Management and Treatment of Pruritus

November 13, 2009 by admin · 4 Comments 

Pruritus, or itch, is a common sensation that causes a person to want to scratch. It is a complex process that may negatively impact quality of life and commonly occurs with skin disorders such as atopic dermatitis and urticaria. It could also be a symptom related to an underlying disease process such as cholestasis or hyperthyroidism, or simply be caused by dry skin, especially in the cold, winter months. Therapy is often aimed at eliminating the underlying cause first, followed by the management of the itchy sensation. Treatment may include prescription and over-the-counter (OTC) medications, herbal remedies, hydrotherapy, phototherapy, and ultraviolet therapy. This overview provides information regarding the various management and treatment options for pruritus.

Pathophysiology of Pruritus

Pruritus is a complex process that involves the stimulation of free nerve endings found superficially in the skin. The sensation of pruritus is transmitted through the C-fibers in the skin to the dorsal horn of the spinal cord, and then, via the spinothalamic tract to the cerebral cortex for processing. Many chemicals have been found to be pruritogenic, therefore causing the itch sensation, including histamine, serotonin, cytokines, and opioids. There are six categories of pruritus: dermatologic, systemic, neurogenic, psychogenic, mixed, and other. Various treatment and management options exist depending on the category or cause.1

Treatment

Treatment of pruritus can be categorized in several ways. A common method of grouping the various options is causative vs. symptomatic treatment. Causative treatment involves finding the underlying disorder and then correcting it, thereby eliminating the itch sensation. Symptomatic treatment involves substituting another sensation for the itch, using methods such as cooling, heating, or counter irritation (e.g., scratching). Symptomatic treatment can be used in addition to treating the underlying disease process in order to provide earlier relief. Most of the available treatment options are categorized under symptomatic therapy and management.

Prescription Medications

Prescription medications include topical and systemic antihistamines, corticosteroids, local anesthetics, and topical immunomodulators, among others. Some lower concentration preparations of these medications are available OTC.

Antihistamines

Itching occurs when histamine is released, causing redness, swelling, warmth, and consequently itchiness. Antihistamines, or H1 antagonists, act by blocking the histamines, and are the most widely used medications for this condition. They take approximately 15–30 minutes to be effective and can be short- or long-acting.2

Topical antihistamines are available in prescription as well as nonprescription forms. Camphor (Caladryl®, Pfizer) is a common diphenhydramine preparation that has both antipruritic and anesthetic properties. This traditional therapy carries with it a small risk of contact dermatitis and allergic sensitization.3

Corticosteroids

Local Anesthetics

Calcineurin Inhibitors

Cholestyramine

Rifampicin

Naltrexone

Ultraviolet (UV) Light Therapy

UV phototherapy is used to treat various pruritic conditions including chronic renal failure; AD; HIV; aquagenic pruritus; solar, chronic, and idiopathic urticaria; urticaria pigmentosa; polycythemia vera; pruritic folliculitis of pregnancy; breast carcinoma skin infiltration; Hodgkin’s lymphoma; chronic liver disease; and acquired perforating dermatoses, among others. It is often undertaken after multiple attempts to treat stubborn itch, and can offer relief without many of the side-effects and risks of systemic medications. UV-based therapy utilizes UVB and UVA in both broadband and narrowband, as well as PUVA (psoralen UVA). Cost and side-effects can be a prohibitive factor for patients. Erythema is common in UVB, as is premature aging and photocarcinogenesis with both UVA and UVB. Side-effects associated with PUVA include redness, burning, headache, and nausea.16,19

UVA, UVB, and PUVA light therapies have been especially useful in the treatment of pruritus in HIV patients, as well as in those patients with systemic mastocytosis and cutaneous T-cell lymphoma. It localizes the effect on the superficial nerve endings, sparing the remaining helper cells, and relieving the pruritus. Because of its more superficial penetration, UVB is believed to be safer than UVA. UVB also spares the remaining helper cells in HIV patients and may localize the effect on the superficial nerve endings, thus relieving pruritus. Systemic mastocytosis and cutaneous T-cell lymphoma also respond to UV therapy and because destruction of the proliferating CD4 clone is desirable, UVA is usually the preferred modality over UVB, although Millikan suggests that the relief of pruritus is more predictable with UVB than with UVA.3

Cutaneous Field Stimulation (CFS)

