with psoralen-ultraviolet light (PUVA) for psoriasis
  • Received radiation therapy for cancer as a child

Individuals at very high risk should be identified by their primary health care provider and offered total body skin examination by a dermatologist or a trained health care provider on a yearly basis. They should also be counselled about skin self-examination and skin cancer prevention by a health care provider (e.g., physician, nurse practitioner, or public health nurse). In case of childhood cancer survivors, the site of radiation therapy should be monitored.

High risk of skin cancer

• Individuals with two or more of the main identified susceptibility factors are at a high risk for skin cancer (roughly 5 times the risk of the general population):
  • A first-degree relative with melanoma
  • Many (50-100) nevi
  • One or more atypical (dysplastic) nevi
  • Naturally red or blond hair
  • A tendency to freckle
  • Skin that burns easily and tans poorly or not at all

  Other factors that may influence the risk of skin cancers that are environmental include an outdoor occupation, a childhood spent at less than latitude 35°, the use of tanning beds during teens and twenties, and radiation therapy as an adult.

  Individuals at high risk should be identified by their primary health care provider and counselled about skin self-examination (specifically focused on the site of radiation for those having had therapeutic radiation) and skin cancer prevention by a health care provider (e.g., physician, nurse practitioner, or public health nurse). High-risk individuals should be seen once a year by a health care provider trained in screening for skin cancers.

The general population not at increased risk of skin cancer

• There is at this time no evidence for or against skin cancer screening of the general population at average risk of developing skin cancer.
• Based on the limited evidence available at present, routine total body skin examination by primary care providers is not recommended for individuals at average or low risk for skin cancer (i.e., those not included in the increased risk groups described above).
• Based on the limited evidence available at present, routine counselling on skin self-examination by primary care providers is not recommended for individuals at average or low risk for skin cancer.

Price of Care in the U.S.

The NY Times had a recent article on the cost of medical care.  The price of care (especially in hospitals) can vary tremendously for the same procedure. In the case below the cost of a procedure varied by a factor of 122!!

"Hospital charges are all over the map: according to the report published Monday in the Archives of Internal Medicine, fees for a routine appendectomy in California can range from $1,500 to — in one extreme case — $182,955. Researchers found wide variations in charges even among appendectomy patients treated at the same hospital."  See: "Confusion of Hospital Pricing" by Roni Caryn Rabin   

Something is definitely wrong, brah!  This is one CRAZY situation!

For the original article, see:

Hsia RY, et. al. Health Care as a "Market Good"? Appendicitis as a Case Study. Arch Intern Med. 2012 Apr 23

Diet and Dermatology

This is a helpful (free full text) reference on skin disorders that can be related to food.

Diet in Dermatology: Revisited (2010)
Kaimal S, Thappa DM
Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605 006, India

Abstract: Diet has an important role to play in many skin disorders, and dermatologists are frequently faced with the difficulty of separating myth from fact when it comes to dietary advice for their patients. Patients in India are often anxious about what foods to consume, and what to avoid, in the hope that, no matter how impractical or difficult this may be, following this dictum will cure their disease. There are certain disorders where one or more components in food are central to the pathogenesis, e.g. dermatitis herpetiformis, wherein dietary restrictions constitute the cornerstone of treatment. A brief list, although not comprehensive, of other disorders where diet may have a role to play includes atopic dermatitis, acne vulgaris, psoriasis vulgaris, pemphigus, urticaria, pruritus, allergic contact dermatitis, fish odor syndrome, toxic oil syndrome, fixed drug eruption, genetic and metabolic disorders (phenylketonuria, tyrosinemia, homocystinuria, galactosemia, Refsum's disease, G6PD deficiency, xanthomas, gout and porphyria), nutritional deficiency disorders (kwashiorkar, marasmus, phrynoderma, pellagra, scurvy, acrodermatitis enteropathica, carotenemia and lycopenemia) and miscellaneous disorders such as vitiligo, aphthous ulcers, cutaneous vasculitis and telogen effluvium. From a practical point of view, it will be useful for the dermatologist to keep some dietary information handy to deal with the occasional patient who does not seem to respond in spite of the best, scientific and evidence-based therapy.

Ladder of Sorrow

Fragmented Medical Care

I saw a young woman recently who is on isotretinoin for cystic acne and noticed a bandage on her left great toe.  I asked about this and was told that a podiatrist had removed part of the nail because it was ingrown.  Isotretinon can cause paronychia and excess granulation tissue in the nail folds and nail removal is not usually indicated in these cases.  I asked if the podiatrist knew she was on isotretinoin and both the patient and her mother said "No."

"The more complicated your medical problems, the more fragmented your care will be. The average Medicare patient sees two physicians and five specialists a year.  Those with a chronic illness see an average of 13 physicians a year. A Medicare patient with coronary artery disease sees ten physicians in six distinct practices annually. Indeed, the more physicians following someone after a heart attack, the lower the survival rates."

It is up to the patient to make sure his primary doctor (and other prescribing physicians) have all pertinent records from other providers.

An article on KevinMD summarizes this topic well:  How to Fix Your Fragmented Medical Care.

Here is a full text article that addresses hypergranulation tissue and nail problems in patients on isotretinoin.