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Melanie Cole (Host): We all know that a sunburn can be very painful but that’s not the most important reason for using sunscreen. My guest today is Dr. Craig Neitzel. He’s a Dermatologist with the Carle Foundation Hospital. Dr. Neitzel, let’s start with a little lesson because not everybody knows, not even other providers always know about UVA, UVB. What do they do to our skin?

Craig Neitzel, MD (Guest): Well it’s important to know that both of them can cause damage to our skin. Some people think that if they are sitting by windows, some sunlight can’t penetrate or even through a car window. And actually, a lot of that is not true. So, some of those can get through and both of them again, can cause sun damage and ultimately what we’re worried about is more of the skin damage that comes with it and especially skin cancer.

There are, as we lead into this, three major types of skin cancers that we see and we actually have, in the United States alone, millions of cases of these, every year. Current literature will say that for a basal cell skin cancer, which is the most common, there are probably almost four million cases in the United States alone.

The next level one is what is called a squamous cell skin cancer and there are easily over a million cases of those a year and then further on, the one that we are actually even most concerned about is what’s called a melanoma. And those are the ones that have a much higher fatality rate and there are hundreds of thousands of those a year. So, the whole goal when we talk about sun damage, is prevention. And most of these, especially the basal and the squamous cell skin cancers, can be prevented because they are more due to a cumulative sunlight exposure whereas the melanomas tend to be more related to a sunburn.

So, ideally, starting from day one of life, if we can be good about our sun protection; then hopefully we can really prevent these or even if we develop them, really minimize them.

Host: What a great explanation. Dr. Neitzel, how often should we be visiting a dermatologist to see about our skin and for other primary care providers, what do you want them to tell their patients about when it’s time to see a dermatologist?

Dr. Neitzel: Well, it’s a great question. And ideally, it would be fantastic if everybody could do their own self skin exams monthly or at least quarterly. And if you are lucky enough to have a significant other that can look at areas like your back and your backside and back of legs; that’s also important because those tend to be critical areas for where melanomas develop.

We think, especially if somebody hasn’t had skin cancers and they are healthy and let’s say they are good about their sun protection; at least an annual skin exam is definitely valid. Now if they don’t have many problems and their primary care physician is comfortable in doing it; that’s totally acceptable and they do a great job at working with us and especially if they see something that looks abnormal, they can deal with it or refer to us for those types of exams.

We typically though, if somebody has had a skin cancer, we see them more frequently. Especially for a basal or a squamous cell skin cancer, a lot of dermatologists will see those patients every six months for a while and if they remain cancer free, then annually. Melanomas are a little bit different because we see patients more frequently over the first few years, maybe even every three to four months, then every six months, then even annually after about a five year mark. But the biggest key is, really paying attention to your own body, watching for anything that may have changed and we can get into that too, because it’s kind of part of your question is what am I looking for.

Host: That’s exactly right. That’s where we were going with this. So, tell us, what are we looking for?

Dr. Neitzel: I figured that would be a good lead in. So, essentially for the two most common types the basal and the squamous cell skin cancers; these typically tend to be bumps that don’t go away. It’s something like it would be a red pimple or waxy like bump for a basal cell skin cancer where you think geez, I think this pimple has actually been there or this bump has been there for a few months and wont resolve. Sometimes, they’ll crust and scab and particularly too, they can also bleed. But they will also try to heal at the same time. So, they cycle through this a lot. So, if somebody has found a lesion that keeps crusting and scabbing and bleeding and crusting and scabbing and tries to heal; those are the major things that we want to see for that. And it’s not something that if something has only been there a few days, that we typically get really worried about it unless it’s really rapidly expanding. But if somebody says boy, I think this has been there for a few months and hasn’t resolved; that’s what we want to know about.

Now a melanoma is a little bit different because those can also crust, scab, bleed and not heal, but they don’t always. Those are the ones that look a little more different where they are more irregular, they have multiple colors, they look irregular in their border and they also have sometimes something that’s growing a little rapidly as well. So, it’s something that when people look for those things; I think some of the bigger words that I use; is it changing, is it different, has it been something that’s progressing? And if that’s something that somebody sees; then we want to know about it.

There are some lesions that people can come in for that can make some changes like that, that can be benign; but that’s great. But at least we’ve ruled that out and then we can all kind of sleep well with that. Or if we see something else suspicious; then maybe we do need to treat it.

Host: Well let’s talk about treatment. If you do detect that someone has skin cancer, whether it’s something that they spotted or a loved one; what do they do next? How do you tell if it’s cancer? What treatment options are available if it is?