CFS, which electrically stimulates thin afferent fibers, including nocireceptive C-fibers, was reported to inhibit histamine-induced itching. The reduction in itching is accompanied by degeneration of the epidermal nerve fibers. In one open trial, localized itching responded to CFS treatment, and pruritus was reduced by 49% at the end of 5 weeks. Itch relapsed gradually after the discontinuation of CFS, which led the researchers to conclude that nerve fibers regenerated into the epidermis.20

Over-the-Counter Treatments

In addition to the nonprescription medications mentioned above, there are other OTC treatments that can be helpful for treating and managing pruritus. Moisturizing after a bath is extremely important, and emollients such as white petrolatum, or petrolatum depositing moisturizing body washes, and in-shower moisturizers (e.g., Olay® Ribbons®, Procter & Gamble; emulsifying ointment USP) can be helpful when applied while the skin is still wet.21

There is new evidence to show that moisturizers containing niacinamide and glycerin (e.g., Olay® Quench®, Procter & Gamble) not only hydrate the skin, but improve the skin’s resistance to external factors and improve the barrier function. Glycerin is required for moisturizers to work quickly and add moisture to the skin, but the niacinamide helps to sustain that benefit over a longer period of time.21

Alternative Therapies

Several alternatives to traditional treatment of pruritus have been proposed. Often these therapies can be used in conjunction with prescribed or OTC medications to relieve symptoms quickly. Compounds that have been found to be effective for pruritus by depressing cutaneous sensory receptors include menthol, camphor, and phenol.7 Some other alternative therapies that have been suggested include herbal remedies, nutritional therapy, reflex therapy, and hydrotherapy.3

Herbal Remedies

Several herbs have been proposed as corticosteroid-sparing agents and may provide a viable alternative to topical steroids and their side-effects. Oatmeal baths appear to be most useful because of its colloidal protein and high mucilaginous content. Other herbs have been suggested because of their high mucilage content as well, including flax, fenugreek, English plantain, hearts ease, marshmallow, mulberry, mullein, and slippery elm.3 More extensive research needs to be conducted regarding their possible use and effectiveness for the treatment of pruritus.

Tannins, also derived from herbs, may be helpful as well. The exact mechanism of action is unclear, but may perhaps be related to the coagulation of proteins in the skin. The most common tannin-containing herb is witch hazel, but others include oak bar, English walnut leaf, goldenrod, Labrador tea, lady’s mantel, lavender, and St. John’s wort.

Other possible herbs that may be advantageous include chamomile, which has shown to be equivalent to low concentrations of hydrocortisone, aloe vera, and capsaicin.3 Some side-effects may include irritant or allergic contact dermatitis. Some herbals can be toxic if ingested as well. Some of the oldest group of medications used to soothe and cool pruritic skin is menthol and camphor, which are both considered low risk and safe to use topically. 3,4

Nutritional Therapy

Nutritional therapy, despite not being sufficiently researched as a monotherapy for pruritus, may be helpful in combination with other anti-itch treatments. Vitamins D and E, and linolenic acid have shown some efficacy in the treatment of psoriasis and atopic eczema.3

Reflex Therapy, Acupuncture, and Hydrotherapy

While they are not traditionally used, reflex therapy, acupuncture, and hydrotherapy are three treatments that may be beneficial as adjunctive therapy, however further research is needed. There is little research available regarding the effectiveness of reflex therapy and hydrotherapy. These options may be considered in difficult-to-treat patients where traditional approaches have been unsuccessful. Acupuncture is based on the gate theory of neurotransmission, however it is infrequently used in the Western world, and therefore has insufficient evidence to fully support its use. 3

Management

The management of symptoms is paramount in the treatment of pruritus. Patients should be educated regarding the self-care aspects of this condition. Eliminating the use of irritating or tight clothing is recommended, as well as maintaining a cool environment. Patients should avoid the frequent use of soap, topical irritants in clothing, dry environments, and vasodilators such as caffeine, alcohol, and hot water. Patients should be advised to take brief, tepid or lukewarm baths using mild cleansers with a low pH. Soap film should be rinsed off completely and skin should be patted lightly, followed by the generous application of a moisturizing lotion or cream.4,7,22

Conclusion

Pruritus is a common complaint, but one that can often be a challenge to treat. It can be a major quality of life issue for patients, so it is important that both the underlying disease and associated symptoms are treated as quickly and effectively as possible. Health teaching regarding the prevention and management of pruritus should be included in the overall treatment of the cause and symptoms.

