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Melanoma And Other Skin Cancers: Being SunSmart

Medically reviewed by Carmen Fookes, BPharm. Last updated on July 12, 2022.

Vote For The Sun Or For Your Skin?

Never understimate how bad the sun can be for your skin. The more sun exposure you have, the more damage you do. Being sun aware - all day, every day, pays off in the long term.

Those who love swimming outside need to take particular care. The suns rays are amplified in an aquatic environment, significantly increasing the level of skin damage that can happen. The more you can do to protect your skin from direct sunlight the better. Swimming early in the morning or late evening means you avoid exposing yourself to the sun when it is at its hottest.

Always apply sunscreen 20 to 30 minutes before going outside or getting in the water and reapply after toweling off since the towel wipes away most of the sunscreen. Better still, wear UV protective clothing in the water to really keep your skin safe.

UV Rays Destroy Supportive Connective Tissue

Our skin is made up of three layers. The epidermis is the outermost layer and contains mainly keratin, which acts as an insulating, waterproof shield. The middle layer, or dermis, contains a network of collagen and elastin fibers that provide strength and elasticity. The subcutis, or base layer, includes a seam of fat to insulate us and cushion our body from knocks and falls.

Ultraviolet radiation from the sun breaks down collagen and elastin fibers in the dermis destroying this supportive tissue, leading to sagging, loose skin, creases and wrinkles.

Skin Cancer: Common. Sometimes Deadly. Mostly Preventable.

Skin cancer is the uncontrolled growth of abnormal skin cells. Our skin cells are constantly regenerating. In fact, we shed almost 30,000 to 40,000 skin cells an hour. But damage to DNA contained within the skin cell can accelerate this rate of division exponentially - and this out-of-control replication is what leads to the formation of malignant tumors.

Basal and squamous cell carcinomas are the most common type of skin cancer, with over 3.3 million Americans diagnosed with one or more of these skin cancers every year. Melanoma is not as common, with an estimated 197,700 Americans expected to be diagnosed in 2022. But melanoma is much more deadly.

Basal Cell Carcinomas (BCC)

BCCs are the most common type of skin cancer, making up around 80% of all skin cancers. BCCs arise in the skin’s basal cells, which line the deepest layer of the epidermis (the top layer of the skin). They often look like open sores, pink growths, shiny bumps, red patches or scars.

BCCs do not usually metastasize (spread) to other parts of the body, although they can be disfiguring if left untreated. Most BCCs develop on sun-exposed areas of the skin, like the face, ears, neck, lips, and the backs of the hands.

Squamous Cell Carcinomas (SCC)

Squamous cells are flat cells that lie in the outer part of the epidermis. These are constantly shed as new squamous cells form.

About 2 out of every 10 skin cancers are SCCs and most are caused by UV radiation. They are usually slow growing, tender, scaly or crusted lumps, and vary in size. Like basal cell carcinomas, SCCs are more likely to develop on sun-exposed areas of the skin. People who smoke, with a history of thermal burns, with longstanding leg ulcers, or taking immunosuppressants such as cyclosporine or azathioprine are more likely to develop more serious, invasive, SCCs.

Most small SCCs that are found early can be cured with early treatment such as surgery. Rarely, some may spread to lymph nodes or distant parts of the body. In these cases, treatments such as radiation therapy and/or chemotherapy may be needed. Cemiplimab (Libtayo) was approved in 2018 for cutaneous SCC that has spread to other parts of the body or cannot be treated with radiation or surgery and may be considered.

Melanoma: When A Mole Isn't A Mole

Melanomas come in all shapes and sizes but most tend to have the following five features in common (known as the ABCDE's).

  • An Asymmetrical shape
  • An irregular Border
  • A varied or uneven Color
  • A Diameter usually greater than 6mm
  • A history of Evolving: the lesion is different than before.

Not all melanomas will behave this way. Bottom line: if you are unsure about any freckle, mole, or sunspot...get it checked!

Why Are Melanomas So Deadly?

Melanomas originate in the pigment-producing cells (called melanocytes) located in the epidermis. They often resemble moles and some develop from moles.

Unlike BCCs and SCCs, melanomas tend to be invasive and can quickly spread to other parts of the body, such as the lungs, liver, lymph nodes, bones and brain.

Visit your physician every year for a skin cancer check, and check yourself and your family members head-to-toe every month. Catching melanoma early might save the life of someone you love! It might even save you!

