Dr. Williams on Skin Cancer Basics 9/3/26

Speaker A: Francis. Um, I went to OU for medical school. More importantly, I went to OSU for undergrad. Um, and I did my intern year at North Carolina, so 10 minutes of your lecture gave me PTSD. And then, um, in my derm residency at UT Medical Branch in Galveston. So I've seen a lot of skin cancer. Um, so we're just going to hit the highlights. You guys are going to be, a lot of the times, the first point of contact for someone who probably has no idea that they have skin cancer. Um, yes, a lot of people show up in a derm office, but a lot of people think they just don't know what to think. They don't know what to look for. This is not like your high school education. Like, guess what? If you have a red, painful bump on your arm, you might have cancer. So you guys are going to be. A lot of the times, the first ones who are seeing this, it does not mean that you need to be an expert, but just so you have feel better for beard. Um, I know I'm like the threshold to your Thursday night. So we're not going to sit here and talk forever, but if you have questions, I'm not actually counting on you to interact, because when I was a resident, that never worked well. Um, and then if. But if you have questions, just ask me. Okay? Okay, so we're just going to start. So non melanoma skin cancer. You may see it abbreviated nmsc. So that's exactly what it sounds like. It's just skin cancer that's not a melanoma most of the time. Like, if you think of, like, Africa, there's like, the big five, the big three. The big three skin cancers are going to be basal cells, squamous cell, and melanoma. Non melanoma skin cancer, like, 98% of the time is going to be your basal cell, your squamous cell. The one that you may hear people ask you about is a Merkel cell, because all your patients were Jimmy Buffett fans, and that's what killed Jimmy Buffett. That's super rare. Um, so these are not to get, like, granular on you, but these are skin cancers that come from keratinocytes most of the time, which, as you can see, are these cells here. So when we're talking to patients. I'm sorry, don't do the pointer. This is your epidermis. This is the stratum corneum. This is your ep. This is like the first layer of the skin. Your squamous cells are coming from. Your basal cells are coming from down here. So a lot of times that's why you're forming skin bumps. You're like right there. Um, so this is of course going to be the most common, especially in your Caucasian patients. But it can happen in patients of all skin types. That is probably the number one thing that your patients don't know is that they can get it. Just because you can tan doesn't mean you can't get skin cancer. Um, so just think about that for everyone. The major risk factor, of course, is the amount of UV radiation that you've been exposed to. Um, but your patients that have had chemical exposures, like, I think the one that we learned about was some, one of the old Ukrainian guys from like the 70s or the 80s had like bad, bad exposure. But, um, even ionizing radiation, immune suppression. So your patients who are transplant patients, or if they are not clinically controlled, like HIV patients, anything that lowers the body's ability to detect something that has go wrong. Okay, a little bit down the rabbit hole. The reason we know that that matters is people that have genetic conditions where their body can't fix UV damage get skin cancer by the time they're like 10. So your body is always fixing and plugging and chugging and then it just does, uh, it can't compensate for all the stuff that we do to our bodies. So risk factors parked on that one, UV radiation. So your basal cells, um, are going to happen more in Strawberry blondes who went to Florida every year and got burned and blistered, and then they came back home and never went outside. Um, your squamous cell, which I saw this so much in Galveston, are like the people who, for the love of all that is good, will never go inside or ever put a shirt on or ever put sunscreen on. It's the, like, you've seen it like the sun damage, the chronic sun damage. Um, and then of course, tanning beds, uh, increase the risk for all things. But melanoma, especially, especially the amount of times you hear people talk about getting a baseline tan, there's no such thing. So they do not need to go pay money to laying a tanning bed to get a baseline tan before they go on their cruise or go to Florida or whatever they're going to do. But I digress. A lot of the gyms have retaining beds. So this just kind of sucks. But, um, all of that, like even any tanning bed use, any sunburn that you blistered increases your risk compared to baseline. Um, kids really, this is like with parents, um, which then of Course you're going to freak out because you want them to put a chemical on