Dear 16-Year-Old Me

Updated 3/2017-- photos/video and all links (except to my own posts) removed as many no longer active. 

I learned about this education video via @SeattleMamaDoc. 

Sun safe practices:

• Staying in the shade, especially between the sun’s peak hours (10 a.m. - 4 p.m.).
• Covering up with clothing, a brimmed hat and UV-blocking sunglasses.
• Avoiding tanning and UV tanning booths.
• Use sunscreen, SPF 15 or above, preferably one with a sunblock component also.  To protect against the UVA rays, the product needs to have avobenzone (Parsol 1789), ecamsule (Mexoryl), titanium dioxide, or micro-zinc oxide.

Sunscreens should not be used in babies under 6 months old.  It is recommended by the American Academy of Pediatrics for this group to use other sun safe practices such as the ones just mentioned.

Related blog posts:
Sun Protection (March 19, 2009)
Melanoma Review (February 25, 2008)
Melanoma Skin Screening Is Important (April 29, 2009)
Tanning Beds = High Cancer Risk (August 3, 2009)
Skin Cancer (March 24, 2010)

Melanoma of the Nail Matrix

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. 

Two recent articles in the Archives of Dermatology serve as a reminder that melanoma may occur under the finger nail in the nail matrix.

The first one (full references for both below) used slides and prepared information from 12 cases to “test” dermatologist. Here is one of the examples given in the paper:

Nevus. A, Clinical features; B, nail plate dermoscopy; C, intraoperative dermoscopy. ABCDEF rule information: A (age, 35 years), C (change in band at 2 years; it became enlarged or darker), D (digit, third finger, right hand), and F (no family or personal history of melanoma)

Only 46-55% made the correct diagnosis of nail matrix melanoma in situ in this study. The level of expertise did not statistically influence the correct diagnosis.

Early diagnosis of melanoma of the nail unit is challenging. The tumor most often presents with a longitudinal nail pigmentation (longitudinal melanonychia), but this is not a specific sign for melanoma.

Longitudinal melanonychia can also be caused by numerous nonmalignant conditions that include nevi of the nail matrix, benign melanocytic hyperplasia (nail matrix lentigo), and a number of inflammatory, traumatic, or iatrogenic nail disorders that induce the activation of the nail matrix melanocytes.

Features on clinical examination that are suggestive but not pathognomonic of melanoma include inhomogeneous pigmentation with bands or lines of different colors, presence of nail plate fissuring or splitting, rapid enlargement of the band, a proximal part of the band that is broader than the distal (triangular shape), blurred lateral borders, and pigmentation of the periungueal skin.

These features have been summarized in the ABCDEF rule for diagnosis of nail melanoma and may help clinicians in distinguishing "nonalarming" from "alarming" bands. Each letter indicates features that are associated with an increased risk of melanoma:

• A (age as peak incidence of nail melanoma is between 50 and 70 years. A also reminds us of most commonly affected races: African Americans, Asians, and Native Americans).
• B (band: black to brown, breadth > than 3 mm, blurred borders)
• C (change: enlarging or darkening)
• D (digit: most fingernail melanomas affect the dominant hand)
• E (extension of the pigmentation to the surrounding tissues)
• F (family or personal history of melanoma)

The second one reminds us that melanoma in the nail matrix location (nail apparatus melanoma or NAM) is associated with a poor prognosis, mainly because of a delay in diagnosis. Too often diagnosed at an invasive stage. The authors note this is particularly true in cases involving amelanotic melanoma. They report 3 cases of in situ amelanotic melanoma with clinical lichenoid features, concluding that chronic unexplained monodactylic nail dystrophy should be investigated histologically.

All three of their patients (ages 39 to 60 yrs) presented with nail alterations characterized by lichenoid changes with longitudinal striation, distal splitting, and nail plate atrophy. Histologic examination revealed in situ amelanotic melanoma extending from the proximal matrix up to the distal part of the nail bed. (photo from article)

The authors give us the background on amelanotic NAM:

Amelanotic NAM represents 20% to 30% of ungual melanoma cases compared with less than 7% of the other cutaneous melanomas.

It usually presents as a chronic paronychia, a torpid granulomatous ulceration, a wartlike keratotic tumor, or a pyogenic granuloma.

It is usually located in the periungual folds or in the nail bed.

Clinical misdiagnosis, which is particularly frequent in amelanotic melanoma, is responsible for a delay in diagnosis as well as a poor prognosis.

