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Melanoma

Diseases & Conditions A-Z

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WOMEN'S HEALTH

Hair/Nails/Skin

  • Corns and calluses

  • Nail fungal infection

  • Ingrown toenails

  • Moles

  • Skin cancer

  • Psoriasis

  • Baldness

  • Sweating and body odor

  • Rosacea

  • Hives and angiedema

  • Athlete's foot

  • Dermatomyositis

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  • Cold sore

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  • Melanoma

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  • CANCER

    Skin

  • Skin cancer

  • Melanoma

  • Melanoma is a disease in which malignant (cancer) cells form in the skin. Skin cancer is the most common cancer, and is increasing rapidly. Although more benign forms of skin cancer such as basal cell and squamous cell carcinomas are on the rise, the greatest increase has been in melanoma, the most serious and most deadly type of skin cancer. In fact, the percentage of people with melanoma has more than doubled in the last 30 years.

    Melanoma develops in the cells that produce melanin (melanocytes) - the pigment that gives your skin its color. It can also form in your eye (intraocular melanoma) and in rare cases in internal organs such as your intestine. But most melanomas develop in your skin.

    Although they make up the smallest percentage of all skin cancers, melanomas cause the greatest number of deaths. That's because they're more likely than other skin cancers to spread to different parts of your body (metastasize). The exact cause of all melanomas isn't clear, but exposure to ultraviolet (UV) radiation from sunlight or tanning lamps and beds greatly increases the risk of developing the disease.

    Avoiding excessive sun exposure can prevent many melanomas. And knowing the warning signs of skin cancer can help ensure that malignant changes are detected and treated before they can spread. Melanoma can be successfully treated if it's caught early.

    Signs and symptoms

    Moles — the medical term is nevi — are clusters of pigmented cells. Normal moles are generally a uniform color, such as tan, brown or black, with a distinct border separating the mole from your surrounding skin. They're oval or round in shape and average about one-quarter inch (6 millimeters) in diameter — the size of a pencil eraser.

    Most people have between 10 and 40 moles. Many of these develop by age 20 although they may change in appearance over time and some may even disappear as you grow older.

    Sometimes you may have one or more large (more than one-half inch, or 12 millimeters, in diameter), flat moles with irregular borders and a mixture of colors, including tan, brown, and either red or pink. Known medically as dysplastic nevi, these moles are much more likely to become malignant than normal moles are.

    In fact, the first sign of melanoma is often a change in an existing mole or the development of a new, unusual-looking growth on your skin. The American Academy of Dermatology has developed an ABCD guide for determining when a mole is a matter for concern:

    • A is for asymmetry. Symmetrical round or oval growths are usually noncancerous (benign). Be alert for irregular shapes, where one half is different from the other.

    • B is for border. Have your doctor check moles with notched, scalloped or vaguely defined borders.

    • C is for color. Look for growths that have many colors or an uneven distribution of color. Growths that have the same overall color are usually benign.

    • D is for diameter. Consult your doctor if you have any growths that are larger than one-quarter inch (6 millimeters) — about the diameter of a pencil eraser.

    Other suspicious changes in a mole may include:

    • Scaliness

    • Itching

    • Change in texture — for instance, becoming hard or lumpy

    • Spreading of pigment from the mole into the surrounding skin

    • Oozing or bleeding

    Cancerous (malignant) moles vary greatly in appearance. Some may show all of the changes listed above, while others may have only one or two unusual characteristics. They can also develop on almost any part of your body.

    Some melanomas develop on skin that's frequently exposed to the sun such as your face, lips, hands and arms. You can prevent these by wearing sunscreen and protective clothing. But the majority of melanomas occur in less exposed areas. In men they're often found on the back. Women tend to develop melanomas on their lower legs.

    Melanomas can also develop in the spaces between your toes and on your palms, soles, scalp or genitals. These are sometimes referred to as hidden melanomas because they occur in places most people wouldn't think to check. Hidden melanomas include:

    • Subungual melanoma. This rare form of melanoma occurs under a nail, most often on your thumb or your big toe. It's especially common in blacks and in other people with darker skin pigment. The first indication of a subungual melanoma is usually a brown or black discoloration that's often mistaken for a bruise (hematoma). See your dermatologist if you develop a nail discoloration that increases in size or that doesn't heal after 2 months.

    • Mucosal melanoma. This relatively uncommon type of melanoma develops in the mucosal tissue that lines the nose, mouth, esophagus, anus, urinary tract and vagina. Mucosal melanomas are especially hard to detect because they can easily be mistaken for other, far more common conditions. A melanoma that develops in your esophagus, for instance, causes pain that's similar to a sore throat. A melanoma in a woman's genital tract usually results in itching and bleeding — symptoms associated with a yeast infection or menstrual irregularities. And symptoms of anorectal melanoma are similar to those caused by hemorrhoids. Your dentist is trained to spot melanomas that occur in your mouth, so having regular dental checkups can help catch this type of cancer. Having regular Pap tests can help spot melanomas in the vagina.