P. Lovell, RN, BScN1; R. B. Vender, MD, FRCPC2
1. Michael DeGroote School of Medicine McMaster University
2. Dermatrials Research, Hamilton, ON, Canada


Skin Biopsies and Skin Lesions

October 31, 2009 by admin · Leave a Comment 

Skin biopsy is a biopsy technique in which a skin lesion is removed and sent to the pathologist to render a microscopic diagnosis. It is usually done under local anesthetic in a physician’s office, and results are often available in 4 to 10 days. It is commonlyskinlayers image Skin Biopsies and Skin Lesions performed by dermatologists.

Skin biopsies are also done by family physicians, internists, surgeons, and other specialties. However, performed incorrectly, and without appropriate clinical information, a pathologist’s interpretation of a skin biopsy can be severely limited. There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy. The choice of the different skin biopsies is dependent on the suspected diagnosis of the skin lesion.

Like most biopsies, patient consent and anesthesia (usually lidocaine injected into the skin) are prerequisites.

Different types of skin biopsies

Shave biopsy

This is done with either a small scalpel blade, a curved razor blade, or a broken piece of “safety” razor. The technique is very much user skill dependent, as some surgeons can remove a small fragment of skin with minimal blemish using any one of the above tools, while others have great difficulty securing the devices. Ideally, the razor will shave only a small fragment of protruding tumor and leaving the skin relatively flat after the procedure. Hemostasis is obtained using light electrocautery, Monsel solution, or aluminum chloride. This is the ideal method of diagnosis for basal cell
cancer.

It can be used to diagnose squamous cell carcinoma and melanoma-in-situ, however, the doctor’s understanding of the growth of these last two cancers should be considered before one uses the shave method. The punch or incisional method is better for the latter two cancers as a false negative is less likely to occur (i.e. calling a squamous cell cancer an actinic keratosis or keratinous debris). Hemostasis for the shave technique can be difficult if one relied on electrocautery alone. A small “shave” biopsy often ends up being a large burn defect when the surgeon tries to control the bleeding with electrocautery alone. Pressure dressing or chemical astringent can help in hemostasis in patients taking anticoagulants.

Punch biopsy

This is done with a round shaped knife ranging in size from 1mm to 8 mm. Some punch biopsies are shaped like an ellipse, although one can accomplish the same desired shape with a standard scalpel. The 1 mm and 1.5 mm punch are ideal for locations where cosmetic appearance is difficult to accomplish with the shave method. Minimal bleeding is noted with the 1 mm punch, and often the wound is left to heal without stitching for the smaller punch biopsies. Disadvantage of the 1 mm punch is that the tissue obtained is almost impossible to see at times due to small size, and the 1.5 mm biopsy is preferred in most cases. The common punch size use to diagnose most inflammatory skin condition is the 3.5 or 4 mm punch. Ideally, the punch biopsy include the full thickness skin and subcutanous fat in the diagnosis of skin disease

Incisional biopsy

When a cut is made through the entire dermis down to the subcutanous fat. A punch biopsy is essentially an incisional biopsy, except it is round rather than elliptical as in most incisional biopsies done with a scalpel. Incisional biopsies can include the whole lesion (excisional), part of a lesion, or part of the affected skin plus part of the normal skin (to show the interface between normal and abnormal skin). Incisional biopsy often yield better diagnosis for deep pannicular skin diseases and more subcutanous tissue can be obtained than a punch biopsy. Long and thin deep incisional biopsy are excellent on the lower extremities as they allow a large amount of tissue to be harvested with minimal tension on the surgical wound. Advantage of the incisional biopsy over the punch method is that hemostasis can be done more easily due to better visualization. Dog ear defects are rarely seen in incisional biopsies with length at least twice as long as the width.

Excisional biopsy

This is essentially the same as incisional biopsy, except the entire lesion or tumor is included. This is the ideal method of diagnosis of small melanomas (when performed as an excision). Ideally, an entire melanoma should be submitted for diagnosis if it can be done safely and cosmetically. This “excisional” biopsy is often done with a narrow margin to make sure the deepest thickness of the melanoma is given before prognosis is decided. However, as many melanoma-in-situs are large and on the face, a physician will often chose to do multiple small punch biopsies before committing to a large excision for diagnostic purpose alone. Many prefer the small punch method for initial diagnostic value before resorting to the excisional biopsy. An initial small punch biopsy of a melanoma might say “severe cellular atypia, recommend wider excision”. At this point, the clinician can be confident that an excisional biopsy can be performed without risking committing a “false positive” clinical diagnosis.