their child. But protecting their skin when they're young, we think makes a bigger difference than like starting to wear sunscreen when you're 50. But I like to tell them the ship has never sailed. Best time to start was yesterday. Next best time is today. So it is important and I think six months and older is when you can start putting sunscreen on. Other than that, rash guards, hats, things like that. Um, so we talked about a little bit of immune suppression. Transplant patients do need to be seen every six months to every 12 months by a dermatologist, um, tacrolimus or prograft cellcept mycophenolate, those are your bigger offenders. Um, really increase their risk. Squamous cell goes up astronomically high, like 65 times risk that they're going to get one. Um, and then uh, Imuran or azathioprine. So not necessarily like your transplant med, but like if you' got old fashioned RA or whatever they have that they're on it for, uh, Imuran can kind of do you dirty on skin cancer risk. Um, a lot of transplant docs will manage that, but some people just have no idea. So um, the kind of historically the ones that we talk about to you, I have no idea if anyone uses moriconazole, but whatever it is, one, um, and then hydrochlorothiazine, it's kind of a hot button of uh, does it cause skin cancer? We don't really know. But it does tend to put people at a little bit higher risk. Are the people taking hydrochlorothiazide, it's just higher risk? Anyway, I'm not honestly sure. But just something to keep in mind, um, some of the cancer growth syndromes like neurofibromatosis, they can start to get skin cancers as they get older. The BRCA mutation. So I have seen that. So if they are BRCA1 or 2 positive, their risk of melanoma goes up. So they should probably be getting an annual, uh, skin check obviously. Oh my gosh, I totally had a typo. Um, lynch syndrome. I don't know how much you see that. Those people usually probably know. And then your toray, um, should be screened. So actin and keratosis, you're going to see these like they're going out of style. Um, so these are precancerous lesions. So sometimes all patients hear is that they have cancer. They are not cancer. They are pre cancerous. Which means, so the path slide that I Showed you. If you biopsy an ak, what makes it an AK is a third of the epidermis has kind of cancerous change to it. It is not full thickness atypia. It does not matter. I just like people to know so you understand, like what am I seeing and why are you calling it that? Um, so it doesn't mean like you caught it with a third and then tomorrow it was going to be two thirds. It's just that's what makes an AK. That's what makes a pathologist call it an AK. Um, the numbers vary. So people think like 1% of these will transform to skin cancer, 10 to skin cancer. It's really all over the board. Um, I. People, you know, if it's made it long enough for your visit to us, then probably should be treated, but they can start to be pretty asymptomatic. And it's just that crusty appearance. Like when you've seen it, you're like, okay, I get what you're talking about. If you feel it, it usually doesn't have like a dermal texture to it. Like you're not feeling something that's kind of palpable beneath the skin. If you're kind of like, am I looking at a skin cancer or am m I looking at a pre cancer spot? Um, uh, there sometimes they'll kind of burn or sting or bother people, but they're usually not like overtly painful. They'll blee need especially for guys who are getting them in, like when they're shaving. Um, but a lot of times they're kind of flat, they're kind of crusty. Um, but a lot of if you kind of want to feel around it, you're not going to feel like there's a little like BB underneath it. If there is, that's usually when I'm biopsy one. And um, so a lot of times we'll freeze them, which patients really love. It hurts, it sucks. Um, it really does not feel good. But they think of it as burning. They'll be like, yes, I've had lots of cancer burned off. No. Um, so that's one way to get it to go. And then um, something that we do that I don't know, the insurance really all that well is photodynamic therapy or pdt, which is basically you take someone in, um, this like sensitizer, like Levyland I think is what we use, and then you put them under a light and it basically melts them. I had one patient tell me it was like seven minutes of hell and the treatment was 16 minutes. And I had one who said he made it like five seconds. So, um, that can, it can do a good job because it's treating a field, but it's, it, it sucks. And then topical chemotherapy creams, which is what I tend to use more, so which is like Fluoro Uracil or Fudex cream, um, if it's a reliable patient. Because we've seen people who will use it for like six months and they will blister and it's not good. But it's typically