Skin Cancer and Wound Healing

Skin cancer is the most common cancer, with basal cell carcinomas (BCC) being the most frequent type. These tumors often appear on sun-exposed skin as pearly-pink, translucent, fragile nodules, frequently accompanied by telangiectasias (thread-like surface blood vessels). They may develop surface erosions or ulcerations. Basal cell carcinomas are typically excised or curetted locally, with larger lesions or tumors, especially on the face, removed using Mohs microsurgery. This technique preserves surrounding skin through sequential removal and microscopic examination of tumor layers.1 TYPES AND VARIANTS OF BCC Some BCCs are more aggressive than the 3 usual subtypes: nodular lesions, superficial, and pigmented variants. Neglected cases and the diffuse infiltrating morpheaform variants can be more challenging to treat.1 In this issue of Advances in Skin & Wound Care, Anjie Ge and colleagues present a case of a large and deep BCC on the posterior shoulder and scapular region (18 × 16.5 cm lesion). This deep lesion required treatment for secondary infection. ADVANCES IN BCC TREATMENT Recently, vismodegib, an oral Hedgehog signaling inhibitor, has become available for treating skin cancers not amenable to surgical removal. This drug shrunk the case report patient’s BCC size by inhibiting the Smoothened receptor. The treatment was combined with radiation to further decrease tumor size prior to surgical resection. Early presentation and treatment could have allowed excisional surgery for this patient. Only 1-10% of patients with BCC have locally advanced lesions that cannot be managed with usual surgical management.1 The case report patient experienced several physical disabilities due to the extent of the surgical procedure to remove the tumor. Basal cell carcinomas can be locally invasive (especially to bone) but do not usually metastasize to distal sites. ADDITIONAL SKIN CANCER CASE STUDIES There are two additional skin cancer case studies in this issue of the journal. Marjolin ulcers result from aggressive malignant transformation, most commonly to squamous cell cancer (SCC).2 These ulcers often occur in burn scars after a long latency period (>30 y) and have a higher than usual spread to regional lymph nodes (20-40%). The clinical triad includes a palpable, deep, solid nodule >1 cm, induration (hardening of the edges), and a central flat ulceration. These lesions may also present as verrucous wart-like growths with better prognosis. Marjolin-related SCCs have been reported in traumatic scars, amputation stumps, radiation dermatitis, and hidradenitis suppurativa.2 CASE REPORTS Dr Berna Aksoy and colleagues report a 53-year-old male with a 33-year history of malunion of the left mid to upper tibia with recurrent osteomyelitis. This is the stage for a usual Marjolin SCC ulcer. Another report by Dr Joseph J. Santora and colleagues describes a 64-year-old female with class II obesity and recurrent abscesses on the lower back treated with antibiotics. Thirteen months later, she presented with a sacral pressure injury measuring 5.5 × 2.3 cm and 3.3 cm deep. Initially, the patient was suspected of having a secondary infection, but subsequent biopsy confirmed Marjolin SCC. This lesion required a large excisional biopsy but had a local recurrence necessitating re-excision, due to the lesion’s aggressive nature. Regional lymph nodes were also identified and required local radiation with systemic chemotherapy. CLINICAL RECOMMENDATIONS These cases highlight the importance of biopsies for nonhealing ulcers; Marjolin ulcers are aggressive and often fatal, and early biopsy is important. If clinical suspicion persists with a negative biopsy for malignancy, repeat biopsies may be lifesaving due to sampling error of a single biopsy. Although Marjolin ulcers usually occur after many years, several reports, as well as the second case described herein, document earlier occurrences. SKIN SCREENING AND SUN PROTECTION Any patient with BCC or SCC should undergo a total skin exam, as other precancerous lesions (e.g., actinic keratosis, dysplastic nevi) may indicate risk or presence of additional skin cancers. This is especially important for individuals with lighter skin, chronic sun damage, immunosuppression, previous skin cancers, and organ transplants. Clinical education for health care providers to detect skin changes in persons with dark skin tones is also needed. Remember to also look on the plantar/periungual skin of the feet for skin cancers, especially melanoma in persons of color (Fitzpatrick 5-Brown skin, Fitzpatrick 6-Black skin). Also, persons with hidradenitis suppurativa are at higher risk for SCC. All persons should practice preventive skin care by wearing a hat with a wide 3-inch brim and applying sunscreen with a minimum of SPF 30-60 for UVB protection. Look on the label for additional UVA protection (the SPF is only UVB). UVA can infiltrate car and other windows; it is responsible for photoaging (wrinkles) and benign freckles (solar lentigines) as well as adding to the UVB predominant carcinogenic damage. Sunscreen should be applied first; avoid applying other preparations at the same time. Reapply sunscreen every 2-4 hours, after bathing, or following activity that causes perspiration. With sun protection limiting vitamin D3 metabolism, taking 1000 IU during warmer months and 2000 IU in cooler climates or during winter months with food is recommended, as vitamin D3 is fat soluble. You could save a life!