Lesion Removal

Skin Cancer Treatment and Mole and Skin Lesion Removal in Bethesda, Maryland

Some types of moles or other skin lesions are with us at birth, while others develop over time as a result of age, disease, or environmental factors. While most are benign, moles or skin lesions are turning out to be malignant with the potential to be life threatening or to cause severe disfigurement, now more than ever before. Many skin growths, including moles, remain in an intermediate phase and are benign, but lesions maintain the capacity to become malignant if left untreated. Whatever their cause, whether they are benign or malignant, skin lesions and moles are often unwanted and although many are harmless, they can be removed for health or cosmetic reasons.

Mole removal and the treatment of moles and other skin growths is very individualized, depending upon the nature of the lesion, any history of change, the age of the patient, and the location on the body. It is of vital importance to determine if the skin lesion is benign and harmless. Dr. Roger J. Oldham performs various types of skin lesion removal, including mole removal and skin cancer treatment, for individuals in and around the Bethesda, Maryland and Washington, D.C. areas.

Benign Pigmented and Nonpigmented Skin Lesions

Benign skin lesions can be categorized into two groups:

Benign Pigmented Skin Lesions


SKIN GROWTH

FEATURES

TREATMENT

Moles (Nevi)

Typically round or oval, can be flat or raised, color can range from tan to dark brown

Surgical excision with suture repair

Atypical moles (Dysplastic Nevi)

Typically larger than normal moles, usually oval in shape, often darker in the center and can have “fuzzy” margins

Surgical excision with suture repair or shave excision for a changing mole

Congenital Nevi

Often larger than ¼ inch in diameter, statistically higher incident of developing into melanoma

Surgical excision (if the appearance changes)

Lentigo (also known as sun spots, liver spots, or age spots)

Ranges from very small to an inch or more in diameter, usually flat, appears after middle age

Laser, electrocautery or freezing

The most effective treatment is laser if there are no suspicious features. It may also be frozen but, unlike laser, this can lead to scarring. Any lesion that changes should be biopsied.

Seborrheic Keratoses

Can be flat and smooth but more often become raised with a rough surface and feel itchy, often pigmented and can become black,

occur after middle age

Shaving, scraping or freezing

Dermatofibroma

Usually only lightly pigmented, very slightly elevated above the skin level, small hard lump that can be felt extending below the skin level

Surgical excision



Benign Nonpigmented Skin Lesions


SKIN GROWTH

FEATURES

TREATMENT

Cyst

Presents as a lump under the skin which is usually very superficial and attached to the undersurface of the skin

Cysts do not always require removal, but there is always a risk that the cyst will become larger or infected, leading to a prolonged drainage and healing time.

Lipoma

Presents as a lump under the skin similar to a cyst, but it is not attached to the skin and usually lies at a deeper level

If the mass becomes larger, as with a cyst, or changes in any way, surgical excision is recommended to be assured the mass is benign.

Congenital Nevi

Often larger than ¼ inch in diameter, statistically higher incident of developing into melanoma

Surgical excision (if the appearance changes)

Actinic Keratoses

Usually presents as a flat pink slightly scaly patch

This comes from sun exposure and is considered a premalignant lesion.

Freezing, biopsy recommended

Keratoacanthoma

Round elevated nodule that is often pink or red and usually has a central crater, usually grows to a relatively large size in a short period of time, easily confused with squamous cell carcinoma

Surgical excision

Pyogenic Granuloma

Raised round growth which is usually red in color, bleeds easily, usually a result of a superficial injury

Electrocautery or surgical excision

Angiomas

Flat or very slightly elevated from pinhead size to ¼ inch, sometimes looks similar to a pyogenic granuloma

Laser, electrocautery or surgical excision for larger lesions

Warts

Usually raised and flesh colored with a very uneven skin surface

Freezing or surgical excision

Skin Tags

Usually appear on the neck, underarms, beneath the breasts, or upper thighs and often become easily irritated

Surgical excision or electrocautery


Treatment of Benign Skin Lesions

There are many different methods of skin lesion and mole removal that Dr. Oldham uses at his Bethesda and Washington, D.C.-area practice, depending on the history of the lesion and the size and nature of the growth. The techniques most commonly employed are: surgical excision and repair, shave excision, freezing (cryotherapy), burning (electrocautery), and laser treatment.

