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Skin Cancer

Skin cancer is among the most common cancers. In our country, one type of skin cancer, Melanoma, has shown a 237% increase in the past 30 years. Although Melanoma is the least common type of skin cancer (less than 2% of cases), it is the most dangerous. Melanoma, which can spread to other organs, accounts for the majority of skin cancer-related deaths. Among non-Melanoma skin cancers, basal cell carcinomas are more frequent than squamous cell carcinomas. In the United States, there are 1 million new cases each year, whereas in our country, the incidence rate is 1.9 per 100,000 males and 1.3 per 100,000 females. The mortality rate for skin cancer is estimated to be 1 in 100 patients. The Dermatology Department of Uniqacare provided information about skin cancer and its treatment.

What is skin cancer?

The skin, which is the largest organ in the body, has many functions. The skin covering internal organs protects the body from potential injuries, prevents excessive water and fluid loss, and assists in providing the body with vitamin D. Additionally, it serves as a protective barrier against microbes like bacteria and harmful ultraviolet (UV) radiation, and helps regulate body temperature. Skin cancer, or dermal cancer, is a malignant growth that occurs on the skin due to various reasons. The skin consists of three layers: epidermis, dermis, and subcutis.

Epidermis: The top layer of the skin is the epidermis. The epidermis is very thin, with a thickness of about 0.05-0.1 mm. It shields the lower layers of the skin and organs from external factors. Keratinocytes are the primary cell type in the epidermis. These cells produce an important protein called keratin, which aids in protecting the skin. The outermost part of the epidermis is called the stratum corneum. In this part, dead keratinocytes are replaced by new ones. The cells in this layer are called squamous cells due to their flat shapes. Living squamous cells are found beneath the stratum corneum. These cells move from the outermost layer to the base layer, the bottom-most part of the epidermis. Cells in the base layer are referred to as basal cells, and their role is to divide to create new keratinocytes. This process gradually replaces older keratinocytes on the skin's surface.

Melanocytes, found in the epidermis, are cells that can transform into melanoma (skin cancer). These skin cells produce brown pigments called melanin, which give the skin a tan or brown color. Melanin protects the deeper layers of the skin from certain harmful effects of the sun. In many individuals, when the skin is exposed to the sun, melanocytes produce more of these pigments, resulting in tanning of the skin. The epidermis is separated from the lower layers of the skin by a basal membrane, which is an important structure. This is significant because skin cancer advances through this barrier and towards the deeper layers.

Dermis: The middle layer of the skin is called the dermis, and it is much thicker than the epidermis. It contains hair follicles held by a protein called collagen, which provides durability and elasticity to the skin. The dermis also houses sweat glands, blood vessels, and nerves.

Subcutis: The bottom layer of the skin is known as the subcutis. The lowermost part of the dermis and the subcutis together form a network of collagen and fat cells. The subcutis helps in maintaining body temperature and has a shock-absorbing effect that aids in protecting internal organs from injuries.

What are the types of skin cancer?

Melanoma Skin Cancer

Melanoma is a type of skin cancer that originates in the cells called melanocytes, which give color to the skin. It is also referred to as malignant melanoma or cutaneous melanoma. Melanoma skin cancer tumors are often brown or black in color since most of the cancer cells continue to produce melanin. However, some melanomas do not produce melanin.

In such cases, the cancer can appear pink, yellowish-brown, or even white. Melanoma skin cancer can develop on existing moles present from birth or those that appear later, and it can occur anywhere on the body, including areas covered by hair and even the soles of the feet.

Melanoma skin cancer is commonly found in the neck and back of men, and in women, it is often observed on the legs, neck, and face. However, it can also develop on the palms, soles of the feet, and even under the nails. Additionally, although rare, it can also occur in the eye, mouth, genital, or anal regions. When diagnosed in its early stages, melanoma is a treatable type of cancer, but if it spreads rapidly, it can become a more challenging form of cancer to treat.

Other Types of Skin Cancer

Basal cell and squamous cell carcinomas are mainly found in areas of the body that are exposed to a lot of sun, such as the head, neck, and arms. However, they can also occur in other parts of the body.

Basal Cell Carcinoma: This is the most common type of skin cancer. It often appears as a small, raised bump that is pale in color and can easily bleed even with minor trauma. It can have a shiny, pearly appearance with a sunken center and may be blue, brown, or black in the surrounding area. Larger basal cell carcinomas may have a crusty or ulcerated surface.

Squamous Cell Carcinoma: This is the second most common type of skin cancer. It can appear as a growing lump, often with a hard, scaly surface. It can also develop as a slow-growing, flat, red patch. Both of these skin cancers can develop in a flat area with minimal changes from normal skin.

