Collaboration between the dermatologist and the aesthetician leads to improved patient outcomes and can potentially save lives. The skin care clinician can also work with patients prior to surgical procedures to help get the skin as healthy as possible. Healthy skin responds better during surgical procedures and heals more quickly post-procedure. Providing appropriate guidance on preparing patients’ skin for treatment and on protecting it afterward is an important contribution the aesthetician can make in the process of caring for the patient with skin cancer.

Assessing the Risks
In a study of 8,000 Americans, published in the Journal of Dermatologic Surgery, 94 percent were concerned that exposure to UV radiation could lead to skin cancer. Unfortunately, 68 percent also felt that they look better and healthier with a tan. This false perception of a “healthy tan” has fueled a continuation of the practice of sunbathing and also the use of indoor tanning beds. On average, one million people tan every day. This poses a significant health risk, as it has been proven that sun exposure is the most preventable risk factor for all skin cancers.

Precancer
Actinic Keratosis (AK) lesions are typically small, red, crusty, scaly bumps. According to the Skin Cancer Foundation, more than 10 million people currently have AK. Those with fair skin are more affected, and men are more likely to develop AK than women, likely due to less frequent use of sun protection and skin care. Sometimes AK lesions are first detected by touch rather than sight. These lesions may feel like sandpaper and sometimes they itch, become irritated, and even bleed. Actinic keratoses are considered precancers, as up to 10 percent develop into squamous cell carcinomas. Patients that potentially have any AK should be referred to a dermatologist, as catching cancers at this early precancerous stage improves patient outcome.

Non-Melanoma Skin Cancer
Non-melanoma skin cancer (NMSC) is the most common form of cancer in humans. There are two types of NMSC, basal cell carcinoma (BCC), representing 75 to 80 percent of NMSC, and squamous cell carcinoma (SCC), 20 percent. One million new cases of BCC arise each year, making it the most common type of skin cancer. BCC tumors originate at the basal layer between the epidermis and dermis and can appear as pearly translucent lesions with small blood vessels or as an open sore that does not completely heal. There are over 26 different subtypes of BCC that have been identified, so its appearance on the skin can take many forms. It is most commonly seen in individuals with lower Fitzpatrick, fair skin, and is typically a result of over-exposure to UVA and UVB rays. The lesions are most common on areas of the body that get the most sun exposure like the face, ears, neck, and back. Although it is usually only locally invasive and rarely metastasises or spreads, if left untreated it can cause damage to the skin around the lesion, permanently scarring, and adversely affecting a patient’s appearance.
The Skin Cancer Foundation notes that 250,000 new cases of SCC are diagnosed in America each year. SCC originates in the squamous cells in the epidermis. It often develops from AK and can spread quickly. It frequently appears as red, scaly lesions that persist and do not heal properly. Chronic exposure to UV rays is the primary cause of most SCC, making the top of the ears, nose, and other areas of the body that receive an abundance of sun exposure the most likely to develop this form of skin cancer. Larger SCC lesions pose a greater risk of the cancer transferring to other parts of the body via the blood or lymphatic systems (metastasis), which means that they can be deadly and destructive.

Melanoma
Melanoma is defined by malignant tumors that arise from the melanocytes, the cells that produce pigment, and it is the deadliest of all skin cancers. Although fair-skinned individuals living in areas of excessive UV exposure, those using tanning beds and people with a family history of melanoma are at greater risk of developing this form of skin cancer, anyone can get melanoma. If recognized and treated early, the prognosis is quite good. If untreated, melanoma can metastasize, spreading to other organs, which makes treatment difficult and frequently results in death.

Identifying When There may be a Problem
The standard for identifying melanoma is the ‘ABCDE of detection.’ This is a screening tool and is not intended as a way for the aesthetician to diagnose skin cancer, as that is outside the training and licensure of an aesthetician. It is, however, an incredibly useful tool for the clinician to identify the warning signs so they can refer their patients to a dermatologist for diagnosis and treatment, if necessary.