about a two week treatment. It's called field therapy because it's going to do the work for, um, it's picking um, up all that background sun damage. It's like a chemotherapy where it's targeting rapidly dividing cells so they can kind of put it on. Like if they're real crusty arms, they don't have to like sit there and pinpoint and guess and try to pick which one it is. So it works really nicely for these poor people who are like coming every three to six months and just are getting lit up by freezing. So a lot of the times we'll do that or for patients who really just don't want to undergo surgery for a skin cancer. Um, so basal cell super common. So common they are. I tell people they're almost more of a nuisance than a threat. Yes, they can spread if you leave them alone for years and years and years. But they grow really slowly. Um, so they can be painful, they can tender. Be tender. A lot of the times I see them just bleed. Um, so they will ulcerate often. So they will be like, oh, I have this spot that I have to keep a bandaid on. And it's like, well, let's think about why. Um, so a lot of times I get people that they're like, this just won't heal. Or it's like a pimple that's been getting bigger. I cannot tell you how many people have had a spider bite that has been there for two years. Never a spider bite. I had a lady tell me that she had a wasp sting her on her cheek four years ago. Not a wasp. Um, it's a skin cancer. So if there's a, like always look under a band aid. Always. I have people be like, that's nothing. Let's just, let's trust but verify, um, that it's nothing. So a lot of the times they're just something that in their mind they think should have gone away. But you know, it comes like a couple of years and then it just hasn't, um, so you don't have to argue with them but just you know, be like m. Let me just check it just to be there. I want to look after you. So they are classically like pink pearly papules. You'll probably hear that buzzword. They're not always that clear, but a lot of the times are pinkish red. Um, with dermoscopy, as you can see on the bottom right hand side they have what we call sharp telangitasia. So that's like what helps us. Sometimes you can see it from the surface. Um, really is helpful if you're not really sure what you're looking at. Um, these are all common locations. So like tear trough face. This tends to be in like sun exposed areas. Um, very low risk that they ever spread. It can happen but very, very low risk. Squamous cell, um, these are the ones that typically will get people into the office because they often are painful. Like these grow fast, they will be like weeks. So if someone has a painful bump that's been there for a couple weeks, most often it's going to be a squamous cell carcinoma. Um, I have seen a not insignificant number of squamous cell carcinoma inside too that people will be like, that's just my patch of psoriasis. But it doesn't go away with clobatazole. And it's like if you have someone who has one patch of psoriasis on their leg, I don't think it's psoriasis. I will always biopsy it. I'd rather check to be sure because it can kind of just spread and do this pink, red kind of scaly thing. Um, and so just, just something to keep in mind, especially on the legs, bas, uh, look like that too. Um, squamous cell carcinoma has gotten a lot of attention because everyone thought about melanoma and obviously melanoma is super, super scary. But the morbidity mortality of squamous cell is almost that of melanoma. So people will die as often if not more from squamous cell as they will from melanoma. These, when they can metastasize, they go fast. So uh, this is a little bit beyond the scope of things that you all need to worry about. But like when we're looking at pathology, like how do you know if you need to do more? Like these have a higher risk of perineural invasion so they'll invade the ne, um and also vascular invasion. So I had a guy who had MOHS done of his claim on his ear. And he came to me and told uh, his. He had like facial droop. And I was like, what's going on? He's like my, you know, his PCP thought he had like Ramsay Hunt or something and was treating him with Valtrex, but his facial droop didn't get better. And I was like, uh, it was on the side of the squam that he had. So we did an MRI and he had metastatic squamous. So just like, they can act dirty. It's not to like fear monger, but just kind of just keep that in mind that this, we have to take it as seriously as we do melanoma. Um, there's a lot of thought that HPV plays a role in, uh, squams. So that's why they're going to be more common in your patients who are also immune suppressed. This is most commonly what they're going to be developing. So they're typically painful, ulcerated, they bleed, they're shiny, bright red, they grow fast. Um, I