Curettage biopsy

This can be done on the surface of tumors or on small epidermal lesions with minimal to no topical anesthetic using a round curette blade. Diagnosis of basal cell cancer can be made with some limitation, as morphology of the tumor is often disrupted. The pathologist must be informed about the type of anesthetic used, as topical anesthetic can cause artifact in the epidermal cells. Liquid nitrogen or cryotherapy can be used as a topical anesthetic, however, freezing artifact can severely hamper the dianosis of malignant skin cancers.

Fine needle aspirate

Needle aspiration biopsy[1] is done with the rapid stabbing motion of the hand guiding a needle tipped syringe and the rapid sucking motion applied to the syringe. It is a method used to diagnose tumor deep in the skin or lymphnodes under the skin. The cellular aspirate is mounted on a glass slide and immediate diagnosis can be made with proper staining or submitted to a laboratory for final diagnosis. A fine needle aspirate can be done with simply a small bore needle and a small syringe (1 cc) that can generate rapid changes in suction pressure. Fine needle aspirate can be used to distinguish a cystic lesion from a lipoma. Both the surgeon and the pathologist must be familiar with the method of procuring, fixing, and reading of the slide. Many center have dedicated team used in the harvest of fine needle aspirate.

Saucerization biopsy

Also known as “scoop”, “scallop”, or “shave” excisional biopsy[2], or “shave” excision. A trend has occurred in dermatology over the last 10 years with the advocacy of a deep shave excision of a pigmented lesion [3] [4] [5] An author published the result of this method and advocated it as better than standard excision and less time consuming. The added economic benefit is that many surgeons bill the procedure as an excision, rather than a shave biopsy. This saves the added time for hemostasis, instruments, and suture cost. The great disadvantage, seen years later is the numerous scallop scars, and a very difficult to deal with lesions called a “recurrent melanocytic nevus”, see recurrent nevus. What has happened is that many “shave” excisions do not adequately penetrate the dermis or subcutanous fat enough to include the entire melanocytic lesion. Residual melanocytes regrow into the scar. The combination of scarring, inflammation, blood vessels, and atypical pigmented streaks seen in these recurrent nevus gives the perfect
dermatoscopic picture of a melanoma[6][7][8][9]. When a second physician re-examines the patient, he or she has no choice but to recommend the reexcision of the scar.

If one does not have access to the original pathology report, it is impossible to tell a recurring nevus from a severely dysplastic nevus or a melanoma. As the procedure is widely practiced, it is not unusual to see a patient with dozens of scallop scars, with as many as 20% of the scar showing residual pigmentation. The second issue with the shave excision is fat herniation, iatrogenic anetoderma, and hypertrophic scarring. As the deep shave excision either completely removes the full thickness of the dermis or greatly diminishes the dermal thickness, subcutanous fat can
herniate outward or pucker the skin out in an unattractive way. In areas prone to friction, this can result in pain, itching, or hypertrophic scarring.

The Pathology Report

A pathology report is highly dependent on the quality of the biopsy that is submitted. It is not unusual to miss the diagnosis of a skin tumor or a skin biopsy due to a poorly performed or inappropriately performed skin biopsy. The clinical information provided to the pathologist will also affect the final diagnosis. An example would be a rapidly growing dome shaped tumor of the sun exposed skin. Despite doing a large wedge incision, a pathologist might call the biopsy keratin debris with characteristics of actinic keratosis. But provided with an accurate clinical information, he/she might consider the diagnosis of a well differentiated squamous cell carcinoma or keratoacanthoma. It is not infrequent for two, three or more biopsies to be performed by different doctors for the same skin condition, before the correct diagnosis is made on the final biopsy.

The method, depth, and quality of clinical data will all affect the yield of a skin biopsy. For this reason, doctors specializing in skin diseases are invaluable in the diagnosis of skin cancers and difficult skin diseases. Specific stains (PAS, DIF, etc), and certain type of sectioning (vertical and horizontal) are often requested by an astute physician to
make sure that the pathologist will have all the necessary information to make a good histological diagnosis.