Treatment Options: Precancer
There are several options for treating AK. Chemical peels, particularly TCA, have demonstrated benefits for reducing and removing precancerous AK. Once the treating physician has cleared the patient of the problematic AK, the aesthetician can continue the chemical peels for the patient as a preventative measure against recurrence. Chemical peels also are a great preventative treatment for a patient with a large amount of sun exposure and solar damage.
Topical chemotherapeutic drugs such as 5-FU (flourouricil) and imiquimod can be used to remove AK as well. 5-FU is a cytotoxic drug, meaning it kills precancer and cancer cells. It does not kill healthy surrounding cells during treatment, although it does cause severe inflammation, crusting, and peeling, which is considered an expectation, not a complication. Imiquimod is an immune response modifier that stimulates the immune system to fight off certain skin diseases, such as AK and superficial BCC. Both of these topical therapies can be beneficial as they clear existing AK in addition to lesions that have yet to become easily visible. 5-FU and imiquimod both cause some similar dermal side effects as internal chemotherapy, like inflammation and severe dryness. The clinician, working with the physician, can help patients overcome these uncomfortable challenges by recommending topical products designed to soothe, hydrate, and protect vulnerable skin. These same skin care recommendations also work well for patients undergoing traditional chemotherapy or radiation therapy for other types of internal cancers like breast, colon, or lung cancer. Products that do not contain any colors, fragrances, or other known sensitizers are the best choice during and immediately after any course of cancer treatment whether internal or topical. Once the skin has returned to baseline, it is of the utmost importance that the patient is properly educated on how to care for their skin to avoid recurrence. The topical treatment options, unlike internal chemotherapy treatments, infrequently cause hyperpigmentation, but the treated skin is vulnerable and needs adequate protection. It goes without saying that daily use of a broad-spectrum UVA/UVB sun protection moisturizer is an absolute must at all times but especially for those who have had previous skin cancers.

Treatment Options: Skin Cancer
BCC and SCC can be treated in multiple fashions. Superficial BCC can sometimes be addressed with the same topical chemotherapeutic drugs that are used to treat AK. Internal chemotherapy is almost never employed to treat skin cancer; rather, topical chemotherapy or surgical excision is the usual treatment plan.


Both BCC and SCC can be removed using either surgical or an even more exact method of excision called Mohs micrographic surgery. Mohs surgery uses a technique during which the tumor, as well as a very small margin of healthy tissue surrounding the lesion, is removed. The tissue is cut, dyed, frozen, and made into microscopic slides. The slides are then reviewed by the dermatologist to ensure all cancer cells have been removed. If there is any cancer left, the Mohs surgeon, who is also a dermatologist, removes an additional small area around the remaining tumor using a mapping system. The process is repeated until the slides are clear of any cancerous cells. Compared to all other skin cancer treatments, the cure rate using the Mohs method is the highest, and the rate of recurrence is the lowest. Once the lesion is gone, the surgeon can reconstruct the area to ensure the best cosmetic outcome and the smallest possible scar. It is for these reasons that Mohs is the best option for removing lesions that are in cosmetically sensitive areas or areas that would benefit from removing less tissue for functional reasons, like the eyelids or hands.
For SCC and BCC that are less concerning, like those on the body, arms, or legs, traditional surgical excision is the more common method of treatment. The tumor is removed with a safety margin of normal tissue and closed using stitches. The slides are sent to be processed by a dermatopathologist to confirm that the cancer has been completely removed. This usually takes a few days as permanent rather than frozen sections are used.
Surgical excisions are also used for melanomas, because physicians prefer not to use frozen sections for melanomas, as the freezing process used in Mohs slide preparation can distort the melanocytes, making reviewing the slides more difficult and less consistent. For thinner melanomas, “slow Mohs” with permanent (non-frozen) slides is occasionally done over several days to trace out the irregular borders of the tumor. Once the melanoma is completely removed, the patient then returns to the dermatologist at frequent repeated intervals – as often as every three months – for skin checks so that both the patient and the physician are confident the tumor is not recurring and to ensure the patient is protecting their skin from the sun and using proper skin care. After the patient is released by the dermatologist, the aesthetician can address the potential post-inflammatory hyperpigmentation that can be left behind following the surgical excision of a skin cancer with peels and daily home care.

Prevention: The Most Important Lesson
It is known that over-exposure to UV rays is the primary cause of skin cancers. The aesthetician has a unique opportunity to influence patients, as they often see patients that never or infrequently see a dermatologist. Watching patients for any suspicious lesions can truly be a life-saving contribution. In addition to this referral to a dermatologist, taking time to educate patients on
the importance of daily sun protection and avoidance is critical. The aesthetician can make product recommendations and work with patients frequently to reinforce that sun exposure is not only the predominant cause of skin cancer, but it also leads to premature aging, hyperpigmentation, and other negative skin outcomes. The dermatologist and the aesthetician both play important roles in keeping patients’ skin healthy and beautiful. Fostering this relationship will lead to better treatment options for patients and hopefully work toward reducing skin cancer rates in the future.

Jennifer Linder, M.D., serves as Chief Scientific Officer for PCA SKIN®, guiding all product development and clinical trials for the company. A board-certified dermatologist and a fellowship-trained skin cancer surgeon using the Mohs micrographic technique, Dr. Linder is one of the foremost U.S. experts in the use of the cosmetic filler, Sculptra. She holds a clinical faculty position in the Department of Dermatology at the University of California, San Francisco.