didn't put it in there, but a lot of the like, kerato achieved, you may see, has that like, like little crater volcano appearance to it. And that's pretty common as well. So here's just like more examples. So this one on the bottom is like your textbook perfect, uh, squam a lot of times what you're gonna see. And so, um, this is that fingers. That's kind of an example. Like if you see that on a leg. And it's only when they have just, you know, don't always think it's psoriasis. Doesn't mean that you have to like go looking for skin cancer in every condition. But just something to keep in mind. Um, so high risk areas are going to be. This is for like MOHS staging for auc. Appropriate use criteria for mohs. This is what's designated, uh, as high risk. Um, so don't forget about genitalia. Uh, so, um, untreated condyloma can transform to squams. That's why we treat them. Obviously people don't like them. Um, that's another reason to treat them if they don't care. Um, and then, so don't forget to look there. And then hands and feet are a little bit higher risk too. And obviously head and neck area, area. So this is more used for like, who gets mohs? Like, if you're like, what in the world? I'll explain those in a second. But, um, this is the, uh, over, you know, lots and lots of data. Like, not that we don't care about the one on your stomach, but just so you know. So how do you make it a diagnosis? Okay, so tissue biopsy is pretty much always necessary because, um, one who knows, it could be some, like, bizarre skin cancer. But a lot of the times it will tell you how to treat it because there's certain, um, treatment protocols based on, like, the subtype of skin cancer. So, uh, don't feel like you have to do this. Like, this is not a pressure. No one's going to be like, oh, my gosh, how dare that person who referred this person to me, not biopsy this skin cancer. Um, it's really okay if you don't feel like doing it. They're trying to. Medicare is trying to cut or no, I'm sorry, Congress is trying to cut Medicare, like a 50% deduction in a 25 modifier, which is what lets you do an E M visit and a, ah, biopsy that day. So, um, obviously that could affect you guys if you're doing joint injections, if you're doing all sorts of stuff. So it may not honestly be worth your time or your money eventually if this goes through, which will suck. Um, so shave biopsy. This is just kind of the different biopsies that you can do. A shave is kind of what it sounds like. You just numb it and you are shaving kind of flush with the skin. That's totally adequate. Uh, it's also less cumbersome than doing stitches and all of that. Um, it also lets you evaluate the whole lesion. So, um, I'll go over this more with like, melanoma. But sometimes a partial biopsy is going to give you a false diagnosis. So a shave helps you to evaluate if you want to do biopsies, um, in like, those claims. So, like these. Oh, shoot. Um, okay, so like this one, if I was biopsying it, I would try to kind of scoop underneath it because it will carve right out. If you kind of like lop the top of it off, these will grow back really fast and they'll also just continue to bleed. So then they'll probably be calling you. So those actually, they kind of like scoop out nicely, like they really want to come out. And so the shave is really helpful. A, um, lot of times we're punching, um, for rashes. So this I try to hit on because sometimes pathologists will put like, uh, basal cell carcinoma margins negative. Okay, well, when they process a tissue for biopsy, what they're doing is if you think about like, I don't know, this, okay, this terrible example. So if your skin cancer is shaped like this, when they do a biopsy, the technician just cuts it in half somewhere and lays it flat on a slide and they make a diagnosis. So did you cut it here or did you cut it here? So that's why I would not trust your margins unless you are doing it as an excision. Because if you do it as an excision, they will process the tissue differently to give you margins. Okay. Um, so that's just something to note. So just in case you get it, I would not count that as like great, totally removed. It just means that whatever arbitrary piece they cut across didn't extend to the edge. Okay. So this format really bothers me. Um, okay, so the treatment. So like I said, biopsies, they're just for diagnosis. Also, your patients might kind of get hosed by their insurance because if you do a biopsy that's kind of for treatment and you code it that way, the patient could be billed for that whole procedure. So it just avoids any unhappiness on their end to just do a biopsy, um, versus doing like an excision. And, and everyone has like different. Someone who's been practicing for 50 years may say that's like total crap. And that's fine. Um, so anyway, just don't trust your margins.