References

1. ^ http://www.virtualcancercentre.com/investigations.asp?sid=3
2. ^ Saucerization biopsy of pigmented lesions . Clinics in Dermatology , Volume 23 , Issue 6 , Pages 631 - 635 J . Ho , R . Brodell , S . Helms
3. ^ http://escholarship.umassmed.edu/ssp/46/
4. ^ http://www.clinmedres.org/cgi/content/full/6/2/86
5. ^ http://www.aafp.org/afp/20021101/letters.html
6. ^ http://www.springerlink.com/content/u353473367570111/
7. ^ http://www.pathology-skin-rjreed.com/html/recurrent_nevus__c20t3_.htm
8. ^ http://dermoscopic.blogspot.com/2007/11/recurrent-nevus.html
9. ^ http://www.pathology-skin-rjreed.com/congenital_nevust_c7bt2_.HTM

Actinic Keratosis Treatments

July 22, 2009 by admin · Leave a Comment 

What Is Actinic Keratosis?

An actinic keratosis, also known as a solar keratosis, is a scaly or crusty growth (lesion). It most often appears on the bald scalp, face, ears, lips,
backs of the hands and forearms, shoulders, neck or any other areas of the body frequently exposed to the sun. You’ll most often see the plural,
“keratoses,” because there is seldom just one.

In the beginning, actinic keratoses are frequently so small that they are recognized by touch rather than sight. It feels as if you were running a finger over sandpaper. There are many times the number of invisible (subclinical) lesions as visible ones on the skin surface. ak 5 08 Actinic Keratosis Treatments

Most often, actinic keratoses develop slowly and reach a size from an eighth to a quarter of an inch. Early on, they may disappear only to reappear later. Most become red, but some will be light or dark tan, pink, red, a combination of these, or the same color as your skin. Occasionally they itch or produce a pricking or tender sensation. They can also become inflamed and surrounded by redness. In rare instances, actinic keratoses can even bleed.

If you have actinic keratoses, it indicates that you have sustained sun damage and could develop any kind of skin cancer – not just squamous cell carcinoma.

How to Recognize Actinic Keratosis

Examples of typical actinic keratoses are shown here, so examine your skin regularly for lesions that look like them. But it’s not always that simple:

Many actinic keratoses have quite a different appearance, so if you find any unusual or changing growth, be suspicious and see your doctor promptly. Numerous actinic keratoses can reveale chronic sun damage. They are elevated, rough in texture, and resemble warts.

Two typical keratoses on rim of ear. The top lesion is crusted, the lower one rough in appearance.ak 4 08 Actinic Keratosis Treatments

While most keratoses have a fine sandpapery roughness, others such as this lesion have an obviously scaly, crusty surface.

Chronic sun exposure is the cause of almost all actinic keratoses. Sun damage to the skin is cumulative, so even a brief period in the sun adds to the lifetime total. Cloudy days aren’t safe either, because 70-80 percent of solar ultraviolet (UV) rays can pass through clouds. These harmful rays can also bounce off sand, snow and other reflective surfaces, giving you extra exposure.

The ultraviolet radiation given off by the lamps in a tanning salon can be even more dangerous than the sun, so dermatologists warn against indoor tanning.

Occasionally, actinic keratoses may be caused by extensive exposure to X-rays or a number of industrial chemicals.

What Age Has to Do with It

Because the total amount of time spent in the sun adds up year by year, older people are most likely to develop actinic keratoses. However, nowadays, some individuals in their 20s are affected. Still, actinic keratoses become much more common in people over the age of 50. Some experts believe almost everyone over 80 has actinic keratoses.

Also, individuals whose immune defenses are weakened by cancer chemotherapy, AIDS, organ transplantation or excessive UV exposure are less able to fight off the effects of the radiation and thus more likely to develop actinic keratoses.

Why Is It Treated?

While actinic keratosis is the most common precancer, not all keratoses turn into cancers. Unfortunately, there is no way to know ahead of time which actinic keratoses are precursors of squamous cell carcinoma. That is why it is fortunate that there are so many effective treatments for eliminating actinic keratoses.

When an actinic keratisis is suspected to be an early cancer, the physician may take tissue for biopsy. This is done by shaving off the top of the lesion with a scalpel or scraping it off with a curette. Local anesthesia is required. Bleeding is usually stopped with a styptic agent.

TOPICAL MEDICATIONS

Medicated creams and solutions are very effective by themselves or in combination with another form of treatment when a person has many actinic keratoses.

