For this episode of Karger’s The Waiting Room Podcast for World Melanoma Day on May 1, 2023, as well as Skin Cancer Awareness Month in May, we spoke with Prof Willie Visser about the importance of skin cancer prevention and regular check-ups with your dermatologist. Prof Visser is the Head of Dermatology at University of Stellenbosch, Tygerberg Academic Hospital, Cape Town, South Africa. He earned his medical degree from the University of Stellenbosch and completed both his Master’s degrees in Family Medicine and Dermatology at University of the Free State in South Africa. Prof Visser has a passion for medical education and teaching. His research focuses on inflammatory skin diseases and skin cancer, especially in patients with skin of color.

An Infographic Summary Sheet for Patients on skin cancer, self-examination and prevention is freely available.

Video Interview

Podcast Interview

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Transcript

It’s good to have you here, because by now, the majority of people are aware of the importance of skin cancer prevention. We know we must protect our skin from the sun and regularly see a dermatologist to be checked for skin cancer. Now, Willie, why is it important to be familiar with your skin and keep track of moles, spots, lesions, and any changes in general?

I think that’s an excellent question. And the reason we say that as dermatologists is firstly, we want to detect skin cancer early. You know, skin cancer is such a common cancer in all races, in all sexes. And probably one of the leading causes of mortality and morbidity in most people in most countries in the world. So, it’s very important for us to catch that early because treatment is then very effective. For most skin cancers, if you catch them early, they are 100% curable. And if you can get them early, we have a very, very good treatment plan for these cancers.

So, that’s why we always advise that you are aware of what’s going on in your body, especially if there’s any pigmented spot or mole, that you constantly, constantly keep your eye on that, be aware of how it looks, and if it rapidly enlarges or changes, then you definitely should report it. So, I think the whole idea is, be very visible, and know what’s going on in your body will also give you peace of mind and have a little bit of more control what is going on with your health. And I think for people with higher risk factors, it becomes even more important to be.

So, for everybody it’s important, but especially if you have a risk factor and, Susanne, that can be something like people who work outside, have of a lot of sun exposure and sunny holidays, burns as a child. So, people with UV ray exposure, especially at an early age or constantly, should be more aware of the visibility of skin cancer. Also, certain vulnerable populations who are immunosuppressed, people who had organ transplants and who are on immunosuppressive therapy, people who have immunosuppressive diseases like HIV, for instance. So, that’s another group of people. Also, the amount of moles. If you have a large number of moles, your chances for the development of melanoma are also higher.

And then depending on your personal or family history of melanoma. Did somebody in your family have skin cancer, especially melanoma, or you yourself had it previously? And then a group of people who have very pale skin, almost like the Irish heritage, very pale skin, freckly, light eyes, light skin color, almost never tan, but always burn. Those people have much more susceptibility to skin cancer. So, if you fall in that specific group, even more the reason to be very adamant in checking your lesions, going for regular skin checks at your dermatologist, and report any change if you see that.

Skin cancer is a very visible cancer. So, you should detect it early, because then the chances for a good treatment are very high. I think this is a very important message. And I think it’s interesting, too, that you mentioned the people who are at risk. So, the other thing you say is “Know your risk factors”.

Absolutely.

So, skin cancer often develops in areas exposed to the sun, as you said. But skin cancer can also develop in rather unusual places where you wouldn’t expect it. Can you tell us more?

Yeah, I think that’s very important for people to know. And that’s if you go to a dermatologist, also the places that we will vigorously check. I always say, if I only check in the areas that you can check, I’m not really doing my job. So, I must check on the back, for instance, between the buttocks, for instance, a very important place to think about is the scalp. We always think our hair protects us, and it does. But as we are getting older our hair gets thinner, you get more UV rays on your scalp. So, that’s a very important point to check. Tip of the ears, for instance, is another important place to check. Your lips. And then also remember, even melanomas can develop on the genitalia, on the vulva, around the anus, on the penis. So, even the genitalia should be checked or even be, just be vigilant on the development of any new pigmented lesions there. And then even the inner thighs.

