Tag Archives: skin cancer

‘Skinvestigator’ Author Describes His Dermatology Detective Series

A 22-year-old model with a distinct tattoo is murdered in Miami Beach. A dermatologist learns of the mysterious case while taking a skin cancer biopsy from a friend, a red-headed, fair-skinned policeman. “Doc, you know a lot about tattoos, don’t you?”

So starts “The Skinvestigator: Tramp Stamp,” the first in the Sunshine State Trilogy series of hard-boiled detective fiction written by Florida dermatologist Dr. Terry Cronin, Jr.

“It takes a lot of the knowledge I have about tattoos and feeds it into the mystery,” Dr. Cronin said in an interview. “But it also talks a lot about ‘scalpel tourism,’ where people go to foreign nations to get plastic surgery and cosmetic surgery at cut-rate prices, and a lot of times they get mutilated. That plays a big part in the murder mystery.”

Dr. Terry Cronin, Jr. (photo by D. McNamara)

Miami dermatologist Dr. Harry Poe delivers some important messages in the book as well. “He’s out there trying to promote prevention of skin cancer.” Like most dermatologists, he faces the challenge of warning people about the dangers of sun exposure in a culture that values tanning and looks above safety. When Dr. Poe goes to the beach, for example, everyone is lying out in the sun while he’s wearing long sleeves, a hat, sunglasses, and sunscreen. “And people make fun of him,” Dr. Cronin said.

A dermatologist as detective makes sense – because they use the same type of skills to diagnose skin conditions in their patients every day, explained Dr. Cronin, who is in private practice in Melbourne, Florida.

“I’ve always had a creative flair. I was involved in film making ‑ short films, going to independent film festivals. I ended up writing for comic books. Then I got the idea that I really wanted to tell a story that was pro-dermatologists.” Although Dr. Cronin had always kept his professional and creative sides separate, that was about to change.

The first book in the Sunshine State Trilogy (photo by D. McNamara)

“I wanted to tell a story in which the dermatologist was the hero. I love mysteries, like the Travis McGee series from John D. MacDonald and books byEd McBain and Ken Bruen. I thought ‘maybe I can make this hard-boiled dermatologist detective story, in which the dermatologist is pulled into an investigation. By using his expertise in diseases of the skin, he is able to help police solve a murder.”

Even though Dr. Cronin went through a “big process” of writing draft after draft, honing the story through multiple editors (including Michael Garrett, an editor for Stephen King), and encountering some challenges along the way, he encourages other physicians to pursue their outside passions as well.

“If a physician wants to be a writer, they should let their creative juices flow and do it. Don’t take ‘no’ for an answer,” Dr. Cronin said. “All doctors are pretty smart people, pretty motivated people, who have lots of talents. Some have those talents, but they tamp them down because of their professional needs. I think you have to have an outlet.”

Dr. Cronin initially self-published and sold copies of “Tramp Stamp” at Comic-Con and through Amazon.com. Then a friend at Barnes & Noble encouraged him to sell the bookstore management on ‘The Skinvestigator” series. They liked it and helped him find a publisher. (The store does not inventory self-published titles.) “Now it’s on the shelf in Barnes & Noble. That’s a thrill.”

Dermatologist colleagues have been very supportive, Dr. Cronin said. “That’s the thing I like the most. A lot of dermatologists have been reading it and giving me feedback that is good. I appreciate that.”

“The lay person will enjoy the book, but a dermatologist will get a kick out of it.  They know the language and they will laugh because so much of it is authentic.”

The second book in the series “The Skinvestigator: Rash Guard” is about surfers, syphilis, and the state department. The third installment, yet to be published, will be called “The Skinvestigator: Sun Burn.”

–Damian McNamara @MedReporter on twitter


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Hats off to Tanzania Albinism Project

In Tanzania, where some of the oldest human fossils have been found, and where Mt. Kilimanjaro rises above the clouds, a group of international dermatologists are hoping to help a very vulnerable population.

The region has one of the highest incidences of albinism in the world. Although the condition is rare in the western world, it is quite common in sub-Saharan Africa, according to some studies. (While the incidence of this genetic condition is about 1 in 37,000 U.S. residents, the rate in this region is as high as 1 in 1,400.)

The people with albinism are also subject to discrimination, stigma and even murder.

Sun Damage to Back of an Albino Individual

But, another important concern is the health of the albinos whose pink skin is exposed to the African sunshine, and where many of the occupations are outdoors and in the field.