Surgical Excision

In order to achieve complete lesion and mole removal, to minimize the chance of a recurrence, and to have adequate tissue for evaluation, lesion excision and mole removal with repair are usually the most advantageous techniques. The lesion is removed and the skin edges are brought together in a straight line with fine suture material. The lesion or mole can then be submitted for pathological analysis, where any cancerous cells will be identified.

Shaving

Growths with the appearance of a more superficial lesion are effectively removed through shaving. The lesion is then submitted for pathological analysis to see if cancerous cells are present.

Cryotherapy or Electrocautery

Cryotherapy, or freezing, is a treatment for an unsuspicious skin lesion that appears superficial. In some cases, electrocautery can be used for removal although, unlike cryotherapy, local anesthesia is required.

Different areas of the body heal with a better aesthetic result and may influence your treatment options. In general, the face heals with a more favorable scar than other parts of the body. There are vast differences in an individual’s ability to make a favorable scar. While one person may make a very inconspicuous scar after surgery, someone else may heal with an obvious scar that remains obvious indefinitely. Applying a thin layer of topical silicone to the skin has been found to improve the appearance of scars. Patients can begin to use topical silicone 10 days after surgery. This silicone preparation is available for purchase in our office for patients who are interested.

Types of Skin Cancer

There are many different types of skin cancer, but 99% of skin cancers are either basal cell carcinoma, squamous cell carcinoma, or melanoma. Skin cancers are the most common form of cancer in both men and women—comprising more than 50% of all cancers—and the incidence of skin cancer is increasing at an alarming rate. According to the American Cancer Society, there are more new cases of skin cancer diagnosed annually than breast, prostate, lung and colon cancers combined. Some factors that are thought to be responsible for this include increased time and activity outdoors and the depletion of the ozone layer, which allows harmful ultraviolet (UV) rays to penetrate the atmosphere with increasing ease. Since the mortality rate of skin cancer is very low relative to other kinds of cancer, it often gets less public attention and therefore less awareness among patients. However, there can be considerable disfigurement and loss of function as a result of skin cancer. As a fundamental guiding principal, any skin lesion, pigmented or nonpigmented, that is an open sore, is crusty or scabby, bleeds easily, has a scarred appearance, or undergoes a change, should be evaluated for skin cancer. Prompt removal of the mole or other cancerous skin lesion and subsequent reconstruction, if necessary, leads to minimal scarring and less chance of the cancer spreading to other areas of the body. If you have a mole or other skin lesion that has changed recently, contact Dr. Oldham for an examination.

Basal Cell Carcinoma

By far the most common form of skin cancer is basal cell carcinoma, which comprises approximately 75% of all skin cancers. Though basal cell carcinoma rarely spreads to other parts of the body, it can invade other structures, including bone and cartilage. Though it can be disfiguring, surgery is an effective treatment to remove this type of skin cancer. A lesion can begin as a small, smooth and shiny bump or appear as a scarred or scaly area on the skin. Occasionally lesions appear as a flat patch on the skin, and may or may not have a dry, rough or mildly crusty appearance. These lesions are often pink, but can also be skin colored.

Typically, basal cell carcinomas start small and progressively enlarge, sometimes reaching a substantial size, if they remain untreated. The nose and upper cheeks are the most common areas for this cancer, but they can occur on any sun exposed part of the body. Rarely, they also can be found on non-sun exposed areas.

Squamous Cell Carcinoma

The second most common skin cancer, accounting for about 20% of all skin cancers, squamous cell carcinoma can spread to the lymph nodes and to other parts of the body if left untreated. Rare in individuals with dark skin, squamous cell carcinoma most commonly occurs in people with fair skin. Actinic keratosis, discussed above, is a precursor of squamous cell carcinoma and is considered a pre-malignant lesion. This type of skin cancer is typically treated with freezing (cryotherapy with liquid nitrogen). Squamous cell carcinoma shares many physical characteristics with basal cell carcinoma, but is more likely to become an ulcerated or open sore in the more advanced cases.

In situ squamous cell carcinoma is a very superficial cancer which doesn’t spread, but can occasionally become an invasive squamous cell carcinoma if left untreated. It often presents as a pink scaly patch.