So, it’s places that we don’t really think about. And then I think, very important places to think of is the palms of the hands and the soles of the feet, because that’s usually where people with skin of color get melanomas. Anybody can get it there. But percentagewise, people with pigmented skin are more inclined, statistically, to get melanomas of the hands and the feet, and also of the nails.

For us, we need to be very vigilant to educate our patients with skin of color, to specifically look for palms, soles, and also around the nail plate. Any darkening there, any new dark spot there, especially a dark line that is getting thicker or even destroying the nail. And then any dark, moly spot that is changing on the feet is a very good indicator that that lesion should be checked out and most likely will be biopsied to exclude a melanoma.

So, basically, the whole surface of your body, will it be exposed to the sun or not, you can develop a cancer there.

Yeah, absolutely. And the risk factors are a little bit different. So, we know about the UV risk factors for your body. And it’s not necessarily always chronic sun exposure. It’s also that periodic sun binges when you take off your shirt and you burn in the sun. So, that’s why we know that males, usually white males, get their melanomas on their trunk, because that’s areas that are usually relatively protected. But when you expose them to the sun, you usually burn.

Women get burned statistically more on the legs. But it is just as important to also spread that message. So, check the hands, check the feet for the development of melanoma. And the risk factor there is probably a little bit different. And we don’t understand them very well. Is it trauma? Is this some infection? Is it just a statistical difference? But we also know that these types of melanomas that we call acral melanomas, have even different genetics. So, we know that the trigger is probably different than the UV damage that we see in the sun-exposed areas.

This might explain or is a good bridge to my next question, because skin cancer has long been perceived as “a disease for people with fair skin”. But obviously this is not true. So, how do you and your colleagues fight this notion?

I think all is about education. And what we know is that everybody can get a melanoma. The melanomas are totally color-blind. Anybody can get them. So, it’s so important to spread the message that all races, all people with any types of skin tone can develop a melanoma. Obviously, the higher your melanin or your skin color, the lesser the chance you will get it in the sun-exposed areas. But you can get it still in those other areas.

If you look at incidences of melanoma, it’s much higher in people with fairer skin, but they are still developing in people with quite darkly pigmented skin. So, we need to fight that message. And all the public type of message that we have, we need to tailor it to our population and make sure that we speak to the acral melanoma groups, which is: “Except for checking your skin, also check your palms, check your feet, and check your nails.”

We constantly need to be aware of that. And interestingly, we’ve done a study in our final year medical students, and we asked about 100 students. We gave them different pictures. And some of those pictures were these melanomas on the hands and feet of pigmented people. And less than 10% of those final year medical students correctly diagnosed that it’s a melanoma. And I mean, I teach them in their fourth year dermatology and I tell them about this, but it almost wears off. And then in a way, even our public or let’s say the health care service is not aware of the fact that people can get melanomas on the hands and feet and nails. So, we really need to make sure that this message gets through to patients, but also to healthcare workers and to the media to spread that message. And that’s why I am so privileged that I can speak to you about this today.

Thank you. So, education is key. That brings me to the question I would want to ask you: What is the ABCDE of skin cancer and why is it important to know about it?

So, that’s usually in any public education process, you want to learn people something very easy. So, we use a mnemonic, A, B, C, D, E, and the A stands for asymmetry. But maybe before I get there, I should tell this is when we look at pigmented lesions. So, if we look at a mole, for instance, or any pigmented freckles, then the first thing you look for is the A, and that’s asymmetry. If you fold the lesion, it must probably fold on each other. So, what it looks like on the one side, it must look at the other side.

The B is for the border. Usually that border should be very regular, and it should be very well seen. But if it fades into the vicinity and becomes irregular, that’s wrong. The C is for the color. So, any change in the color, any difference in color, if you get to see two or three colors in a mole, that’s something to be aware of. Then if we go to the D, that’s the diameter. We always think if a lesion becomes larger, or larger than for instance the back of an old pencil with an eraser. So, if it gets larger than that, and it then constantly changes, it’s something to think about. For me, the D is more the diameter that changes, so anything that’s getting bigger. And then the E is for evolving. So, any change, any crustiness, any symptoms that you’ve never had before on that lesion, that is very important to take note of.