Many of the locals with albinism die of cancer before age 40; in fact, fewer than 2% make it to their 40th birthday. And almost all of the children with albinism show signs of sun damage before age 10.

Because of a lack of funding, many can’t afford hats to protect themselves; because of a lack of education, many don’t know the link between sun damage and cancer.

That’s according to Dr. David McLean, the secretary-general of the International League of Dermatological Societies, a nongovernmental organization affiliated with the World Health Organization.

Dr. McLean has been visiting the region for the past 2 decades, helping to establish and grow the Regional Dermatology Training Centre (RDTC), an ILDS program, in the town of Moshi in Tanzania.

He is also among a group who recently spearheaded a project to make hats — the ones with 7.5-cm rim — available to the albinism population in Tanzania. [Listen to Dr. McLean below.]

Called “Hats On for Skin Health,” a collaboration between the ILDS and Stiefel, the project is a global effort to raise funds for the purchase of hats and other protective items for albinos in Tanzania.

Sun-Protective Hat on an Albino Girl

The items will be distributed by RDTC that manages a mobile skin care clinic, which regularly visits people with albinism living in the region and educates the locals, especially parents, about albinism. The lesson they try to get across, said Dr. McLean, is to let their children play outdoors, but cover them up first.

The group has located a hat manufacturer in Moshi, which is currently producing template models for children and adults. Many of the workers, said Dr. McLean, have albinism. “We think that’s definitely part of the solution going forward,” he said.

The cost of manufacturing a hat in Africa? Less than $2.50. The hats are expected to last for at least for 10 years.
To start the campaign, Stiefel, a subsidiary of GlaxoSmithKline, has donated $25,000, and Dr. McLean hopes that dermatologists, other professionals, and even the public, get involved with the campaign.

“Our people are on the ground there. We know what happens to every donated dollar,” said Dr. McLean.

The group expects to have handed out at least 15,000 hats by this time next year. Visit www.hatsonforskinhealth.org to learn more.

(Photos courtesy of the patients and staff of the Regional Dermatology Training Centre, Tanzania.)

By Naseem S. Miller (@ReportingBack)

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Mohs — The Man, the Surgeon, the Superstar

The esteem that practitioners of Mohs micrographic surgery hold for the founder of the technique, the late Dr. Frederic E. Mohs, can’t be overestimated. Although he died in 2002 at the age of 92, the man and his accomplishments are still so admired that the American College of Mohs Surgery invited his son, Frederic E. Mohs, Jr., to share reminiscences of his father at the college’s annual meeting.

Hundreds of Mohs surgeons filled the conference hall. “Dad would have been totally shocked to walk in here and see this many people,” Mr. Mohs said, because there was a time when the only Mohs surgeons were ones that Dr. Mohs had trained himself. Today there are at least two Mohs professional organizations and thousands of physicians who offer Mohs surgery.

Frederic E. Mohs, Jr. (Photo by Sherry Boschert)

Mr. Mohs is not one of them. He is a lawyer and real estate specialist in the firm Mohs, MacDonald, Widder, and Paradise in Madison, Wisc., where Dr. Mohs lived and practiced for many years. And he is not, it seemed clear, an experienced public speaker. But the attention focused on him by the ballroom full of Mohs surgeons was so intense that you could have heard a pin drop throughout his entire talk. They listened partly out of respect and partly, I think, because our human nature is to want to know more about the people we admire.

Mr. Mohs said he came to talk about his father “as a person.” But he also provided some interesting historical context. The way his father came to be a surgeon and the inventor of Mohs micrographic surgery was “an accident,” Mr. Mohs said. His father had a passion for radio and hoped to become an engineer. To fund his college education, he worked in the University of Wisconsin’s biology department cleaning laboratory animals’ cages. The department chair noticed him and mentored him, explaining the lab’s cancer research and teaching Mohs Sr. to look at slides of skin cancer. It was during this period that Mohs Sr. visualized his now-famous techniques, and the department chair offered him a chance to pursue research as his assistant.

That almost didn’t happen, because Mohs Sr. was reluctant to give up his dream of being a radio engineer. But once he embraced the opportunity, he ran with it. He earned his bachelor’s degree in 3 years and entered medical school while continuing his laboratory experiments and cleaning rat cages. “He was a hard worker,” his son said understatedly.

