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Emergency and Acute Medicine - Skin Cancer
Skin cancer is the most common cancer in the United States, with a lifetime risk of approximately 1 in 6 individuals. Its incidence continues to rise, largely due to ultraviolet (UV) radiation exposure. Skin cancers are broadly categorized into nonmelanoma types—such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)—and melanoma, which is less common but far more lethal.
Actinic keratosis is a premalignant lesion caused by chronic sun exposure. It appears as a rough, scaly, pink lesion on sun-exposed areas and carries a small but real risk (0.1–10%) of progression to SCC. BCC is the most common skin cancer, accounting for about 75% of nonmelanoma cases. It typically presents as a painless, pearly or waxy papule with telangiectasia and may ulcerate or bleed easily. It is locally invasive but rarely metastasizes and is most often found on the head and neck of fair-skinned individuals.
SCC is the second most common skin cancer and may arise from actinic keratosis. It presents as a firm, raised, keratotic lesion that may ulcerate and become painful as it invades surrounding tissue. Unlike BCC, SCC has the potential to metastasize to regional lymph nodes and distant sites, particularly when arising from mucosal surfaces or in immunocompromised individuals.
Melanoma arises from melanocytes and accounts for only about 5% of skin cancers but causes the majority of skin cancer-related deaths. It is strongly associated with sun exposure, especially blistering sunburns, and risk factors include fair skin, multiple or atypical nevi, family history, and immunosuppression. The ABCDE criteria are key for identifying suspicious lesions: asymmetry, border irregularity, color variation, diameter greater than 6 mm, and evolution or enlargement. Subtypes include superficial spreading melanoma (most common), nodular melanoma (more aggressive), lentigo maligna melanoma, and acral lentiginous melanoma, which occurs on palms, soles, and under nails.
Diagnosis of skin cancer is primarily clinical but must be confirmed with biopsy, which is typically arranged outside the emergency setting. Imaging may be used in advanced cases to assess metastasis, particularly in melanoma and aggressive SCC.
In the emergency department, management focuses on recognizing suspicious lesions and ensuring appropriate referral rather than definitive treatment. Most lesions do not require acute intervention unless complications such as bleeding, infection, or metastatic disease are present. Patients should be discharged with clear instructions for urgent dermatologic evaluation and biopsy.
Key points include maintaining a high index of suspicion for changing or atypical skin lesions, educating patients on sun protection (including both UVA and UVB exposure), and emphasizing the importance of early diagnosis. Patients with one skin cancer are at significant risk (30–50%) of developing another within five years, making follow-up essential.
Skin cancer is the most common cancer in the United States, with a lifetime risk of approximately 1 in 6 individuals. Its incidence continues to rise, largely due to ultraviolet (UV) radiation exposure. Skin cancers are broadly categorized into nonmelanoma types—such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)—and melanoma, which is less common but far more lethal.
Actinic keratosis is a premalignant lesion caused by chronic sun exposure. It appears as a rough, scaly, pink lesion on sun-exposed areas and carries a small but real risk (0.1–10%) of progression to SCC. BCC is the most common skin cancer, accounting for about 75% of nonmelanoma cases. It typically presents as a painless, pearly or waxy papule with telangiectasia and may ulcerate or bleed easily. It is locally invasive but rarely metastasizes and is most often found on the head and neck of fair-skinned individuals.
SCC is the second most common skin cancer and may arise from actinic keratosis. It presents as a firm, raised, keratotic lesion that may ulcerate and become painful as it invades surrounding tissue. Unlike BCC, SCC has the potential to metastasize to regional lymph nodes and distant sites, particularly when arising from mucosal surfaces or in immunocompromised individuals.
Melanoma arises from melanocytes and accounts for only about 5% of skin cancers but causes the majority of skin cancer-related deaths. It is strongly associated with sun exposure, especially blistering sunburns, and risk factors include fair skin, multiple or atypical nevi, family history, and immunosuppression. The ABCDE criteria are key for identifying suspicious lesions: asymmetry, border irregularity, color variation, diameter greater than 6 mm, and evolution or enlargement. Subtypes include superficial spreading melanoma (most common), nodular melanoma (more aggressive), lentigo maligna melanoma, and acral lentiginous melanoma, which occurs on palms, soles, and under nails.
Diagnosis of skin cancer is primarily clinical but must be confirmed with biopsy, which is typically arranged outside the emergency setting. Imaging may be used in advanced cases to assess metastasis, particularly in melanoma and aggressive SCC.
In the emergency department, management focuses on recognizing suspicious lesions and ensuring appropriate referral rather than definitive treatment. Most lesions do not require acute intervention unless complications such as bleeding, infection, or metastatic disease are present. Patients should be discharged with clear instructions for urgent dermatologic evaluation and biopsy.
Key points include maintaining a high index of suspicion for changing or atypical skin lesions, educating patients on sun protection (including both UVA and UVB exposure), and emphasizing the importance of early diagnosis. Patients with one skin cancer are at significant risk (30–50%) of developing another within five years, making follow-up essential.
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