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Maggie McKay (Host): No matter where you live, the sun is out at least part of the year, and that can damage our skin and maybe even put us at risk of getting skin cancer if we don't try to prevent it. Thankfully, there are ways to take care of our skin. So today, we're going to find out more from Dr. Ryan Wells,

Dermatologist and MOS surgeon at Community Memorial Healthcare about dermatology, skin cancer prevention, and healthy skin tips.

This is Wise and well presented by Community Memorial Healthcare Thanks so much for joining us. I am so excited to talk to you, doctor, because I spend every minute I can outside, literally. And I live in Southern California, and the sun is always blazing here, so it never hurts to be reminded of how powerful the sun is and all the possible consequences.

Dr Ryan Wells: You're absolutely right, Maggie. It is a beautiful area and we all live in different parts of this country and we take advantage of the time we can be outside. But we definitely have to be cautious because the sun is our friend, but it also can cause some negative impacts on our life, in particular, our skin.

Maggie McKay (Host): What inspired you, doctor, to go into dermatology and become a Mohs surgery specialist?

Dr Ryan Wells: I actually didn't become a dermatologist and start my dermatology residency until about nine years after medical school. I initially entered the field of emergency medicine. And in medical school, you have to seek out a dermatology rotation, it's not one of the requirements. And I really had no prior exposure to dermatologist or needing to see a dermatologist prior to starting medical school, and so it wasn't really something on my radar. And I ended up enjoying nine solid years as an emergency physician, but always really enjoyed the skin presentations, whether it was a primary skin issue, like a cellulitis, which is an infection of the skin or an abscess, which is another type of skin infection or whether it was a viral exanthem, which is a rash you develop when you have an illness with a virus or some other clue on the skin that led us to understanding what was going on internally a little better. I was always interested in these findings.

And after nine years, I got the permission of my wife to pursue a second residency, which that was asking quite a bit, but she said, "Let's do it." And so, I started the second residency in dermatology. And early on in my residency, I came across Mohs surgery, which I had very limited knowledge of Mohs surgery when I started my dermatology residency. But as the years went on, I grew to truly love and appreciate dermatology in general and then, in particular, Mohs micrographic surgery.

Maggie McKay (Host): First of all, you are so lucky you've never had to go to a dermatologist when you were in, you know, high school or college for acne. That is amazing. And secondly, what is Mohs surgery? Because we hear about it all the time and I've had friends and even my mom had it. But tell us what it is.

Dr Ryan Wells: So, Mohs surgery is a specialized technique for removing skin cancers. It was initially developed in the late 1930s by Dr. Frederic Mohs, who was a general surgeon at the University of Wisconsin Madison. Over the years, it's become essentially the gold standard for the treatment of many skin cancers.

Mohs surgery is typically utilized for skin cancers in areas where you want to leave as much healthy skin as possible. Areas where healthy tissue conservation is critical. So, it's oftentimes used in the head and neck region. It's also used in other areas where you want to limit how much skin you remove, such as the hands, the fingers, the shins, the ankles, the feet, and a few other limited areas.

In addition, it can also be used for skin cancers that are not in these areas where you're really focused on tissue conservation, but areas such as the chest or the back or the forearms or the thighs, areas where you could take a little more tissue. But when you have aggressive subtypes of skin cancer, you may lean towards Mohs surgery rather than a standard excision. Mohs surgery is performed by one person, the Mohs surgeon, and their job is to remove the cancer and pathologically evaluate the tissue edges. And that's all done on the same day in the same setting, typically outpatient setting.

Maggie McKay (Host): And maybe 10, 20 years ago, it seemed like recovery from Mohs surgery was a pretty long process. How is it today?

Dr Ryan Wells: Recovery from Mohs surgery can take days, but oftentimes takes a week or two or potentially even longer based on how the wound is repaired following the removal of the skin cancer. And that'll of course be based on the size of the wound, how many stages are required to remove the cancer. It may also be related to where the cancer is on the body. Certain areas heal quicker than others and certain areas such as the lower legs heal very slowly. It also depends on what type of repair is performed. Sometimes we're able to keep the wound very shallow and we allow it to heal on its own, let the body do what it's really good at, and that's heal wounds. However, other times, which is probably the majority of time, we need to do a repair, and that can either be a straight line closure or it can be a tissue flap or even a full thickness or split thickness skin graft. And based on what type of repair is done, for instance with the graft, there's a much slower healing process. It's a much more fragile process. So, it can be potentially a week, two weeks, but it can even take several weeks to a month plus for complete healing of a Mohs surgery wound.

Maggie McKay (Host): And who is a good candidate for Mohs surgery?