Speaker B: Good gracious.

Speaker A: I mean so many typos. Um, so in the standard of care differs. So like a basal cell, for example, you're going to take like 4 millimeter margins. But if it was a melanoma or a severe dysplastic neva, that's half centimeter margins. So the, the pathology is going to tell you what is an appropriate treatment decision. So that's why I, I tried to never. Unless this is like someone driving three hours away and they're, you know, can't sit for more than 30 minutes or something. And then, you know, just insurance, unfortunately never really gets better at covering stuff. So the treatment options. So Mohs is the one that you'll probably hear about the most. This is just a surgical technique where the dermatologist who completed a one year fellowship to do this, they act as the um, surgeon and the pathologist. So that's what makes it special. So they kind of like flash freeze the tissue, they look at it in real time. So it saves the patient from having to like go home, wait 24, 48 hours and then come back because her margins were positive. It's quote unquote, tissue Sparing, meaning that you're supposed to be able to take the smallest piece that you can to try to achieve clear margins. And then if it's positive at like, you know, one to two o', clock, you just go back there, you take a little bit, and then you're done. Um, it obviously costs more because you can bill as like the surgeon and the pathologist, which is why insurance will only approve it for certain skin cancers of certain sizes in certain locations. Um, obviously a standard excision, your margins are going to be bigger because you're just going off what standard. So did you really need 4 millimeter margins on that person? Maybe on the other person, maybe not. But that's your standard kind of football shape. Stitch it up, call it a day. Ed&C. Um, this is just electrodesication and curettage. This is something that I'll do for like, low. Either patient who is not a candidate to do all this other stuff or just a low risk kind of smaller spot. They're in and out. You just curettage the base and cauterize it. I mean, it's. If you do it well enough, the Cure rates are 90 to 95%, but it's going to have a higher risk of recurrence. And then topical, uh, chemotherapy cream, especially for legs, uh, heal terribly terrible. Um, so the legs are great. It's tight, they tend to de. Hiss. Um, so sometimes we'll even do it like they'll treat with a topical, see what's left, and then excise what's left after that just to make the wound healing a little bit better. Um, okay, so melanoma, the one that everyone's worried about, and patients will tell you that they've all had a melanoma when they've had a basal cell. Um, so this, of course, everyone, um, is probably more familiar. But this comes from melanocytes. I put this about the neuroendocrine because it can develop anywhere. That's why you hear the crazy stories of someone who showed up in the hospital with brain mets and no one ever found a mole. Um, so it can come from the cns, it can come from the skin, it can come from the mucosa, it could be a mole that the body regressed and you never find a prim. So it can happen. Um, this one is more genetic, more mutation influenced. So, um, it's like, people be like, oh, my gosh, I don't understand. I never get sunshine there. And it's like, well, it doesn't always matter because there's so Many different mutations with uh, melanoma. So it's more uh, genetically linked. So I'll get over into this but um, we'll screen like primary relatives. So if you have a 50 year old lady who comes in and she's had a melanoma diagnosed, like we need to screen her sibling, her children, her parents because that first degree like branch has a higher risk than just your population level. Um, also the mutations are kind of what drive therapy. So like BRAF inhibitors are going to be what are used in patients who have a BRAF positive melanoma. So that's where some of the genetics gets into play. Um, again a skin cancer that can happen in all skin types. I have taken them off the chest of like a 45 year old Hispanic man. Obviously a lot of people are increasing awareness of like April melanoma. So I can feet, um, Bob Marley is always a good example when people are like my feet. Um, yes. Bob Marley died of a melanoma that started on the bottom of his foot. He didn't treat it, but whatever. Um, so look everywhere. Even if they're like oh my gosh, how could you look there? Any skin is fair game. Um, it's happened in genitalia, reaching regions, eyes. So anyway, just low threshold. Um, because all of the time and attention especially in dermatology went to melanoma and like the 2000s, early 2000s, uh, really survival is better than it ever has been. Uh, we're probably also catching more. So I don't know that we've actually changed the. There's a lot of debate. Like have we actually changed outcome or are we just like catching so many who were so far back here that they're all just kind of living the same time? Anyway, the jury is out. But um, we have a lot more tools to use. I mean they're advertising keytruda for now. You know, it's incredible. So if you see a path report of a melanoma, the biggest prognostic factor is the breslow depth. Um, so that is how far down in the skin it goes. So um, there's a whole table. You can google it if you are so inclined. But that is what's going to be the most important thing is how deep that guy is going. So you can have the most gnarly looking thing on the skin, but superficial spreading melanoma, that's like 0.2 millimeters. And that thing is just a skin excision. And then you can have this tiny little guy that's 1.4 millimeter and you're getting like sentinel lymph node radiation, immune therapy, etc. So the risk factors, you know, more common in males over 60. Men, it's going to be more common on the trunk, women, the back of the legs. So that's your classic like high risk, uh, skin areas. Um, there are different genetic syndromes. So if you have someone who's like had multiple family members with melanoma, pancreatic cancer, that's a certain genetic mutation that kind of goes together. So they should probably be sent to genetics. Obviously some of these random like uvul and bilium, blah, blah, blah, those are certain genetic mutations. Um, but if someone's like, oh, everyone in my family has weird moles and they've been removed and then someone's had pancreatic cancer, I'll actually send those to genetics because they do need testing if they agree. Um, obviously your fair skinned people, so they're your redheads, blue eyes, all of that good stuff. The, the tanning