Actinic Keratosis, also known as solar keratosis, can sometimes be a pre-cancerous condition that develops due to excessive sun exposure. Actinic keratosis typically presents as small, firm, or scaly patches that are pink-red or skin-colored. They often start on the face, ears, backs of hands, and arms, but can be found on other sun-exposed areas of the body. Actinic keratosis is usually numerous. Some may progress into squamous cell carcinomas, while others may remain the same or progress on their own.

What are the symptoms of skin cancer?

The most important symptom of skin cancer, characterized by changes in the size, shape, or color of a mole or the appearance of a new spot on the skin, includes the following signs:

  • Non-healing and recurring sores

  • Spreading of pigments beyond the border of the spot

  • Development of moles that are larger than 5 mm and shift towards red and blue colors

  • Increase in the number and size of moles

  • Changes in the surface of a mole, such as becoming raised, bleeding, or taking on a nodular or lump-like appearance

  • Development of a new bump or swelling beyond the border, with redness

  • Increased sensitivity, itching, or pain

Differentiating between a normal mole and melanoma can sometimes be challenging. In such cases, the best course of action is to consult a specialist dermatologist as soon as possible.

What are the risk factors and causes of malignant melanoma (skin cancer)?

Ultraviolet (UV) Radiation Exposure: UV rays are a primary risk factor for melanoma skin cancer. They damage the DNA of skin cells, initiating the development of skin cancer. Sunlight is the main source of UV rays, and tanning beds can also emit UV radiation. People who are excessively exposed to UV rays from these sources are at an increased risk of various skin cancers, including melanoma.

The primary skin cancer risk factors are as follows:

UVA Rays: These rays contribute to cell aging and can damage cell DNA. They are thought to be associated with long-term skin damage, such as wrinkles, and the development of some types of skin cancer.

UVB Rays: These rays cause sunburn and directly damage cell DNA. They are believed to be responsible for most skin cancers.

UVC Rays: These rays cannot penetrate the atmosphere, so they are not present in sunlight and do not contribute to skin cancer.

Tanning Beds: Research indicates that individuals who frequently use tanning beds have a higher risk of melanoma skin cancer. Tanning beds should use "ultraviolet lamps" for tanning and carry labels stating, "Exposure to UV radiation can lead to early aging of the skin and skin cancer." Additionally, labels indicating "regular doctor check-ups are necessary for skin cancer" for users constantly exposed to these rays could serve as a warning. This is aimed at reducing the use of UV products, such as tanning beds, especially for individuals at risk of skin cancer, those under 18, and those with a family history of skin cancer.

Moles: Moles on the body are benign growths and can develop not only at birth but also during childhood and adolescence. Most moles don't cause any issues. However, individuals with a high number of moles are at an increased risk of developing melanoma.

Dysplastic Nevi: Also known as atypical moles, dysplastic nevi appear somewhat similar to normal moles but carry some of the characteristics of melanoma. They are often larger than regular moles and have an unusual shape or color. Most of them do not turn into cancer.

Congenital Melanocytic Nevi: Moles that are present at birth are referred to as congenital melanocytic nevi. The risk of developing melanoma is estimated to be between 0% and 10% depending on the size of the nevus at birth. Individuals with larger congenital melanocytic nevi have a higher risk of melanoma. For example, if the congenital nevus is smaller than the palm of the hand, the risk of melanoma is lower. On the contrary, large congenital nevi on the back or buttocks significantly increase the risk of melanoma.

Fair Skin, Freckling, and Light Hair Color: Individuals with fair skin, light hair, and freckles have a melanoma risk that is 10 times higher than those with darker skin. Red or blonde-haired, fair-skinned individuals with blue or green eyes and freckles have an increased risk of skin cancer.

Age: Melanoma often appears in individuals aged 15-29, particularly between 25-29 (especially among young females). However, it can also occur in older individuals.

Gender: Considering the incidence rates and biological differences, skin cancers are divided into malignant melanoma and non-melanoma skin cancers. For young adults, specifically males aged 25-34, it's the 4th most common cancer type. In females, it's the second most common cancer type after breast and gynecological cancers.

Occupational Exposure to Source and Metal: It has been shown to increase the risk of melanoma in the eyes.

Phototherapy (Light Therapy): UV radiation exposure from phototherapy used to treat certain skin conditions like psoriasis has been linked to an increased risk of squamous cell skin cancer.

What are the genetic factors of skin cancer?

  1. Family History: Individuals with a family history of melanoma, especially in first-degree relatives (parents, siblings, children), have a higher risk. Approximately 10% of individuals with melanoma have a family history of the same disease. The increased risk could result from similar sun exposure habits within the family, prevalence of fair-skinned individuals, or genetic factors. Genetic mutations can also contribute to melanoma risk; mutations are found in about 10-40% of individuals with a strong family history of melanoma.