Dr Ryan Wells: Typically, we work on patients that have skin cancers, and the most common skin cancers we work on are basal cell carcinoma, squamous cell carcinoma, but we also work on less common skin cancers. But in general, at least the majority of our patients have a basal cell carcinoma or a squamous cell carcinoma. And we focus on using Mohs surgery only for patients that need Mohs surgery. And there's actually something called the Mohs appropriate utilization criteria. And for us to push forward with Mohs surgery, typically we need to qualify with the Mohs appropriate utilization criteria. That was put into place so that not every tumor gets treated with Mohs surgery because it is more labor and time and potentially even slightly more expensive type of removal and repair versus doing a standard excision, not much more and definitely significantly less in the operating room, but we do try to limit which patients are treated with Mohs surgery. So, as I discussed a little bit earlier, potentially patients that have cancers on the head and neck region, hands, fingers, lower shins, and feet and ankles, places where we really want to limit the healthy tissue removal. We want a spare removal of tissue that doesn't need to go away.

In general, when it's off of those areas, we typically only treat with Mohs surgery for more aggressive subtypes of skin cancers. And those would be cancers that may have an infiltrative pattern or what we call a morphea form or scarring pattern that creates a little bit more difficulty in knowing where the margins are, which makes standard excision more difficult because you're guessing to a degree and you don't know with certainty that you have the cancer removed when you do a standard excision until you get the pathology results back maybe a week or so later. So, Mohs surgery really is used for patients that have cancers in areas where we need spare tissue or cancers that are more aggressive.

Maggie McKay (Host): Do you always have to have plastic surgery after Mohs surgery or not?

Dr Ryan Wells: No, you don't need to see a plastic surgeon after Mohs surgery a good percentage of the time. I think there are a couple reasons why I will typically send patients to a plastic surgeon after Mohs surgery, and one would be the repair is one that is big enough that I truly think they will benefit from having some sedation that puts them in a twilight or potentially under full general anesthesia. However, I do the vast majority of repairs in my office that same day.

When you do your Mohs surgery fellowship, I mean, your training is on skin cancer removal, the pathologic evaluation of the margins. And as I mentioned, it's a hundred percent margin evaluation. And you also train in reconstruction of facial wounds and defects, as well as wounds and defects on pretty much the entire body. Another time when I may send a patient for plastic surgery is when we start to go in areas that are very difficult to access, like into the ear canal or other areas that are tough to access without specialized instruments and also a little bit difficult for patients to do when they just have local anesthetic on board.

Maggie McKay (Host): And Dr. Wells, a lot of residents in Ventura County, California where you practice, which is so gorgeous, enjoy spending time at the beach, surfing, hiking the trails, just outdoors in general. So, what are some skin cancer prevention tips that you tell your patients?

Dr Ryan Wells: One of the reasons we live in Ventura County is because it is beautiful and you are able to be outdoors much of the year, if not all of the year, but that also does put us at risk for developing skin cancer. So, what I'll oftentimes recommend to my patients is, number one, sunscreen. When you're outdoors, you're going to want to be using sunscreen. I typically recommend using a sunscreen that's at least 30 SPF, broad spectrum, meaning it covers UVA and UVB, and typically water-resistant or very water-resistant. I oftentimes will actually recommend a 50 or higher because that sunscreen wears down as time goes on, and 30 gets down pretty low pretty quickly.

In addition, I'll typically recommend sun protective clothing, broad brimmed caps, because baseball caps really don't protect anything but our scalp and our forehead. But our ears, our neck, our lower and mid-face are all exposed with baseball caps. So broad brimmed caps as well as maybe some UV protecting long sleeved shirts. And if you're really going to be out, especially if you're up in the Eastern Sierras or hiking at altitude, potentially long sleeved shirts and even gloves. And especially if you're a fisher person or spend a lot of time at the water and you get a lot of reflection, you're getting more than even a hundred percent of the UV coming down because you're getting the reflection as well.

Maggie McKay (Host): And what about reapplying? How often? I'm always so confused about that with sunscreen.

Dr Ryan Wells: That's a great question and there are some caveats to it. In general, the rule is to reapply every couple of hours because it is wearing down. With time, the SPF, the sun protective factor is wearing down. So you start off at a 30, you go to a 25, then a 20. And as time goes on, it becomes less protective. So even if you're not doing anything special like swimming and toweling off or sweating, which those actually increase the speed at which it comes off the skin or loses its SPF, you still should apply every couple of hours. Then, I usually will recommend if you're swimming out in the ocean, come in and towel off, you've probably taken a good percentage of that protective factor off, and you should reapply. So, at least every couple of hours when you're outdoors.

Maggie McKay (Host): Okay. That's good to know. And you have three daughters. I have a teenage son. He's a surfer. How in the world do you get them to put on sunscreen every day? Because I am telling you what, it is a constant battle.