bed is really the biggest thing to get. Those tiny little dark moles that you see everywhere, those are usually melanocytic nevi that are coming from that intense sun exposure over time and then your immune suppression. And then if you're like, I don't know, this person has crazy amounts of moles, like, this is kind of like my skin check. That takes me forever. Some patients think that they have a crazy amount of moles and they have like 2, 2, 3, that's nothing. Um, we're talking like 50 or more. 50 to 100. Those are the people that will screen more often because their risk is just a little bit higher. So obviously you guys probably all seen photos of it. It can look any type of way. Um, patients always are like, what am I looking for? And they'll know that ABCDs and stuff. Um, change is the biggest thing. If someone's like the spot has changed. It didn't used to look like that. Even if it looks totally normal, I take it off. It doesn't always mean it's something, but it's been something before. So just low threshold patients kind of know when something's changed. Um, a lot of the times though, like, you don't have to be like, oh my gosh. I think that's like kind of a little like these are like you, you know, from the doorway, like, that's, that ain't good. So, um, don't stress yourself out too much on like the really subtle findings. Like it's, you know, these have like 12 colors each, so that's A good place to start. They're really irregular. You just kind of know. Um, just don't forget about the weird spots like mucosa. Uh, um, you probably, especially if you say anywhere around Oklahoma will see that top right corner is an example of a lentigo malignant which is just a chronic sun damaged skin area. Those we think take like years to really develop. That thing has been cooking like a sunspot for a long time versus like your scary melanomas that pop up in like three months. Um, so not that those aren't as serious but that, that's like your 75 year old golfer who will stay home kind of a person. And then of course nail melanomas. Um, it's never a bad idea. Nails are hard, so always feel like you can refer those and then just don't forget bottoms of the theme between the toes. So dermoscopy is something that if you rotate with us where you just, I don't know, you guys do it. I don't have no idea. Uh, it's really hard. Uh, but dermoscopy. So if you see the little dermatoscope that we carry around and patients are like, is that a flashlight? Sort of. Um, it's, it's high magnification polarized, non polarized light. Um, it helps to bring out some of these features that we talk about. Please don't feel like you need to like have one of these. Um, but sometimes you can start to see like all these. Like this picture in the middle is like every bad feature that something could have. But a lot of these, like it doesn't take a dermatoscope to be like, that needs to come off. So um, but we use, we use it all the time to help us um, if the lighting is kind of nice but just to have more specific uh, information about a lesion. So like I was saying, broad shapes are preferred for sure for melanoma. So this is where you can get a false diagnosis. If you punch a melanoma or a mole that looks weird because part of it may be a melanoma in situ. Like just kind of skating along the epidermal dermal junction where this part over here was invasive and that's where you're going to get your breslow depth. So pretty much, unless it's like a really big, like I showed you that one that I said was a lentigo malignant and you're like, like that part looks fine but this part over here looks kind of weird. Pretty much always a broad shape or a melanoma because it can vary in a lesion and you need the most complete information to know truly what stage that m melanoma is. Um, so I have seen, unfortunately, multiple melanomas in pregnant women. Um, don't delay a biopsy. I had one who was told that she didn't need a biopsy, and so they waited until she had delivered and it was not good. Um, use lido without EPI and that's really all you have to do. Uh, so the path is what dictates treatment. So that is getting a little bit granular. But if people are like, you know, I, I make phone calls and I say melanoma and I can tell, like, holy crud. I'm, I'm, you know, like in getting chemotherapy, my hair is falling out. No, um, it's like melanoma and situ, such as skin problem. We haven't gone below the surface. Um, but it's that breslow depth that's going to tell you, like, is this person going to surgical oncology and stuff like that. So if you're ever cur a T1B, which is like 0.8 millimeters and greater with ulceration or 1 millimeter in depth, those are. That's when we start kind of circling the wagons with all the specialties. Um, for melanoma, they need skin checks every. A lot of people just kind of like one and done, and then they disappear. And it's like they need skin checks every three to six months for two to five years. The guidelines have kind of relaxed on that, but it's kind of a judgment call too. So everyone's a little bit different on how we'll do that. And then, gosh, this really just irritates me how it did that. Um, okay, so we went over the first degree relative. If they have a melanoma, definitely just do some regular skin checks. Um, with a history of non melanoma skin cancer, we want to see them at least once a year. These are the people. Gosh, nothing is a clinic day. Like someone who had a basil or like five basils five years ago, and then now they're coming in because you're just like, what have you grown? Um, so they just need to be seen regularly. Um, with melanoma, I will pretty much work up any symptom, anything that's like, just kind of weird. Now, obviously you're allowed to have a headache or a backache, but if they, if your patient has had melanoma and now they kind of have these weird symptoms, super low threshold. Um, even if it was a low stage melanoma. Like, these in metastasize whenever they want, which is the scary thing. And that's what freaks people out. Like, it can go 10 years, clean margins, whatever. And like, it happened to my sister's best friend from college. She's 36. She has metastatic melanoma to her brain, to her liver, to her mesentery, everywhere. And she had a clear margin excision 10 years ago. So if they're like, you know, you don't have to let your hearts. You probably are like, we have every symptom thrown at us, and I need to, like, not think about all of them. But if it's anything that just kind of doesn't sit right with you, just low threshold to work up. Um, and then don't underestimate your squams. So that's pretty much it. Yes.