Not Melanoma: But A Warning Sign

There are other spots you should be aware of that are considered precancerous or an early form of skin cancer. Talk with your physician if you notice:

  • Actinic keratosis: Small, rough, scaly, flaky areas of dry skin, also known as solar keratosis. Common on the backs of the hand, nose, scalp, tops of the ears, forehead, and lips.
  • Bowen Disease: Irregular, flat, red patches of skin, several centimeters in diameter, less scaly than actinic keratosis.

Early Treatment Saves Lives

Basal cell carcinomas, squamous cell carcinomas and precancerous lesions can easily be treated when found early. Treatments include:

  • Topical creams or cryotherapy (liquid nitrogen) to freeze off the lesion
  • Curettage and electrodesiccation: removal of the lesion with a sharp instrument
  • Mohs Surgery: lesion is removed layer by layer and examined
  • Excisional surgery: Entire growth removed plus a safety margin
  • Radiation: X-ray beams destroy the lesion
  • Photodynamic and laser therapy

Topical Treatments

Some cancerous lesions may be treated with topical medications.

Imiquimod (Aldara, Zyclara) activates the immune system, causing it to produce interferon, a chemical that attacks the cancer. The cream is rubbed on the lesion five times a week for up to six weeks and cure rates are usually 80-90%. Redness and irritation may occur.

Topical fluorouracil (Carac, Efudex, Fluoroplex) has similar cure rates to imiquimod. It is used twice a day for three to six weeks. It causes a vigorous skin reaction that may ulcerate.

Odomzo: Noninvasive Treatment For Locally Advanced BCC

Although BCC rarely becomes advanced, when it does it can be highly disfiguring. Sonidegib (Odomzo) offers another treatment option for adults with locally advanced BCC who are not candidates for surgery or radiation therapy, or where the BCC has recurred following surgery or radiation therapy.

Odomzo is an oral treatment that has been linked to birth defects so precautions against pregnancy should be taken when used by people of child-bearing age. Common side effects that may be experienced include muscle pain or spasm, alopecia (hair loss), dysgeusia (foul, salty, or metallic taste in the mouth), fatigue, nausea and diarrhea.

Option For Rare Invasive BCC

Vismodegib (Erivedge) became the first oral medicine approved for very rare, life-threatening metastatic or advanced basal cell carcinoma (BCC) in 2012. It works by blocking a signaling pathway which is a key step in the development of BCC but can only be used if other treatments (surgery, radiation therapy) are not an option.

Erivedge is very expensive (over $13,000 per month). It can cause birth defects so must not be used by pregnant women. Women who are capable of becoming pregnant should also use birth control.

Melanoma Treatment: Depends On Stage And Location

For melanomas that have not grown deeper than the epidermis (stage 0), localized surgery to remove the lesion and a safety margin of skin around it is usually effective.

For stage I to II melanomas, examination or removal of the lymph nodes may be necessary in addition to removal of the melanoma. Interferon or vaccines (as part of a clinical trial) may also be recommended for melanomas at stage Ib or above. Interleukin-2, radiation therapy, imiquimod cream, or other therapies may also be considered if the melanoma has already reached the lymph nodes and is considered stage III.

Stage IV melanomas can be extremely hard to cure. However, biologics have made significant progress in melanoma treatment. Clinical trials have shown immunotherapy drugs such as nivolumab (Opdivo), ipilimumab (Yervoy), and pembrolizumab (Keytruda) all impact on tumor size in the majority of people and help extend survival; however, side effects may interfere with treatment.

In March 2022, the FDA approved Opdualag injection, which is a combination treatment that contains 2 types of immune checkpoint inhibitors, the PD-1 inhibitor nivolumab (Opdivo) plus the novel LAG-3 inhibitor relatlimab-rmbw, for adults and children aged 12 years of age or older with melanoma that has spread or cannot be removed by surgery.

Targeted Therapies: BRAF Gene

Changes in the BRAF gene have been detected in almost half of all melanomas.

The BRAF gene makes a protein that is part of a signaling pathway which controls several important cellular functions, such as cell growth and function, cell movement, and cell death. BRAF is a type of oncogene that if mutated, has the potential to cause normal cells to become cancerous.

Some newer drugs are designed to target this gene change. Examples include cobimetinib (Cotellic), dabrafenib (Tafinlar), trametinib (Mekinist) and vemurafenib (Zelboraf).