Melanoma

Of the more frequent types of skin cancer, melanoma is the least common, comprising about 4% of all skin cancers. While rare, it is also the most lethal skin cancer, since it accounts for nearly 80% of skin cancer-related deaths. With the exception of lung cancer, the mortality from melanoma is rising faster than with any other cancer. Melanoma, like squamous cell and basal cell carcinoma, is related to sun exposure and occurs more commonly in people with outdoor occupations and on sun-exposed areas of the body. Unlike squamous cell carcinoma, however, it can readily occur on areas of the body not exposed to the sun. While skin coloration is a very important predisposing factor, 5-10% of melanomas develop in people with a positive family history of melanoma.

Melanomas can start as a melanoma from the beginning, or it can arise from a benign pre-existing skin lesion. The most common precursor to melanoma is the dysplastic nevus or atypical nevus. Congenital nevi, especially larger lesions, have a higher chance of becoming melanoma, so they should be watched very closely for any change. Any pigmented skin lesion that changes in any way - becomes darker, lighter, larger, or irregular - should be evaluated by a physician who is trained in recognizing the signs of melanoma and skin cancer.

ABCDE Criteria of the American Cancer Society

The ABCDE criteria developed by the American Cancer Society is an important tool when performing a self examination of pigmented skin lesions:

  • A=Asymmetry: One half of the pigmented lesion should look like the other half.
  • B=Border: The border should be smooth and even.
  • C=Color: The color should be an even tan or brown, without color variation.
  • D=Diameter: The diameter of the lesion should not change over a few months and should be approximately the size of a pencil eraser.
  • E=Evolving: The skin lesion should not undergo any significant change in color, size or shape.


When caught in the very early stages, melanoma can be successfully treated. If left untreated, it becomes deeper, and has a greater chance of spreading to the lymph nodes and throughout the body. Surgery is the only truly effective treatment for melanoma, although Interferon and other immunotherapeutic agents can sometimes be helpful in controlling the disease. Close observation is very important for anyone who has been diagnosed with melanoma. The enlargement of the regional lymph nodes is often the first sign that a melanoma has spread beyond the skin lesion . If enlarged lymph nodes are found to be metastatic melanoma, surgical removal of the involved lymph nodes can prevent the cancer from spreading further and save the patient’s life.

Treatment of Skin Cancers

The treatment of skin cancers is very individualized and depends on the cancer type. As noted above, 99% of skin cancers are basal cell carcinoma, squamous cell carcinoma, and melanoma. While some skin cancer treatments involve the removal of the cancerous mole or skin lesion, cancers that have spread often involve surgery and subsequent reconstruction of the area affected by the skin cancer. Dr. Oldham has experience providing skin cancer treatment to patients from Washington, D.C., Bethesda, Maryland, and surrounding communities.

Treatment for Basal Cell Carcinoma and Squamous Cell Carcinoma

The following are the most common treatments for basal and squamous cell carcinomas:

Surgical Excision

The most commonly performed skin cancer treatment for basal cell carcinoma at our Bethesda practice is surgical excision. This has the advantage of providing tissue that can be submitted to the pathologist and evaluated microscopically to ensure that the entire tumor has been removed. Depending on the size and location of the growth and the experience of the practitioner, the incision can be closed with sutures. Areas with unique anatomic features where skin cancer has been removed can be reconstructed using special techniques to minimize scarring and deformity.

Curettage and Desiccation

During this skin cancer treatment technique, the growth is scraped out with an instrument called a curet and the base of the wound is cauterized to remove the last remnants of the tumor. One disadvantage of this technique is that there are no tissue margins to evaluate microscopically, so the removed tissue cannot be examined to determine if more should be taken out. Additionally, scarring is usually less favorable for most parts of the body.

Mohs Micrographic Surgery

Mohs micrographic surgery involves surgical excision of the tumor with a small margin of normal tissue. Immediately, the deep and peripheral margins are then carefully and systematically evaluated microscopically. The tissue where residual cancer is found can then be removed and further examined until all of the cancerous skin tissue has been removed. This technique is particularly useful for recurrent cancers, and for cancers with indistinct borders.

Radiation Therapy

Basal cell and squamous cell carcinomas are very sensitive to radiation treatment, and in some situations, radiation is a worthwhile skin cancer treatment option to consider. The cosmetic result is often very good, but it is a very time-consuming approach, sometimes requiring 20-25 treatments.