5-fluorouracil (5-FU) ointment or liquid in concentrations from 0.5 to 5 percent has FDA approval and is the most widely used topical treatment for actinic keratoses. It is effective against not only the surface lesions but also the subclinical ones. Rubbed gently onto the lesions once or twice a day for two to four weeks, it produces cure rates of up to 93 percent. Reddening, swelling and crusting may occur, but they are temporary. The lesions usually heal within two weeks of stopping treatment. There is rarely scarring and the cosmetic result is good.

Imiquimod 5% cream, also FDA-approved, works in a different way: It stimulates the immune system to produce interferon, a chemical that destroys  cancerous and precancerous cells. It is rubbed gently on the lesion twice a week for four to sixteen weeks. The cream is generally well tolerated, but some individuals develop redness and ulcerations.

Diclofenac is a non-steroidal anti-inflammatory drug used in combination with hyaluronic acid, a chemical found naturally in the body. The resulting gelis applied twice a day for two to three months. The diclofenac prevents an inflammatory response, so this topical is well-tolerated, and the hyaluronic acid delays uptake of the diclofenac, leading to higher concentrations in the skin. It is used in persons who are oversensitive to other topical treatments.


CRYOSURGERY

This is the most commonly used treatment method when a limited number of lesions exist. No cutting or anesthesia is required. Liquid nitrogen, applied with a spray device or cotton-tipped applicator, freezes the growths. The lesions subsequently shrink or become crusted and fall off. Temporary redness and swelling may occur after treatment, and in some patients, white spots may remain permanently.

COMBINATION THERAPIES

If one form of therapy is good, two may be better; some of the treatment options described here are especially effective when used together or in sequence. This approach can both improve the cure rate and reduce side effects. One to two weeks of 5-FU followed by cryosurgery can reduce the healing time for 5-FU and decrease the likelihood of white spots following cryosurgery.

CHEMICAL PEELING

This method, best known for reversing the signs of photoaging, is also used to remove some actinic keratoses on the face. Trichloroacetic acid (TCA) and/or similar chemicals are applied directly to the skin. The top skin layers slough off and are usually replaced within seven days. This technique requires local anesthesia and can cause temporary discoloration and irritation.

LASER SURGERY

A carbon dioxide or erbium YAG laser is focused onto the lesion, and the beam cuts through tissue without causing bleeding. This is a good option for lesions in small or narrow areas, and, therefore, can be particularly effective for keratoses on the face and scalp, as well as actinic cheilitis on the lips.

However, local anesthesia may be necessary, and some pigment loss can occur. Lasers are useful for people taking blood thinners or as a secondarytreatment when others have not succeeded.

PHOTODYNAMIC THERAPY (PDT)

PDT can be especially useful for lesions on the face and scalp. Topical 5-aminolevulinic acid (5-ALA), a photosensitizing agent, is applied to thelesions. Subsequently, the medicated area is exposed to strong light that activates 5-ALA. The treatment selectively destroys actinic keratoses, causing little damage to surrounding normal skin, although some swelling and redness often occur.

How to Prevent Actinic Keratosis

The best way to prevent actinic keratosis is to protect yourself from the sun. Here are some sun-safety habits that really work.

* Seek the shade, especially between 10 A.M. and 4 P.M.
* Do not burn.
* Use a sunscreen with an SPF of 15 or higher every day.

* Apply 1 ounce (2 tablespoons) of sunscreen to your entire body 30 minutes before going outside. Reapply every two hours or immediately after  swimming or excessive sweating.
* Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses.
* Keep newborns out of the sun. Sunscreens should be used on babies over the age of six months.
* Examine your skin head-to-toe every month.
* See your doctor every year for a professional skin exam.
* Avoid tanning and UV tanning salons.

Medical Reviewers:
Rex A. Amonette, MD
David J. Leffell, MD
Perry Robins, MD

A PUBLICATION OF THE SKIN CANCER FOUNDATION
For more information or to order this article as a brochure, please contact:
The Skin Cancer Foundation
149 Madison Ave., Suite 901,
New York, NY 10016
© 2008

Photos courtesy of:
Pearon G. Lang, Jr., MD, and
MSKCC Dept. of Dermatology
Photos courtesy of:
Pearon G. Lang, Jr., MD, and
Memorial Sloan Kettering Cancer Center
Deptartment of Dermatology