REFERENCES
Dermatologists' Accuracy in Early Diagnosis of Melanoma of the Nail Matrix; Nilton Di Chiacchio; Sergio Henrique Hirata; Mauro Yoshiaki Enokihara; Nilceo S. Michalany; Gabriella Fabbrocini; Antonella Tosti; Arch Dermatol. 2010;146(4):382-387.
In Situ Amelanotic Melanoma of the Nail Unit Mimicking Lichen Planus: Report of 3 Cases; Josette André; Isabelle Moulonguet; Sophie Goettmann-Bonvallot; Arch Dermatol. 2010;146(4):418-421.

Malignant Melanoma, "FDR's Deadly Secret"

Earlier today I wrote a short article which resulted in correspondence with one of the authors of the new book, 'FDR's Deadly Secret' by Steven Lomazow and Eric Fettmann.

Dr. Steven Lomazow sent me a copy of his Archives of Dermatology article with Dr. Bernard Ackerman, this photo, and a pdf of his book which I have spent the afternoon reading.

The article goes through a series of photos of FDR from his younger days to his older ones, showing the progression and changes. From the article:

The criteria currently touted for diagnosis of a slightly raised lesion of melanoma, a malignant neoplasm composed of abnormal melanocytes, are the "ABCDEs": Asymmetry, Border irregularity, Color variability, Diameter greater than 6 mm, and Elevation (or, for some proponents of the mnemonic, Enlarging or Evolving). The fully developed pigmented lesion above Roosevelt's left eyebrow admirably fulfills those criteria. But the ABCDEs also are encountered from time to time in a disparate variety of other pigmented lesions of the skin, among them being solar lentigo/seborrheic keratosis, melanocytic nevi of different kinds, and pigmented basal cell carcinoma.

The book is a “medical biography of Franklin D. Roosevelt. It presents a strong circumstantial case, backed by surviving medical records and analysis, that Roosevelt did indeed have cancer – melanoma, to be exact, originating in the pigmented lesion above the eye – that eventually spread to his brain and his abdomen. In other words, the cerebral hemorrhage that struck him down less than a month before V-E Day was not a “bolt out of the blue,” as his doctors contended, but the inevitable result of a deadly illness, compounded by catastrophic heart problems.”

Steven Lomazow and Eric Fettmann have done a great job with their book. I have enjoyed it immensely. Anyone who likes medical history will enjoy this book. Chapter 6 is entitled “The Brown Blob” and discusses the skin lesion seen in the photo above.

Back in FDR’s time, there were only two types of treatment for melanoma: surgery and radiation.

You may also like to check out Dr Lomazow’s blog: Magazine History: A Collector’s Blog.

For those of you who need to be educated regarding melanoma:

• Melanoma is the most serious form of skin cancer. If caught early, it is curable. If not, it becomes hard to treat and can be fatal.
• Melanoma accounts for less than 5% of all skin cancers, but accounts for the approximately 74% of all deaths from skin cancers.
• Melanoma metastasizes to the brain more than any other cancer. Of all the patients who die from melanoma, 90% will have brain metastases.
• Melanoma also metastasizes to the intestinal system more than any other tumor. Three cases in five metastasize to the small intestine.
• The American Cancer Society estimates that in 2009, there will be 8,650 fatalities in the U.S. The number of new cases of invasive melanoma is estimated at 68720. Overall, the lifetime risk of getting melanoma is about 1 in 50 for whites, 1 in 1,000 for blacks, 1 in 200 for Hispanics.

For many years, the early warning signs of melanoma have been identified by the acronym "ABCDE" (A stands for Asymmetry, B stands for Border, C for Color, D for Diameter and E for Evolving or changing was recently added.).

A new concept of the “ugly duckling” has been added to pick up the melanomas that don’t fit the ABCDE rule. This new method of sight detection for skin lesions is based on the concept that these melanomas look different -- ie, "the ugly duckling" -- compared to surrounding moles.

For early detection of melanoma, look for lesions that manifest the ABCDE's AND for lesions that look different compared to surrounding moles.

For more information on malignant melanoma:
National Cancer Institute
eMedicine
The Skin Cancer Foundation

REFERENCE

An Inquiry Into the Nature of the Pigmented Lesion Above Franklin Delano Roosevelt's Left Eyebrow; Arch Dermatol, Apr 2008; 144: 529 - 532; A. Bernard Ackerman; Steven Lomazow