Some characteristics of Dr. Mohs “the person” seem dated, while others may be inspiring, disappointing, or surprising, depending on your view. “From every account I ever heard, he was an incredibly wild driver” who once got his future wife grounded for a full year by slamming on the brakes and causing the car to spin in a circle in front of his future father-in-law, Mr. Mohs recalled.

Dr. Mohs was a devotee of Horatio Alger’s books, admiring their themes of hard work, ingenuity, and a scientific system of inquiry.

Once married and with a young family, he didn’t spend much time at home, it seems. He would leave home at 8 in the morning, return for dinner at 6 p.m., briefly read the newspaper, then go back to the hospital “every single night” and return late at night or even the next morning, his son said. When the family entertained visitors on weekends, most bored Dr. Mohs, so he would go back to the hospital.

None of that bothered his son. “He was an honest and good man. I don’t have a single complaint” about him, Mr. Mohs said. An older sibling once said that Mr. Mohs and a younger sibling “weren’t raised, you were just turned loose,” Mr. Mohs recalled. “It was true.”

Still, Dr. Mohs imparted his values to his son, who described them as, “Earn your own money, be honest, and don’t disturb property. Anything else is okay.”

The children usually took their school report cards to be signed by their mothers “because Dad was a little scary,” Mr. Mohs recalled. Once when he asked Dr. Mohs to sign a report card, his father signed it without looking at it, and handed it back. “Don’t you want to look at it?” his son asked. “No,” Dr. Mohs replied. “It’s your life. If you screw it up, it’s your own fault.”

Occasionally Dr. Mohs broke out of his routine, joining a geology club in one period, and a church’s board of directors in another. As his techniques gained recognition, he traveled quite a bit to give presentations or trainings, and often took the family with him.

In 1955 when he was invited to demonstrate his techniques in Moscow, he accepted in part out of a desire to improve international relations. Dr. Mohs went so far as to learn Russian and gave his entire presentation in Russian. Thereafter, the Russians “lionized him” and often sent surgeons to Madison to learn from him.

He is still lionized today. But for one hour, his professional descendants got to hear about the human being behind the public image.

Before Dr. Mohs died, he picked a simple bronze plate to mark his grave. “He liked the idea. Mowing was more efficient,” his son said.

–Sherry Boschert

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A Little Mohs Respect

The Mohs technician – a non-physician (often even a non-healthcare worker) – occupies a unique place in the medical pantheon.

The Mohs surgeon’s right hand must be as steady as the surgeon’s own, capable of working with the most minute wafers of tissue, just a cell or two thick. A natural tinkerer who can adjust a highly complicated machine whenever its temperamental temperament gets out of whack. A perfectionist whose urge for the precision can never be shaken by deadlines, fussy patients, or cranky docs who just want to get out of here already.

At a Mohs surgery training course, sponsored by the American Society of Mohs Surgeons,  I learned first-hand (no pun intended) about what the tech brings to this fascinating area of surgery.

Alexander Lutz, the owner of Travel Tech Mohs Services, Inc., Carson, Calif., put it well during his talk on the issue: “It’s a rare relationship between and physician and non-physician, even more so than a surgeon with his surgical nurse or tech. The nurse might be helping the surgeon, but you aren’t depending on them to complete the surgery. With a Mohs technician, you are.”

A physician who wants to learn Mohs surgery can choose to hire and train a formally educated lab tech or histotechnician – or pick a staff person to train. It can be a nurse or medical assistant, or even the office manager. 

Knitting could be a sign of tech talent.

Photo courtesy Loggie-log/Wikimedia Commons

Mr. Lutz gave some pointers on picking the right trainee. Two characteristics are key: manual dexterity and a perfectionist personality. “In my experience, good Mohs techs have these things in common. I always ask if they have a hobby that shows dexterity-like knitting, musical instruments, or even juggling.”

And though the perfectionist personality part might drive the doc nuts in a personal relationship, it  will serve both well in the surgical suite. The success of Mohs surgery – and even the life of a human being – depends on those beautiful clear margins. The surgeon can only create those margins if there are plenty of beautiful slides to guide the surgery. And only a dedicated, skilled technician can make those beautiful slides.

— Michele G. Sullivan (on Twitter @MGSullivan)

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Beyond ABCDs for Melanoma

The month of May marked 25 years since dermatologists began using the ABCD rule to help screen for melanoma, and advances in diagnosis since then have leaned toward newer and better use of imaging technology instead of clinical mnemonics.