Dr. Neitzel: Sure, it’s a good question. Well, first of all, coming in is probably the biggest thing, recognizing that something’s going on or coming for their regular skin exams and we notice something that needs to be treated. Now, some of these can be in a precancerous realm where they are early on and sometimes, we will treat those with what’s called cryotherapy which is treatment with liquid nitrogen where that’s applied to the individual lesion.

But let’s say if we are suspicious for it being a skin cancer like a basal or a squamous cell skin cancer, or even a melanoma; then we will do a biopsy of it. and there are different ways of doing a biopsy. You can do something that’s called a shave biopsy where if we are suspicious more for a basal or a squamous cell skin cancer; essentially under local anesthesia, where we numb it up, you shave that spot off and we send all these in to have them looked at underneath a microscope for pathology. And it’s the same thing with a melanoma. Although typically, if we suspect something to be a melanoma; more often in that we will do something that’s called a punch biopsy where you take a piece of the lesion or you try to cut out the whole lesion, what we call an excisional biopsy.

Regardless to that though, we still send everything in to have it looked at underneath a microscope for pathology. Because that will then tell us what we are dealing with and sometimes, with a basal or squamous cell skin cancer; you can remove it all with doing the biopsy if they are small and early. If it’s a melanoma, that being more aggressive, essentially all the time, they are going to have to have more surgery but depending upon it’s depth and there are some other characteristics for it; that might make it more aggressive. Sometimes people have to get set up with an oncologist for chemotherapy and there are a lot of other newer therapies that are out there that we work with the oncologist in getting somebody treated for a melanoma.

The bottom line for this whole thing though is for everyone of these, the earlier you catch it in it’s development; the better bar none. Because even for a melanoma; the ones that we are super concerned with; if we catch it early and being in situ or very thin, then there’s a lot of times the only thing the patient will need is surgery and then their regular skin exams and the five year survival rate is much greater in that category than if it’s something that’s deeper and more invasive. And we can even say the same thing for a basal and a squamous cell skin cancer.

It’s fairly rare for a basal cell skin cancer to spread to the rest of the body, but they can become very invasive and very destructive and then a squamous cell skin cancer can metastasize. So, it’s not a zero sum affair with any of these, but kind of the long winded way of saying it; we evaluate it, pretty much standard therapy is to do a biopsy to see what it shows, then we decide treatment from there.

Host: What a great explanation Doctor. So, Boomers, we were never really aware of the risks. If we use sunscreen now, are we decreasing the risk, or did we do that damage at our younger years and the damage is done and we can’t do anything about it now?

Dr. Neitzel: That’s the 64,000 dollar question. And I smile you saying it because it’s not a never too late situation. In a lot of studies, and even what we’ll see clinically is that even let’s say somebody starts today about being good about their sun protection and we will get into that in a second; but you can actually prevent further damage, because like we talked about before, it’s cumulative so every little bit that we get adds up ever since the day we were born to the day we die. And by preventing more damage; then hopefully we are helping preventing more of the development of new lesions and the progression of old lesions.

So, inherently, it makes sense that even if there’s not been a day in your life where you’ve been good about your sun protection; if you start today, you’ll definitely have an advantage for that. Now, I think the obvious part to that though is that if you start day one, you will be way better off on how your skin does and we’re not even talking from a skin cancer standpoint, we’re also talking about it’s appearance standpoint. Wrinkling, freckling, age spots, blotchy skin, skin that’s thin, bruises and tears easily. A lot of that is due to chronic sun damage. So, if we can really start early, way better, but I do agree, this is something that we’ve really learned over the last several decades of knowing that we have to be good about our sun protection.

Host: Well, so tell us how to do that. There’s a lot of sun protection on the market. You go into the pharmacy and boy there’s 50 different things from 10 to 70. What are we looking for? What do you want us to know about sunscreen and Doctor, while you’re answering that, does it expire? Should we get new sunscreen every year?

Dr. Neitzel: All the above. So, we’ll start with the number one thing is avoidance. The more you can do things such as staying in the shade, staying under umbrellas, trying to do things earlier in the day and later in the days opposed to straight at noontime; that’s a big part to it. the second part to it, hats and clothing. Trying to wear a wide-brimmed hat and we are a little bit lucky nowadays too because there are so many different makers of sun protective clothing now in brands, it’s lighter weight, it dries easily. It’s the same thing that we use and use on my own kids what are called swim shirts or sun shirts. They’re great because they are long sleeves, they don’t wipe off or sweat off, they are easy to take on and off, they dry quickly. So, even if they come out of the pool or off of the beach; they can put them back on and get back in again.

