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Medical Intel

Aug 6, 2019

Skin cancer, which often appears as brown or red spots, is the most common type of cancer in America. Dr. Sanna Ronkainen discusses the best ways to prevent it, as well as how we treat it.



Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Sanna Ronkainen, general dermatologist at MedStar Washington Hospital Center. Thank you for joining us, Dr. Ronkainen.

Dr. Ronkainen: Thanks for having me today.

Host: Today we’re discussing key ways to prevent skin cancer, which affects millions of Americans each year. Dr. Ronkainen, could you start by discussing the most common types of skin cancer you see?

Dr. Ronkainen: Absolutely. So typically, in our dermatology clinic, we see kind of three main types of skin cancer. There are basal cell skin cancer, squamous cell, and then melanoma. There are a few other more rare skin cancer types that we also treat here at this facility. However, those three are kind of the ones that dominate our interest.

Host: Could you walk us through what differentiates these common types of skin cancers?

Dr. Ronkainen: Absolutely. So, basal cell and squamous cell skin cancers we typically lump under the non-melanoma skin cancer category. And those are usually non-pigmented or non-mole-like skin cancers that can show up, usually on sun-exposed areas, that will show up kind of like a pimple that is just not going to heal or as a rough spot that bleeds easily. These are much more common in our older patient population. Melanoma is well known, I think, to most listeners. It’s a type of skin cancer that is one of the more dangerous types of skin cancers and those typically look like dark spots that come out of the cells that produce pigment called melanocytes. 

Host: Could you describe your typical patient population?

Dr. Ronkainen: Here at Washington Hospital Center we see patients from all walks of life and from the whole spectrum of ages. For patients who are coming in for skin cancer, we’ve seen everything from teens to people who are elderly. So, you know, it can really be anybody who walks through the door. Often, we’re seeing young people in their 20s for skin cancer screenings because they have a family history of either melanoma or non-melanoma skin cancers and just want to get a physician’s eyes on them to make sure that we don’t see anything concerning.

Host: What are some common risk factors for developing skin cancer?

Dr. Ronkainen: There are a few main risk factors that we think about when it comes to skin cancer. First and foremost, is UV radiation. Cumulative exposure to the sun or to tanning beds can increase your risk of skin cancers, including the worrisome melanoma type. In addition to that, as patients get older, there’s a higher risk just because of that cumulative damage. Also, if they’re more fair, that’s a risk factor. But I’ve seen skin cancers in our African American patients here in the District of Columbia, so it really can happen across the whole spectrum of how dark your skin is. Also, if you have a family history or a personal history - if you’ve had a skin cancer before - those certainly play a role. And then last, if you have had a history of a medical treatment such as radiation for an underlying cancer or if you have immunosuppression, whether that’s from a transplant or HIV, those can certainly play a role and do increase your risk of all three types of skin cancer, but particularly the squamous cell type.

Host: When it comes to preventing skin cancer, what are some key things people can do?

Dr. Ronkainen: In preventing skin cancer, sun protection is very important. Staying out of the sun between the harshest hours, between 10 and 2, during the midday is important. Wearing sun protective clothing or getting that sunscreen on can be very helpful. And also, keeping a close eye on your own skin and seeing if there’s a spot that has come up that bleeds easily or is scaly or rough or is growing - those are things to keep an eye out for. Certainly, I love going outside and exercising outside and enjoying the good weather when we have it here in the district, but just being mindful that those UV rays do add up over time is important.

Host: And, speaking of sunscreen, there are a lot of options out there. Some people prefer things like all-natural ingredients. What are some important things people should look out for when they’re picking out sunscreen?

Dr. Ronkainen: Absolutely. The number of different types of sunscreen has exploded, and every five minutes I’m hearing about a new type of sunscreen that’s come out. When thinking about what type of sunscreen to use, certainly the higher the SPF the better. However, sometimes when you’re using a higher SPF sunscreen it can come out pretty chalky and it can make you look like you’re wearing glue on your face. So, I often say that the best sunscreen that you can put on is the one that you don’t mind putting on. So, certainly testing out some different brands to figure out which ones you like is helpful. But in terms of trying to go towards all-natural ingredients or ingredients that don’t absorb into your skin, I typically tend to recommend sunscreens that have the physical blockers such as zinc or titanium or iron oxide. However, those tend to be a little bit thicker and less cosmetically appealing to patients because they don’t blend in as well as the chemical blockers.

Host:  For sunscreen, is there an SPF level that you usually recommend?

Dr. Ronkainen:  When I’m talking about sunscreens with my patients, I always recommend that they use an SPF 30 or above every day. And, typically I recommend that patients get that on in the morning as part of the moisturizer that they apply while they’re getting ready. And then, SPF 30 to 50 is typically what I recommend when they’re out being active, on vacation, at the beach, or things like that.

Host: Are there symptoms of skin cancer that people should look out for?