  2. Xeroderma Pigmentosum (XP): This rare hereditary condition arises due to damage in DNA repair enzymes. XP patients' skin is more vulnerable to sunlight, and they are unable to repair DNA damage caused by the sun. As a result, their risk of developing various skin cancers, including melanoma, significantly increases with sun exposure.

  3. Normal Moles: Moles are usually brown, skin-colored, or black spots on the skin. Their size is typically smaller than 6 mm, and they can be flat or raised. Moles can be present from birth or develop during childhood and adolescence. New moles that appear in adulthood may require a doctor's examination to check for signs of potential skin cancer.

  4. Changes in Moles: Moles on the body generally maintain their size, shape, and color over years. However, some moles may fade or change over time. Many individuals have harmless moles, but being vigilant about changes in a mole's shape, size, or color is crucial to identifying potential skin cancer risks.

Unusual wounds, swellings, spots, scratches, or alterations in the appearance of a certain area of the skin can be indicators of melanoma or other types of skin cancer, or they can serve as warnings of the risk of cancer development. When such changes are noticed, consulting a medical professional is important.

The importance of early detection of skin cancer

Skin cancers are visible cancers. Just like other types of cancer, when changes on the skin are noticed early in skin cancer, it can be treated before it spreads.

Furthermore, in cases where skin cancer is treated early, the side effects of treatment are minimized.

Do early signs of skin aging indicate skin cancer?

Spending extended periods in the sun increases the risk of both skin cancer and premature aging of the skin. This product should include the statement: "This product helps protect from sunburn, not from skin cancer or early skin aging." This same warning should be included on sunscreens that are not labeled as "broad-spectrum."

Products with low Sun Protection Factor (SPF) should have warning labels. Sunscreens with an SPF lower than 15 must include a warning label. "Water-resistant" does not mean "waterproof." No sunscreen is waterproof or "sweat-proof." Manufacturers cannot claim this anymore. If the product's front label says "water-resistant," it must indicate the duration of its effectiveness while swimming or sweating, either for 40 minutes or 80 minutes. Products cannot promise more than they can deliver. Sunscreens cannot promise immediate protection or protection for over 2 hours without reapplication. They cannot use the term "Sunblock." By protecting yourself from the sun's damage, you can prevent premature aging and skin cancer.

Early Detection Screening Recommended Age Range:

There is no specific recommended age range. Skin cancers can be examined at any age, for both men and women, young and adult.

How is skin cancer diagnosed?

The most important signs of skin cancer are the appearance of a new spot or changes in the size, shape, or color of an existing spot on the skin. Unusual and non-healing sores, swellings, spots, scratches, or changes in the appearance of the skin, changes on the surface of a mole (elevation, bleeding, or a nodular or lump-like appearance), itching, sensitivity, and pain can all be signs of melanoma or another type of skin cancer. When encountering such symptoms, it is essential to consult a specialist doctor promptly, as seeking medical attention early can lead to swift resolution of potential health concerns.

Self-Examination for Skin Cancer: It is crucial to examine the skin twice a month. Knowing the characteristics of moles, spots, and freckles by looking at photos of skin lesions and recognizing your body well enough to notice any new mole or spot is important. Self-examination should be conducted in a well-lit room using a full-length mirror that allows you to observe the entire body. Using a hand mirror can help view blind spots like the back and buttocks in the full-length mirror. In males, 1 out of 3 melanomas is detected on the back. All areas of the body, including the back, palms, soles, scalp, eyes, and nails, should be examined.

Medical History and Physical Examination: A physical examination for skin cancer should initially be performed by a dermatologist. A technique called dermatoscopy (also known as epiluminescence microscopy or surface microscopy) is used to closely examine skin lesions or moles, and if necessary, images can be taken, allowing possible spread to be observed in nearby lymph nodes. Some skin cancers spread to lymph nodes, causing them to enlarge and become harder than normal. This can be highly effective in early skin cancer detection. It is important for individuals with dysplastic nevus syndrome, a family history of melanoma, or a personal history of melanoma to undergo regular skin examinations.

Dermatoscopy in Skin Cancer Diagnosis

Dermatoscopy is a skin surface microscopy technique used for diagnosing moles and pigmented lesions. In this method, the lubricated skin surface is examined using a dermatoscope that provides illuminated magnification. Dermatoscopy, resembling an otoscope used for ear examinations, has been widely used for over a decade. A few years ago, mole tracking was achieved by taking photographs of dermatoscopic images. Then, computer technology was added to this method, resulting in digital dermatoscopy. This technique creates a map of moles on the body, determining their specific locations. Dermatoscopic images are taken and saved for each mole. This allows comparison with images obtained in subsequent exams.