Left side, top to bottom: melanomas showing (A) asymmetry, (B) irregular border, (C) unusual coloring, and (D) diameter that had changed in size. Right column: Normal moles. Images from National Cancer Institute via Skin Cancer Foundation, merged by WikiMedia Commons user Stevenfruitsmaak.

You do know your ABCDs, don’t you? Moles with “A” for asymmetry, “B” for border irregularity, “C” for uneven color, or “D” for diameter greater than 6 mm. If you see these, think melanoma.

Advances over the quarter-century since then have focused on helping physicians “see” melanoma better. Dr. Darrel Rigel described some of these at the annual meeting of the American Society for Mohs Surgery. Dermoscopy allowed non-invasive imaging of melanomas. Digital photography came along, and some dermatologists began using serial digital imaging to track changes in moles over time. Most recently, various groups have been trying to add assessments using infrared (non-visible) light through computer-aided programs to aide diagnosis.

As a woman of letters, I have to admit a fondness for the ABCDs. But the imaging advances do have more of a new-school, digital-age feel to them. I think both can happily co-exist in dermatology. Time will tell if that’s old-school thinking as the digital age advances.

—Sherry Boschert (@sherryboschert on Twitter)
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Vanity, Thy Name is Tan

“Because tan fat  looks better than white fat.”

That’s my 30-year-old daughter, justifying her recent trip to the tanning salon.  Yes, she knew it caused wrinkles. Yes, she knew it was linked to skin cancer. But she heeded not a single warning—either from  me as a concerned mother, still nagging after all these years, or as a medical reporter who sees the data over and over.

1960s ad for a East German solar lamp promises a quick and healthy tan. Courtesy Flickr user allerleirau (CC).

My most recent eye-opener came last week at the WONCA World Conference of Family Physicians, where Dr. Tina Ninan said it plainly: When it comes to tanning, vanity is queen. Dr. Ninan, a general practice physician in Newcastle-Upon-Tyne, England, wanted to find out how much patients know about sunbeds and their associated risks.

She distributed simple surveys to patients waiting at a dermatology clinic at the University Hospital of North Durham. Most of the respondents were women, with 60% over age 40. Of the 102 patients surveyed, 34 said they used sunbeds. Most of these (27) were women, meaning that 42% of the women surveyed admitted to using the devices. But they weren’t alone—18% of men surveyed said they used sunbeds, too.

Almost 90% of the tanners said they’d started using sunbeds before 35, a period considered critical in the development of skin cancer risk.  Forty percent used them at least weekly, and many used them without any supervision, favoring either coin-operated sunbeds or home-use models. These people were not ignorant; 94% said they were aware of a link between sunbed use and skin cancer. They wrote in other risks as well: “it’s bad for your skin.” “They cause wrinkles” “They are bad for your eyes.”

But apparently the lure of a tan is too strong to resist. The majority (64%) said they used sunbeds for cosmetic reasons, either they were trying to get a base tan before holiday or they just “liked the look of a tan.” Fourteen percent said they were trying to treat a skin condition with ultraviolet light; acne and rosacea topped that list.

Photo by Flickr Creative Commons user redspotted.

Courtesy by Flickr user redspotted (CC).

recent study that found sunbed tanning as addicting as alcohol. Published in the Archives of Dermatology, the study used two validated addiction questionnaires to qualify sunbed use among 421 women at a northeast U.S. university. More than half of the women were “users.” When using the DSM-IV addiction criteria, 39% scored as addicts. The CAGE (Cut down, Annoyed, Guilty, Eye-opener) Questionnaire determined that 90% were addicted. “Users” also had significantly more anxiety and greater use of alcohol, marijuana, and other substances than non-users.

So what’s a white girl to do? Spray-on tans are becoming increasingly popular, as are pills containing beta carotene or canthaxathin, a natural food colorant. A quick Google search also delivers plenty of results for pills that claim to stimulate melanin production. I found just one product currently under scientific review. Clinuvel, an Australian drug company, is developing what it calls a “photoprotective drug” (afamelanotide), marketed under the name Scenesse. A form of alpha-melanocyte stimulating hormone, afamelanotide is being investigated for prophylaxis of photosensitive disorders, not for any cosmetic indications. It doesn’t take a leap of imagination, however, to wonder whether it could become—literally—the Golden Child of the self-tanning set.

In the meantime, I’ll keep preaching the gospel of high SPF to all my children, and try to follow my own advice. I came back from the WONCA meeting Cancun with a little glow myself,  and—although I hate to admit it—I loved the way it looked.