Dr. Ronkainen: When patients develop a spot that is new, growing, changing, is very sensitive or painful, or bleeds easily - those are signs of skin cancer. Certainly, sometimes patients will come in with a mole that’s just been irritated but rubs on the clothing or gets caught by the razor blade if it’s in the beard area, and we provide reassurance to that, but those red flag symptoms that I mentioned earlier certainly warrant just an extra vigilance of that spot. 

Host: What are some common treatment options for people who do develop skin cancer?

Dr. Ronkainen: Treatment of skin cancer depends on the subtype of skin cancer and that is a conversation between a patient and a dermatologist. However, typically most of the skin cancers that we’ve discussed today require excision, so cutting the spot out. We either do that as a conventional excision where we cut a little rim of healthy skin around the spot to cut it out completely or we send the patient for a special type of surgery called Mohs surgery. We have a Mohs surgeon here at Washington Hospital Center who is available to do surgeries like that. Very rarely, certain types of skin cancer can be treated with a topical cream. However, that decision needs to be made at the time of diagnosis.

Host:  Could you further discuss the topical skin cancer treatment?

Dr. Ronkainen:  Sometimes, when a skin cancer affects only the very top layer of skin, a topical cream can be used to treat the area. This is usually done by the patient at home over the span of several weeks, with close follow-up with the dermatologist to ensure that this spot is resolved completely with the topical treatment. Again, it does require that close follow-up to ensure that there’s nothing left over once the area is healed up. Usually, using the topical creams, the area tends to get red and inflamed, which is a sign that the cream is fighting off the skin cancer cells. Sometimes we use creams like that as a preventative measure in patients who have a high risk of skin cancers like the squamous cell-type, who have a lot of the pre-skin cancers, or sun damage, called actinic keratosis.

Host: Could you describe what Mohs is?

Dr. Ronkainen: So, Mohs surgery is a specialized type of surgery that is done by a dermatologic surgeon where the patient comes in to the clinic and has the cancer cut out with a very narrow margin. They try to spare as much of the healthy skin around the cancer as possible. The patient then waits until the surgeon is able to look at the slides, that are processed in-house, to make sure that the edges of the tissue that was taken out show no signs of skin cancer. If there is still cancer left at the edges of the spot that was taken out, then the surgeon will go back in and take out more of the skin until they know that the entire cancer is out. Sometimes it can take a little bit longer than just doing a general skin cancer surgery. However, it does spare as much of the healthy tissue around the skin cancer as possible to try and minimize any cosmetic defect there. So, it usually takes about a half a day and the patient waits in the clinic between the different stages of the surgery. However, the ultimate cosmetic result is usually very good.

Host: Could you discuss the risks of not treating skin cancer?

Dr. Ronkainen: Sure. So, for skin cancers like basal cell skin cancer, this seems to be a slow growing skin cancer that grows on the top layer of skin, which patients might be tempted to leave alone without treatment. However, it can cause a lot of discomfort as the spot continues to grow, bleeds easily after even just gently scratching the skin, and can eventually erode in to the tissue under the skin. Sometimes I’ve seen basal cells even go so deep as they go in to bone. However, things like melanoma or squamous cell skin cancer can travel to the lymph nodes and become more widespread and metastatic, which then would require systemic treatment with chemotherapy instead of just having the spot cut out.

Host: Why should people who have skin cancer seek treatment at MedStar Washington Hospital Center?

Dr. Ronkainen: We do offer comprehensive care for skin cancer here at Washington Hospital Center. It’s nice because we do have a specialized surgeon who does Mohs surgery here. We also have multiple dermatologists who feel comfortable doing general local excisions on kind of more simple skin cancers. So, it’s nice to see your own dermatologist for the procedure, that they initially diagnosed by biopsy. But also, if, unfortunately, you have an aggressive type of skin cancer, such as a more invasive melanoma, we do have the ability to work with our colleagues in general surgery or oncology or radiation oncology to optimize a multidisciplinary form of care.

Host:  Could you share a patient story of someone who came in with a minor skin condition, or what they perceived as minor, and ended up needing serious treatment?

Dr. Ronkainen: Sure. I’m thinking of one patient in particular who came in for a spot on his back that was just a rough, raised growth that caught easily on his clothes. And on evaluation of that spot, we realized that it was a benign seborrheic keratosis, which is just a benign warty growth that tends to come up with patient’s age. However, when we were examining the patient, we happened to notice a dark spot very close to that that the patient had not noticed because, again, it was on his back so that he couldn’t see it, that ended up being a melanoma. Thankfully, we were able to get a biopsy of the melanoma early enough and we were able to excise it and we were able to treat it completely without it causing him any further grief other than causing a scar from the surgery. But thankfully we caught it early.

Host: Thanks for joining us today, Dr. Ronkainen.

Dr. Ronkainen: Thanks for having me.

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