Speaker B: Few questions with the ak. How long do you freeze? How many freeze cycles?

Speaker A: That's a good question. Uh, I think in our notes it probably says, like, seven seconds. No one can have freezing. Um, everyone's really different because you'll have the ones that start, like, whiplashing their head away, and then you're like, this is just not going to work. And a lot of those people, I'll just end up doing a chemo cream because, like, it's, like, pointless. Then you're, like, spraying all around it because they, like, won't sit still. Um, other people are like, I don't even know if they have pain receptors because they can tolerate it so well. Um, so like, three to five seconds, it's going to, like, turn it into an ice cube, so it turns it white. Um, but I just kind of do like, a few, like, little squirts like that, and then you just want to see it turn white. Um, everyone's really different. Like, you know, some people will be like, that didn't work at all. And other people are going to, like, blister. So every patient is just different. But I just do one. Unless it has that really thick crust on it. Um, if it has a thicker crust, I'll do a little bit longer. If I freeze.

Speaker B: How deep do you want to go with the melanoma frog shape?

Speaker A: That's a good question. So you don't have to scoop it out, because, of course, then that sucks if someone's like a nine lesion and now they have like a crater. Um, but it's basically, um. Gosh, I wish I could, like, bring you all into clinic. Um, you're not scooping down so much I would just kind of like wiggle, angle a little bit down and just try to get like the full lesion. So um, even if you transect it like that's still enough to make a diagnosis and that thing's getting cut out. But you don't have to like scoop, scoop down like that. You just maybe want to angle 15 degrees down and then just kind of do it that way. So the broad shave is mainly just try to get as much of the lesion off versus like the total death. Does that make sense?