These drugs may be tried before or after immunotherapy drugs such as ipilimumab (Yervoy) and pembrolizumab (Keytruda), although they are not used at the same time. Research shows these drugs help extend the life expectancy of some patients with advanced melanoma.

In 2018, the FDA approved the use of encorafenib (Braftovi) and binimetinib (Mektovi) in combination to treat advanced melanoma. Encorafenib blocks BRAF, while binimetinib blocks another molecule, called MEK, that receives signals from BRAF. This combination approach is more effective than using either drug alone to stop the growth and spread of melanoma cells.

Tecentriq (atezolizumab) is another option that may be given to treat people with unresectable or metastatic melanoma that has tested positive for a BRAF V600 mutation. It is used in combination with cobimetinib and vemurafenib.

Targeted Therapies: C-KIT Gene

Changes in the C-KIT gene have been detected in a small number of melanomas. C-KIT is a protein that binds to another substance, causing certain types of blood cells to grow. On some types of cancer cells it is found in higher than normal amounts, or in a mutated form.

Drugs that target the C-KIT gene, such as imatinib (Gleevec) and nilotinib (Tasigna) may help treat some people with advanced melanoma.

Virus Therapies

In October 2015, the FDA approved talimogene laherparepvec (Imlygic), for the treatment of melanoma lesions in the skin and lymph nodes.

Imlygic was developed by genetically modifying the herpes simplex type 1 virus (HSV-1), a virus normally responsible for causing cold sores. Imlygic is injected straight into a person's tumors and works by directly attacking cancer cells and also by secreting a substance that stimulates the immune system. The virus has been modified to such an extent that it no longer causes cold sores and is very selective for cancer cells.

Imlygic may be used to treat inoperable melanoma lesions, and 16% of participants in one study experienced a significant decrease in the size of their skin lesions. However, Imlygic does not improve overall survival and is not effective for metastatic melanoma.

Newly Approved Bavencio Fills Treatment Void For Merkel Cell Carcinoma

Merkel cell carcinoma (MCC) is a rare type of skin cancer that is more likely to develop in older people. It usually appears as a blue or flesh colored nodule on the face, scalp, or neck. MCC grows fast and quickly spreads to other parts of the body. People with a history of long-term sun exposure or a weakened immune system are more at risk of MCC.

Up until now, treatment of MCC relied on surgery, radiation therapy and/or chemotherapy. In March, 2017, Bavencio (avelumab) became the first drug to be approved for metastatic MCC in adults and children over the age of 12. Bavencio helps stimulate the immune system to attack cancer cells. In one trial, a third of people with MCC experienced complete or partial shrinkage of their tumors. Side effects include tiredness, muscle pain, diarrhea, nausea, rash, a loss of appetite and peripheral edema (a swelling of the limbs). There is also a risk of precipitating immune-mediated reactions (where the immune system attacks healthy organs) and some serious infusion-related reactions.

Know Your Risk: It's In Your Genes

Your skin type is one of the main factors in your level of risk for skin cancer. People with very fair skin and light-colored eyes are extremely susceptible to skin damage and skin cancers like basal cell carcinoma or squamous cell carcinoma. But even darker skinned people are not immune. One of the most virulent forms of melanoma, Acral lentiginous melanoma, is more common among darker-skinned people.

Your risk is also increased if you have a family history of skin cancer or if you have been treated for skin cancer before.

Skyrocketing Risk With Sunburn And Abnormal Moles

Every time you get sunburned you increase your chance of developing skin cancer. Sunburned at least five times? Double the risk of melanoma.

Being outside frequently or living at a higher altitude also puts you at an elevated risk. Skin cancers are also more likely in people with actinic keratosis, with lots of moles, or a specific type of mole called dysplastic nevi. Dysplastic nevi are irregular in shape, generally larger than normal moles, and more likely to become cancerous.

Be Sun Smart And Cancer-Free

Always be sun-smart when outside.

  • Seek shade between 10 AM and 4 PM.
  • Never allow yourself or your child to get sunburned.
  • Avoid tanning beds.
  • Wear UV protective clothing and sunglasses.
  • Use a broad spectrum (UVA/UVB) sunscreen (SPF 30 to 50+), even in the winter.
  • Apply sunscreen liberally, 30 minutes before going outside, reapply every 2 hours.
  • Keep babies under 6 months out of the sun.
  • Get your skin checked yearly.

Finished: Melanoma And Other Skin Cancers - Being SunSmart

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