Richard Usatine, MD, FAAFP
Richard Usatine, MD, FAAFP
Technology is paving the way to more-efficient skin cancer diagnoses in the office
Richard Usatine, MD, FAAFP, reviewed the latest diagnosis and treatment options
available for basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and
melanoma during his "Skin Cancer Update: For the Family Physician” CME session
Friday morning at FMX.
"Dermoscopy really is the cutting-edge way to diagnose skin cancers and diagnose
them early. The evidence is clear, if you use a dermatoscope, your sensitivity and
your specificity for diagnosing skin cancer will go up,” said Usatine, professor of
family medicine and professor of dermatology and cutaneous surgery, University of
Texas Health Sciences Center, San Antonio.
Dermoscopy helps differentiate benign and malignant lesions, meaning fewer
missed melanomas and fewer biopsies of benign lesions.
"In the future, I think all family physicians will have dermatoscopes, and they will be
using them to see into the skin,” Usatine said.
Usatine reviewed the characteristics of the major BCC types, including nodular,
superficial, and schlerosing/infiltrating.
A shave biopsy is the fastest and most effective way of diagnosing a BCC, Usatine
said. However, he suggested a punch biopsy may be considered if the lesion is
atrophic and hard to shave or if a deeper, more aggressive lesion is suspected.
"Over 90 percent of the time, my diagnosis for BCC is with a shave or saucerization.
If it is flat, I just take the blade, bend it and saucerize underneath it,” he said.
Treatment options for BCC include electrodessication and curettage, cryotherapy
with 3 to 5 mm margins, excision with 3 to 5 mm margins, and Mohs surgery.
Treatment with Imiquimod or 5-fluorouracil is appropriate for superficial BCC, and
hedgehog inhibitors (Vismodegib and Sonidegib) may be used for locally advanced
or metastatic BCC, although they are all extremely expensive, he noted.
Mohs surgery, though, is the treatment of choice for BCCs with poorly defined
"I would recommend—if you have an aggressive cancer on the face or on the
nose—that you send someone to a Mohs surgeon, even if they have to drive an hour
down the road,” he said.
More rare and usually found on sun-exposed areas, SCC's found on the lips or
mouth, on the ear, or arising from a burn are at increased risk for metastasis.
Usatine said excision with a 4 to 6 mm margin, or Mohs for the worst ones, are
usually indicated as treatment options, although SCC in situ can be handled with
curettage and desiccation after a shave biopsy or cryotherapy.
"Once you've had a patient with one of these skin cancers, they need to be
monitored for life,” said Usatine, who suggested that patients be checked every six
months for new cancers.
Usatine also reviewed the types of melanomas and National Comprehensive Cancer
Network guidelines, which indicate deep-shave biopsy is preferable to superficial-
shave or punch biopsy for the diagnosis of thin and intermediate-depth (<2 mm)
"Almost all of my melanoma biopsies are done with saucerization, and that is what
my dermatology colleagues do, too,” he said.
Surgical literature supports the practice of saucerization, (scoop or deep-shave
biopsy). Usatine said the research indicates it leads to accurate diagnosis and
staging 97 percent of the time.
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Dermatoscopes lead the way in the future for skin cancer detection