Speaker B: Yeah. I was just wondering because you said with the screen, this is kind of one.

Speaker A: Yeah. If it like has that dome, um, appearance to it, those. So like my attending and residency, he would take an 11 blade and do like kind of a little cut at the top, cut at the top, cut at the top, cut at the bottom, or like kind of the four corners and those things would just pop right out when you scooped up because it's just really contained in that. But for the, the broad shave, it's really just try to get the full lesion. For the melanoma, don't worry so much about going like down. Just worry about trying to get the whole versus, like if I have someone that has a textbook basil, like you only need like a tiny piece. Like that's a, it's a really easy path diagnosis to make. Um, but a melanoma, it can just vary so much. And then the squams just, I've had them like blow right back up after you biopsy them if you don't get a lot of it out or they'll just sit there and bleed. And so it's more for like the patient's comfort to try to get like a decent amount of it out. But if you're not sure, I would take a shallow biopsy because then they're going to have like uh, a bad scar.

Speaker B: Right.

Speaker A: And that's where if you're like, that sounds like too much. I'm not dealing with that. It's really okay. Often with your shaves you do the desiccation and curettage. I, so I do it patient dependent. So I. Dr. Ladette, who we work with, thinks I'm like. Well, he doesn't say this to me personally, but I know he thinks I'm insane for doing it. But we did it a lot at our residency. Um, my like 85 year old, like, okay, you know, this, this, this basal on the arm is like not the root of our issues. I'll do it if it's a centimeter and under. But I never do it. Head and neck, ever, anywhere. That's a high risk area. I'll never do. Do it. So if it's like an arm, a back, it's like a real small one. I'll do those. Just. And for some people, they get surgery fatigue, so that's just something to be mindful of. Like, it's so easy to just be like, well, you have this, you need excision, you have this. But like, uh, some of these patients are like, they're over it because they've had so many. And so if you can just spare them, like, you know, one excision or something, I, I think they really appreciate it.

Speaker B: So.

Speaker A: And if it comes back, you cut it out and you deal with it then. But for it is. Their health comes into play for me a lot. So if they're. If they're not super healthy or they can't sit for a long time or something, I'll do it. Any other questions?

Speaker B: Yeah, why lido without EPI for the melanomas?

Speaker A: Uh, only for pregnancy.

Speaker B: Only for pregnancy, yeah.

Speaker A: So the EPI theoretically could contract their, um, like placental vasculature. Like, do I really think occ and a half? Probably, but.

Speaker B: Okay.

Speaker A: Yeah, just. Just to be safe. So I think, um, that's the only time you really have. I have some patients who have, like, feel they're very sensitive to it, but that's the only thing. So that's probably the only case that you'd have to do. No epi. Yeah, questions.

Speaker B: Do you know epion, like, if you're taking something off someone's nose.

Speaker A: No, that's a good question. Um, so fingers and noses, you don't have to, um. It blanches it out pretty good. So you'll be injecting it and it'll go like all white. And then the fingers, technically, like, if you can put under one or two CCs, you're probably fine. Um, but the nose bleeds like a mother. So you. I want the heavy. And if you can let it. If you're doing a scalp or something, if you can let it sit for 10 or 15 minutes, go see someone else come back. The scalp also bleeds like crazy. So, um, those are areas where, like the note. This is why I did not do most. Um, so know it that the most. If you can do epi, it's really nice, but it doesn't take very much. So if it's blanching around it like, you're probably pretty good on your dummy. Questions.

Speaker B: Ah,

Speaker A: well, if you guys have anything that's my email, even though it's kind of, like, over it. But, um. And then he has my email, too, so. Yeah. Hopefully you guys have a good Labor Day. Or maybe don't have to work. I don't know if that's realistic. It all gets better than. No, that was me. It. Of course, yeah, if you need it.

Speaker B: M.

Speaker A: I'm definitely.

Speaker B: Gotcha.

Speaker A: How's the hospital bed?