Digital dermatoscopy calculates the suspicious changes in moles mathematically, creating an index indicating the risk of malignant melanoma. This index assists in diagnosis and treatment planning. While the naked eye has a 60% chance of diagnosing early-stage melanoma, digital dermatoscopic examination increases this rate to the 90s.

Skin Biopsy: If a certain area is suspected to be skin cancer, a tissue sample is taken from that area and examined in a laboratory, a procedure known as a skin biopsy. Skin biopsies can be performed in various ways. The type of biopsy will depend on the location, size, and suspected type of skin cancer. If a suspicious mole or lesion is identified as cancer or precancerous, your doctor may recommend further tests or treatments. If the suspicious mole or lesion is small and localized, a more extensive biopsy (to obtain more tissue) or a form of surgical intervention may be used. In cases of metastasized skin cancers, imaging tests and treatments such as immunotherapy, targeted therapy, chemotherapy, and radiation therapy will be necessary.

What are the treatment methods of skin cancer (malignant melanoma)?

In the treatment of skin cancer, the primary goal is to completely remove the cancerous tissue without leaving any residue. Surgical treatment can achieve high success rates in this regard. By adequately removing the cancerous tissue in terms of depth and breadth, the recurrence of the cancer can be prevented. In the treatment of skin cancer, in addition to the eradication of cancer cells, importance is also placed on not leaving visible scars and avoiding functional loss. The location of the cancerous tissue, the patient's age, overall health condition, tumor size, skin characteristics, and the likelihood of lymph node involvement become significant factors.

Skin cancer treatment involves personalized approaches rather than a uniform treatment method. Small tumors are often successfully treated with surgical procedures and radiotherapy. It is also crucial for an experienced medical team to perform the tumor removal procedure.

If it is desirable to avoid leaving scars after surgery or if the tumor can be controlled through radiation therapy, radiation therapy can be a preferable option. Especially for non-melanoma skin cancers seen on the cheek, forehead, or nose bridge, radiotherapy can be highly effective, especially for basal cell carcinomas. Cryosurgery is an option for treating small tumors. In this method, liquid nitrogen is applied to freeze and destroy abnormal cells in the tumor region. After the frozen tissues thaw, dead tissue is eliminated from the body. Another treatment method called curettage involves scraping the cancerous area with a spoon-shaped instrument, stopping bleeding with an electric current, and killing cancer cells. At the end of the procedure, a flat, white scar remains on the skin. For superficial skin cancers, topical chemotherapy in the form of creams or lotions is also considered as an option.

What are the ways to prevent skin cancer?

The risk factors causing skin cancer and UV exposure can be reduced to prevent it. So, what kind of precautions can be taken to protect oneself from the sun?

Cover up. If you're not sunbathing, wear protective clothing, a wide-brimmed hat, and try to shield your skin as much as possible. You can also protect your eyes by wearing sunglasses that block at least 99% of UV rays.

Stay in the shade. Avoid sunbathing between the hours of 10:00 AM and 4:00 PM when the sun's rays are strongest. Limit your direct exposure to sunlight according to the timeframes recommended by experts.

Avoid tanning in tanning beds. It can contribute to the development of skin cancer and cause long-term damage to your skin.

Pay attention to the expiration dates of cosmetic products.

Use broad-spectrum sunscreens with at least SPF 30. Make sure to reapply your sunscreen every 2 hours, especially after swimming and sweating.

The U.S. Food and Drug Administration (FDA) has implemented regulations for sunscreens that protect not only against sunburn but also against UVA rays, which can trigger skin cancer and premature aging. Additionally, it is required that moisturizers, lip balms, and makeup products indicate their sun protection factor (SPF) level on the labels, similar to sunscreens.

How should sunscreen be correctly used to protect against skin cancer?

Test-supported "Broad Spectrum": New regulations will ensure that consumers, when purchasing sunscreen, are certain that it provides protection against both UVB and UVA rays by being labeled as "broad spectrum." All sunscreen products have protective properties against UVB rays, which cause sunburn. Now, they will also carry protective features against UVA rays that contribute to the formation of skin cancer and premature aging of the skin. The label "broad spectrum" can only be used on products that have passed the tests.

Is skin cancer dangerous? Is skin cancer fatal?

It is necessary for everyone to self-examine their entire body (using a mirror for hard-to-see areas such as the back) regularly, starting from the scalp down to the feet. Moles present on our body should be closely monitored, and any changes observed or non-healing, bleeding skin wounds should be brought to the attention of a specialist. Suspicious lesions or previously diagnosed skin cancer should be examined using a dermatoscope (surface microscopy) device.

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