Dr Ryan Wells: It really is. That has been quite difficult. It's easier said than done. You give all these recommendations and then you have teenagers. It was a lot easier when they were seven or eight and younger. Yeah, I have three teenage daughters who love to play sports outdoors. They actually love to get into the ocean and surf a little bit, and so it is difficult. That being said, I just really, really emphasize to them that I stay very busy related to skin cancer treatment. I personally have had skin cancer and I did what they are currently doing and wasn't wearing sunscreen. So if they want to try to avoid getting skin cancer, which is very, very common for people that grow up in this area, they really need to focus on when are they outside? Are they applying sunscreen or wearing sun protective clothing? Now, do they do that every time? Absolutely not. You know, even with a dad who's a dermatologist, it's not like it automatically will happen. I do my best. They will battle me, and we just see what we can do.

Maggie McKay (Host): Right. I tell my son, it should be like brushing your teeth. Right after you brush your teeth, put on your sunscreen. It should be an everyday occurrence. But anyway, is skin cancer easy to see or detect? Because I had it. I didn't even know it. It worked out fine. They got it. But do young people need to worry about skin cancer?

Dr Ryan Wells: It's very uncommon to develop skin cancer under 20, extremely uncommon and quite uncommon under 30. It becomes a little bit more prevalent in the 30s. But really, skin cancer oftentimes appears in the 40s, 50s, and then increases every decade after that. Some of that is due to chronic exposure and just the additive effects of more and more UV over the years. But also, some of that is related to the ability of our own skin's immune system to survey for injuries and repair. And as we get older, we repair less efficiently.

So going back to your question, is it easy to see? Sometimes very easy, sometimes quite difficult. And so, that's a little bit tricky. So, sometimes you'll get a big, rough, scaly nodule grow really quickly, and it's not a subtle process. Or you develop a really shiny kind of pink bump that breaks down and bleeds on itself, that's also not very subtle. But then, there are much more subtle presentations as well.

Maggie McKay (Host): And how important is the yearly checkup as we age? And when when should we start doing that?

Dr Ryan Wells: Definitely there's a lot of debate relating to that. So if you have a family history of melanoma and have a lot of moles, it's probably important that you start at a younger age. If your family member had melanoma at a younger age, you should probably start at a younger age, late teens, early twenties for once a year. And if the dermatologist looks at your skin and says, "Hey, you're extremely low risk, let's make it every couple of years," then that's fine. But if they see a lot of moles and potentially some questionable moles, it might be where you're coming in every six or 12 months indefinitely.

If your family member has had a basal cell or a squamous cell but not a melanoma, then you may be able to start a little bit later, potentially in the 30s. That being said, the caveat is if you ever have something that's suspicious. And what I mean suspicious, something that doesn't look like anything else you make on your skin, or you have a mole that all of a sudden is changing, either its color pattern or its size, or it's becoming itchy or bleeding, or it develops a little ridge or scalloping where all of a sudden it's no longer a smooth, circular or oval area, then you might want to come in. Even if you're younger than your 30s or 20s, you just come in and get a check on that, and then you can get kind of a global analysis and recommendation on when you need to come back, if you need to come back.

Maggie McKay (Host): When it comes to skincare and preventing signs of aging or acne, what are some helpful tips that you can share with us on that?

Dr Ryan Wells: I think that almost one, two and three are going to be sunscreen or sun protective clothing but, more likely, and, in addition; sunscreen and sun protective clothing. The sun has quite an impressive effect on the aging of our skin. And so, I think that if you are really focused on sun protection, you're going to do a very good job at limiting that aging of the skin.

As far as acne goes, gentle face wash, if you have mild acne, ones that are not too drying or bothersome with different active ingredients in them. Simple things like Cetaphil or CeraVe, just gentle face wash. If you have more inflammatory acne but not quite enough to go see a dermatologist, then you might want to use some face washes that have some active ingredients like a benzoyl peroxide or potentially a salicylic acid. But if you're having difficult to control acne and it's bothersome, you can probably get a much better tailored and specific regimen or protocol to use if you go see a dermatologist.

Maggie McKay (Host): Definitely. I have to tell you, I was just so grateful when Accutane came out, because after 20 years my mom always said, "I put that doctor's kid through college" because I had to go literally 20 years. And then, Accutane and totally gone. It was like a miracle.

Dr Ryan Wells: Accutane, it's a game changer for a lot of patients because for the type of acne that Accutane works for, there's not a whole lot out there that'll do what Accutane can do. So yeah, you're absolutely right.

Maggie McKay (Host): Great advice. Thank you so much for sharing your expertise and helping us keep our skin healthy and hopefully preventing skin cancer.

Dr Ryan Wells: You're very welcome. It's been a pleasure, Maggie. I really appreciate the time to talk with you.

Maggie McKay (Host): Again, that's dermatologist, Dr. Ryan Wells. For more information, please visit my cmh.org. That's my cmh.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you.

This is Wise and well presented by Community Memorial Healthcare. Thank you so much for listening