So, those are really big parts to that. Now the question comes too when it comes to sun protection with sunscreens, there are a few keys to that. The first is, trying to put it on 30 minutes even before you go out, so you are not trying to do it as you are running out the door and it gives it a better chance to stay in place and get spread all over your body. Typically we tell people, you want to use a sunscreen even from a daily use of at least a 30. Now it really doesn’t have to be much higher than a 50 because it really plateaus out in its ability to block light, but we want, and most of them do now, it should say to block UVA and UVB light and have a minimum of a 30 for a daily use.

And I bring this up with a lot of patients too and you probably hear me reiterating daily use because even a lot of our sunlight exposure comes from a daily exposure. When we try to add it up, if you think about going to the car, walking to the mailbox, going out for lunch, walking back and forth to class. It really adds up to all of the sudden people like well geez maybe I did have an hour or two of exposure where I wasn’t even just laying out or mowing the grass. So, that’s where the sun protection really plays a big role in that.

Now, most sunscreens typically, I tell people get a new sunscreen every year. Because if they overwinter or they are left in your car or in your golf bag or they are out at the pool; they still get exposed to all of these temperature changes, so it may break them down and secondly, it inherently just makes sense to get a new one every year so essentially you are getting a fresh fully active sunscreen. And truly, again, the biggest keys, using one that has UVA and UVB protection and has a number of at least a 30, but it really doesn’t have to be any higher than a 50. Now sometimes, I have patients say that they got one that’s a 70 or an 80; but they like it better because they like its vehicle or it’s easier for them to spread. And I have no problems with that, it’s just that it doesn’t gain them much more over what a 50 would be. But if I find that they like it, then I know they’re going to use it and reapply it.

And that’s the other crux of the matter is making sure that they reapply it as well. It isn’t just that you get to put it on before you go out the door, and you have this feeling that I’m okay for the whole day and I can have hours of sunlight exposure and we don’t want people to have that kind of false thought with that. The idea is that if you put it on ideally, especially if you are out, hot sweaty, swimming, towel drying, whatever, that you should reapply it at least every two to three hours.

It’s like I tell a lot of golfers, it’s like if you are playing golf; after you finish the first nine holes; try to reapply it before you go back out for the second nine holes.

Host: Wow, what great information. You are an excellent educator, Doctor. So, as we wrap up, what would you like other providers to know about counseling their patients on the importance of sunscreen, on the importance of avoiding sunburn at all costs and when we should be seeing our dermatologist and having that overall body check?

Dr. Neitzel: I think it’s important for them to discuss this with every patient that they see. I almost put it akin to talking about smoking, weightloss, and blood pressure because the number one thing of cancers in the United States right now is skin cancer. Something that’s preventable. So, if you are going to talk about stop smoking and losing weight and do these things; your sun protection should be easily part of that. It just inherently should be part of everyone of their visits especially for their yearly physical.

Stressing like we talked about hats, and clothing and sun protection and the one thing that we really like to try to tell people is there’s no such thing as a safe tan. And I try to remind myself to make sure I tell that to everybody too because people think oh, I get this base tan and then I’m good. Well, there really isn’t much evidence that shows that that prevents sunburns and like we talked about before, every little bit that we get, adds up. So, it’s still an added effect to that. And I think that they should really reiterate to their patients as well, what are they looking for, looking for changes to moles, looking for lesions that don’t heal, and there are a lot of primary care physicians that are just excellent at doing that and some of them are very comfortable in doing biopsies.

The flip side of that though is, I think it’s inherent from us in dermatology, is for us to available that if somebody has a spot, that we are available to take care of it. We work really well with our primary care physicians here at Carle. We have a fantastic relationship with them so that they know that if somebody needs to get in; we do everything in our power to get them seen as soon as possible so that we put their minds at rest and sometimes too, if we can take care of it sooner, then we don’t even have to do a biopsy of it or can maintain it and still try to impress upon them how much they need to be diligent with their sun protection and getting them in the habit of what to watch for, for their overall skin regimen.

Host: What great information. Dr. Neitzel, thank you so much for joining us today and sharing your expertise. What really a great segment. That wraps up this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, head on over to our website at www.carleconnect.com for more information and to get connected with one of our providers. If you found this podcast as informative as I did, please share with other providers, share with your friends and family, on social media and be sure to check out all the other interesting podcasts in our library. I’m Melanie Cole.