—Michele G. Sullivan (@MGSullivan on Twitter)
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Will FDA Deliver a Knock-Out Punch to Indoor Tanning?

The Food and Drug Administration has announced that it will finally be taking a closer look at the health effects of indoor tanning, starting with an advisory committee meeting on March 25.  Considering that the agency has taken a decade (and counting) to release regulations guiding the manufacture, composition, and advertising of sunscreens, the FDA is acting relatively quickly on indoor tanning.

Image by Flickr user cogdogblog by Creative Commons license

Dermatologists, cancer advocates, and pediatricians, among others, have been seeking some kind of stricter regulations on indoor tanning, or, more hopefully, an outright ban.  Many states and localities have begun to restrict the use of indoor tanning by minors. But, despite a wealth of evidence that excessive exposure to ultraviolet radiation, even when delivered indoors, leads to skin cancer, the federal government has not moved to more strictly police tanning salons.

Congress has been prodding the FDA for years.  In 2007, the Tanning Accountability and Notification Act was included in the Food and Drug Administration Amendments Act of 2007.  The TAN Act (see page 36 here) directed the FDA to study tanning bed warning labels that had been in place since 1985, with an eye toward making them more prominent and comprehensible by consumers. The FDA was then to report back to Congress.

In December 2008, the agency told lawmakers in its required report that it was considering updating the warning labels.  A series of focus groups led it to believe that maybe the almost-quarter-century-old labels might have reached their expiration date.

A year later, the FDA created a web page warning consumers about the dangers of tanning indoors.

And now, the advisory panel. According to the announcement, “There continues to be a growing body of literature showing association of skin cancer with use of tanning lamps and the committee will discuss this information and other information related to the association of UV and skin cancer (both melanoma and non-melanoma). The committee will be asked to recommend whether changes to current classification or current regulatory controls of UV emitting devices [lamps] used for tanning are needed.”

Expect a lively discussion at the meeting, with likely appearances by tanning salon owners and the Indoor Tanning Association. Those groups are already unhappy about a 10% tax on tanning users that’s being proposed as part of health reform.

The agency usually takes its advisory committees’ advice to heart.  We’ll be keeping an eye on this panel’s proceedings.

— Alicia Ault (on Twitter @aliciaault)

This post also appears on The Mole, the blog of Skin & Allergy News, an International Medical News Group/Elsevier publication.

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Filed under Dermatology, Drug And Device Safety, Health Policy, health reform, Internal Medicine, Oncology, Pediatrics, Primary care

Mohs Surgeons Don’t Get No Respect

From the American College of Mohs Surgery annual meeting, Austin, Texas

Plastic surgeons have their own TV show and have their own walking billboards in the form of prettified, petrified and enhanced celebrities–some of whom prove the adage that there’s no such thing as bad publicity (hello? I’m talking to you, Joan Rivers).  Mohs surgeons can be true artists — removing potentially disfiguring and deadly skin cancers, often curing the disease, and leaving hardly a trace.  But they don’t even get a hello-how-are-you from patients who are referred to them, complained a surgeon here. 

No respect?

No respect?

Tired of being the perpetually passed over ugly stepsister, Dr. Vinh Q. Chung decided to quiz folks on why they always seemed to want a “plastic surgeon,” even as they’d been referred to the Mohs specialist. 

The popular myth seems to be that “anyone with plastic surgeon in their title can perform magic,” said a disgruntled Dr. Chung.

In his survey of about 500 patients, a significant majority said they thought plastic surgeons were more highly trained and more experienced than Mohs surgeons and would never leave a scar. (Even though Mohs guys get three years of derm residency plus another year of specialized Mohs training.)

But when these patients were asked to look at photos of a scar, no one saw any particular magic. Given four photos labeled “plastic surgeon”, “Mohs surgeon”, “general surgeon” and “unknown”, patients all pretty much had the same opinion of each picture – yeah, looks good to me.

Maybe not a giant vote of confidence in any particular subspecialty, but Dr. Chung felt vindicated.  He said that maybe in another 5 to 7 years, the general public might actually preferentially ask for Mohs surgeons when faced with large skin cancers.

Hey, anything’s possible.  I just wouldn’t expect FX to be knocking on your door looking for help on the “Melanoma Madness” pilot.

— Alicia Ault  (On Twitter @aliciaault)


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