Pathophysiology and Etiology

• Most basal and squamous cell carcinomas are located on sun-exposed

areas and are directly related to ultraviolet radiation. Sun damage is
cumulative.
• Risk factors for skin cancer include:
• Fair complexion, blue eyes, blond or red hair.
• Working outdoors.
• Older people with sun-damaged skin.
• History of X-ray treatment of skin conditions.
• Exposure to certain chemical agents (arsenicals, nitrates, tar and pitch, oils, and
paraffins).
• Burn scars, damaged skin in areas of chronic osteomyelitis, fistulae openings.
• Long-term immunosuppressive therapy.
• Genetic susceptibility.
• Multiple dysplastic nevi moles that are larger, irregular, more numerous, or
variable colors or family history of dysplastic nevi.
• Congenital nevi that are large (more than 20 cm in size)
• Melanoma in situ. Earliest phase, difficult to recognize because clinical
changes are minimal.
• Superficial spreading melanoma (most common).
• Circular, with irregular outer portions; the margins may be flat, or elevated
and palpable.
• Has combination of colors hues of tan, brown, and black mixed with gray,
bluish black, or white.
• May be dull pink-rose color in a small area within the lesion.
• Occurs anywhere on body; usually affects middle-aged persons.
• Nodular melanoma.
• Spherical blueberry-like nodule with relatively smooth surface and relatively
uniform blue-black, blue-gray, or reddish blue color.
• May be polypoidal and elevated, with smooth surface of rose-gray or black color.
• Occurs commonly on torso and extremities.
• Invades directly into the subjacent dermis (vertical growth) and hence has a
poorer prognosis.
• Lentigo malignant melanoma.
• First appears as tan, flat macule”malignant degeneration is manifested by
changes in color, size, and topography.
• Evolves slowly; occurs on exposed skin surfaces of persons in their 40s or 50s
• Acrolentiginous melanoma (uncommon).
• Irregular pigmented macules, which develop nodules; may become invasive
early.
• Occurs commonly on palms, soles, nail beds, and rarely on mucous
membranes.
• Most common type of melanoma in Blacks and Asians
Diagnostic Evaluation
• Excisional biopsy (for histopathologic diagnosis) and microstaging
determination of thickness and level of invasion; helps determine
treatment and prognosis.
 Management
• Complete excision of lesion. If depth is between 1 and 4 mm, or there is
ulceration present, sentinel lymph node biopsy may be done at the time of
reexcision. Margins of 1 cm are required on reexcision. Close subsequent
follow-up is necessary.
• Systemic chemotherapy generally used for recurrence of metastasis or
palliation; may be combined with autologous bone marrow
transplantation or several agents used in combination.
• Early detection has a 5-year survival rate approaching 95% for thin (< 0.75
mm) in primary melanoma. The 8-year survival rate for lesions of 0.76 to
1.69 mm in thickness is 85.6% but drops off to 33% for lesions. 3.60 mm
Nursing Assessment

• Have a high index of suspicion for persons at risk.

• Ask about sunbathing habits. Question patient about pruritus, tenderness, pain, or
bleeding, which are not features of a benign nevus (mole).
• Ask about changes in preexisting moles or about development of a new pigmented
lesion.
• Use a magnifying lens in a brightly lit room to look for variegated color and
irregular border and surface in the mole. Use side lighting to assess subtle
elevation.
• Examine entire skin surface, including scalp, genital area, gluteal folds, and soles of
feet.
• Examine diameter of mole; melanomas are usually larger than 2½ inches (6 cm);
look for lesions situated near the mole.
Nursing Diagnoses

• Deficient Knowledge related to risk factors for skin cancer

• Anxiety related to diagnosis of cancer
 Nursing Interventions

1. Increasing Knowledge and Awareness

• Encourage follow-up skin examinations and instruct the patient to examine skin
monthly as follows:
• Use a full-length mirror and a small hand mirror to aid in examination.
• Learn where moles/birthmarks are located.
• Inspect all moles and other pigmented lesions; report any change in color, size, elevation,
thickness, or development of itching or bleeding.
• Teach the patient to use a sunscreen with at least SPF 15 routinely and to avoid
becoming sunburned.
• Sunlight permanently damages the skin and the cumulative effects of the sun may result in skin
cancers.
• Avoid tanning, especially if skin burns easily, never tans, or tans poorly.
• Avoid unnecessary exposure to the sun, especially during times when ultraviolet radiation is
most intense (10 A.M. to 3 P.M.).
• Wear protective clothing (long sleeves, broad-brimmed hat, high collar, long pants). However,
clothing does not provide complete protection; up to 50% of sun's damaging rays can penetrate
clothes.
2. Reducing Anxiety
• Provide dressing changes and wound care while teaching patient to
take control, as directed after surgical intervention.
• Administer chemotherapy with attention to possible adverse effects,
as directed.
• Allow patient to express feelings about the seriousness of diagnosis.
• Answer questions, clarify information, and correct misconceptions.
• Emphasize use of positive coping skills and support system.
 Patient Education and Health Maintenance
• Encourage lifelong follow-up appointments with dermatologist or primary
care provider with examinations every 6 months.
• Encourage all individuals to have moles removed that are accessible to
repeated friction and irritation, congenital, or suspicious in any way.
• Teach all individuals the importance of sun-avoidance measures; teach
proper use of sunscreen:
• Sunscreens with SPF 15 or greater offer good protection.
• Sunscreens should be used from infancy through old age.
• Sunscreens should be applied, before going outdoors, to all areas that may be
exposed, preferably before dressing. They should be applied liberally to achieve the
stated SPF.
• Newly developed sunscreens are more resistant to removal by water, clothing,
sweating; however, periodic reapplication is necessary when spending prolonged
periods outdoors, especially when swimming.
• Protect lips with a lip balm that contains a sunscreen with the highest SPF.
Evaluation: Expected Outcomes

• Uses high SPF sunscreen, wears protective clothing, and performs

monthly skin examinations
• Verbalizes decreased anxiety