But saying that, you can now think about the melanomas we talked about, for instance on the hands and feet or other places, that they don’t always fulfill these criteria. You can get a nodular melanoma, which is a very dangerous melanoma that just starts as a rock, as a reddish or darkish little bump, that grows fast and bleeds. So, any red or bleeding bump should also be regarded. And again, I always say that ABCDE and then check your hands and your feet and your nails. That’s very important.

And we talked about melanoma in people with higher pigmentation or with people with skin of color. And what is also seen is that these people have actually a higher disease burden. And also worst outcome. And it’s not because the melanomas are necessarily more aggressive, but it’s because they’re not aware. And when we see them, they have these large, thick tumors. And then the outcome of these are dismal. So, it’s very important to have a very low threshold for the development of these cancers on the hands and feet.

Okay. That’s a lot to take in. And I think we will put the ABCDE plus your information “check your hands, feet and nails” into the show notes. Because it’s really important to know this and maybe read about it, if you forget what it means, the ABCDE. So, my last question for you is: What is your personal approach when it comes to preventing skin cancer? You as the expert?

I think the universal message is that we know the most important trigger for skin cancer or the development of skin cancer is UV rays. So, always protect yourself from UV rays as much as you can. And that’s the general rule: You always cover up. So, you put on a hat, you put the sunscreen, you put dark glasses, you cover yourself with clothes, and you use sunscreen in the areas that you can’t cover with clothes – that’s your face and your hands. And you make sure that you use a broad spectrum sunscreen of at least 30 to 50. I always say, in South Africa, use a 50 and above as much as you can. Don’t use a sunscreen because you’re going to tan or lie in the sun. That’s not what sunscreens were designed for. It’s: Cover your body with as much as you can and then cover those areas with sunscreen that you can’t cover with clothes or with other protection.

And another, I think, very important message is: Don’t use artificial tanning booths. Those UV rays are extremely damaging, not only for skin cancer, but also for skin aging. So, it’s much better to either go your natural color or to use some other alternatives, like a spray tan that is much safer than that. But don’t use artificial tanning booths. That’s very, very important. And then go regularly for checks, especially if you fall into that high-risk group that I’ve said. And remember, even age is another risk factor. So, the older we get, the more regular we should get our skin checks. On your first visit to the dermatologist, they will determine your risk profile and tell you when you come back for your follow-up. And that’s a very important point.

And then lastly, I think just as part of our whole holistic management, it is important for us to live a healthy lifestyle ,to exercise, to eat well, to drink a lot of water, to stay out of the sun, as we say, don’t smoke, not necessarily for skin cancer, but as a general idea of good living and also to make sure that your immunity is then good to fight any type of skin cancer. So, I think that will summarize my almost like practical approach to tell in help alleviating the burden of skin cancer.

Well, thank you very much. And I think there still has to be done a lot education-wise, because when I think of the sun, I think, yeah, I want to go out, I want to feel the sun, I want to be there without covering up. So, we all have to learn how to think differently and approach the sun. It’s like the sun turned from a friend to an enemy, which it shouldn’t be. But yeah, let’s still enjoy the sun, but be careful.

It’s absolutely not the enemy, and we want to have good quality of life, and living outside and doing things are so important, but it’s just being a little bit more vigilant and just a hat, your sunscreen, your glasses to protect your eyes and protective clothing. I think you can still do exactly the same. You can go to the beach, go for a swim under the umbrella, put your protective clothing on, put your sunscreen on the areas. So, I think you can build it into your lifestyle. And especially we live in a very sunny country, still enjoy all the good things in life, but just be a little bit more sensible. Think a little bit before. Put your sunscreen in your training bag. Put it in the cubbyhole of your car, so that you are never caught out of hand and don’t burn in the sun.

Okay. Thank you very much. Thank you for taking the time and speaking to The Waiting Room, Willie.

Absolutely a pleasure, Susanne.