Treatment for Melanoma

Surgical Excision

The only consistently effective treatment for melanoma is surgical excision. Unlike basal cell and squamous cell carcinomas, in which a narrow margin of two to three millimeters is adequate, invasive melanomas must be excised with a much greater margin extending through the fat layer down to the covering of the muscle. Depending on the thickness of the melanoma, as measured by the pathologist under the microscope, the resection margin around the melanoma must be at least one to three centimeters. Failure to do so may put the patient at risk of subsequent spread of tumor into the surrounding tissue. The excision of an in situ melanoma, which requires only a five millimeters margin, should not be confused with invasive melanoma described above.

Skin Cancer Reconstruction

Most skin cancers can be treated by removing the cancerous skin lesion and surrounding edges to ensure the excision of all cancerous cells. While skin cancer treatment is critical and often saves lives, surgery can necessitate the permanent removal of cancerous skin tissue and leave behind scars, which can be particularly noticeable in facial procedures. Fortunately, skin cancer patients have the option to undergo reconstructive surgery. Skin cancer reconstructive surgery can restore form and function to areas such as the nose, eyelids, ears, or lips. Dr. Oldham treats each skin cancer patient with compassion and uses adept skill to achieve the best possible results.

Prevention of Skin Cancer

The lifetime probability of having skin cancer varies with gender, geographic region, skin coloration and sun exposure. The occurrence of skin cancer is related to sun exposure in 90% of the cases of non-melanoma skin cancer. The American Cancer Society estimates that one million skin cancers can be prevented each year with adequate sun protection. The nature of the sun exposure influences the risk factors for the type of skin cancer. Individuals who get sporadic sunburns in the early years of their life have an increased risk of melanoma; people whose exposure to the sun is more constant, such as farmers and other outdoor workers, have a greater risk of squamous cell carcinoma. Sunburn is also an adverse event for melanoma. Someone who has three or more blistering sunburns in their lifetime have an elevated risk of developing melanoma, four to five times greater than the normal population.

There are other factors that can predispose an individual to skin cancer, such as prior skin radiation (often used for acne in childhood in past years), and immuno-suppressive drugs. Due to its relationship to sun exposure, 80% of non-melanoma skin cancers are found on the face, head and neck. People with lighter skin coloration are much more susceptible to skin cancer than those with darker skin coloration. Frequent usage of sunscreen in childhood in the first eighteen years of life has been found to decrease the incidence of non-melanoma skin cancer by nearly 80%. The lifetime risk for skin cancer in Americans has been estimated at one in six. Avoiding the sun is of vital importance since patients who have enough sun exposure to develop skin cancer experience a fifteen fold increased risk of developing a second non-melanoma skin cancer within five years.

There are several important factors in minimizing sun exposure. Staying indoors during the hours of 10:00am and 4:00pm avoids the more intense sun rays that can lead to sun damage. Wearing a hat and protective clothing is also helpful, although thin, light clothing does not completely filter the harmful rays of the sun. A light T-shirt may only provide an SPF of 5-9, and even less when it is wet.

Sunscreen, when used correctly, is a very effective deterrent to the damaging effects of sun. It is measured in units called SPF (Sun Protective Factor). An SPF of 15 means that you can stay in the sun 15 times longer before getting the same sunburn that you would get without any sunscreen. Sunscreen must be applied in the following manner:

1. Apply sunscreen at least 30 minutes prior to going into the sun, since it isn’t effective for the first 30 minutes.

2. Reapply sunscreen every two hours, since it loses its effectiveness after that time. Apply it more often than two hours if you go into the water or perspire heavily.

3. Apply sunscreen heavily. Sunscreen that is applied lightly has an SPF factor of only one half of the labeled SPF.

Contact Dr. Oldham to Learn More about Skin Cancer Treatment in the Washington, D.C. Area

For all varieties of moles, skin lesions, and skin cancers, surgical excision can be the safest, most effective treatment. Dr. Roger J. Oldham specializes in the treatment of skin cancer and lesions, performing mole removal and surgical excision in-office at the Bethesda Surgery Center. Call the office, serving Washington, D.C. and communities throughout Maryland, to set up a consultation and to schedule a minor, minimally-invasive treatment for your mole or skin lesion. Pay attention to the American Cancer Society’s ABCDEs and call Dr. Oldham if you feel your lesions have changed. The health of your skin is important; Dr. Roger J. Oldham can help.

To: Roger J. Oldham, M.D

Dear Dr. Oldham,
interested in scheduling an appointment with you
and would like to receive information about
. Please
at your earliest convenience.

Expand to Personalize Your Message

Roger J. Oldham, M.D

Phone: (301) 530-6100
Fax: (301) 530-6104