    • Ocular melanoma. Symptoms of this type of melanoma, which may develop in the lining of your eyelids (conjunctiva) or the pigmented coating within your eyeball (choroid), include a scratchy feeling under your eyelid or a dark spot in your vision. The number of white American men with conjunctival melanoma have increased greatly over the past 30 years, most likely as a result of sun exposure. This increase emphasizes the importance of wearing dark glasses when you're spending time in the sun.

    Most melanomas occur in more conspicuous places. The most common melanomas include:

    • Superficial spreading melanoma (SSM). Approximately two-thirds of all melanomas are of this type. An SSM usually first appears as a flat or slightly raised mark that's dark with variegated colors and an irregular border. It occurs most often on the legs in women and on the back and upper arms in men. It can also occur on the soles or palms, especially in people of African or Asian descent. Initially, an SSM spreads through the top layer of skin (epidermis). If it's not caught and treated at this stage, it eventually begins to grow into the underlying layers of skin — the dermis and fatty layer — and may then spread to other parts of your body.

    • Nodular melanoma (NM). The most aggressive of all melanomas, NM usually appears as a small, round bump (nodule) with a smooth border. Most NMs are black, although some may be brown, blue, gray or even red in color. Because this type of cancer spreads so rapidly, it's often quite advanced by the time it's diagnosed.

    • Acral-lentiginous melanoma (ALM). The most common skin cancer in people with deeper skin color, such as blacks and Asians, ALM usually develops on the palms, soles or nails. It's normally brown or black with irregular borders. Because ALM is often mistaken for a minor problem, such as a bruise or blister, it may have penetrated deep into the underlying layers of skin before it's diagnosed.

    • Lentigo maligna melanoma (LMM). The least threatening form of melanoma, LMM tends to develop on the nose or cheeks of older adults. The lesions are flat and range in size from 1.2 inches to 2.4 inches (3 centimeters to 6 centimeters) or more. They tend to be tan, brown or black and generally don't spread to other parts of the body. Instead, they're likely to spread in the epidermis for months or even years before spreading to the deeper layers of skin.

    Sometimes people mistake seborrheic keratoses for skin cancer. Seborrheic keratoses are waxy yellow, brown or black growths that look as if they've been pasted on your skin. What causes them is unknown, but they tend to occur in fair-skinned people older than 40. The growths aren't cancerous, but you may want them removed for cosmetic reasons.

    Causes

    Although it's common to think of skin in cosmetic terms — how soft, smooth or resilient it is — your skin is your body's largest organ and performs a number of essential functions, including protecting you from temperature extremes, injury and infection.

    Your skin consists of three layers — the epidermis, dermis and subcutis. The epidermis, the topmost layer, is as thin as a pencil line. It provides a protective layer of skin cells that your body continually sheds. Squamous cells lie just below the outer surface. Basal cells, which produce new skin cells, are at the bottom of the epidermis. The epidermis also contains cells called melanocytes, which produce melanin — the pigment that gives skin its normal color. When you're in the sun, these cells produce more melanin, which helps protect the deeper layers of skin. The extra melanin is what produces the darker color of a "tan."

    Normally, skin cells within the epidermis develop in a controlled and orderly way. In general, healthy new cells push older cells toward the skin's surface, where they die and eventually are sloughed off. This process is controlled by DNA — the genetic material that contains the instructions for every chemical process in your body. But when DNA is damaged, changes occur in these instructions. One result is that new cells may begin to grow out of control and eventually form a mass of malignant cells.

    Just what damages DNA in skin cells and how this leads to melanoma is under study. Cancer is a complex disease that often results from a combination of factors rather than from a single cause. Still, excessive exposure to ultraviolet (UV) radiation is a leading factor in the development of melanoma.

    UV radiation is a wavelength of sunlight in a range too short for the human eye to see. Commercial tanning lamps and tanning beds also produce UV radiation. UV light is divided into three wavelength bands — ultraviolet A (UVA), ultraviolet B (UVB) and ultraviolet C (UVC). Only UVA and UVB rays reach the earth — UVC radiation is completely absorbed by atmospheric ozone, a naturally occurring substance that filters UV radiation.

    At one time scientists believed that only UVB rays played a role in the development of melanoma. And UVB light does cause harmful changes in skin cell DNA, including the development of oncogenes — a type of gene that can turn a normal cell into a malignant one. But UVA light may also damage melanocytes. People who visit commercial tanning salons are especially at risk because tanning lamps and beds mainly produce UVA radiation.

    Even so, UVB light remains a major concern, especially because of the ongoing depletion of atmospheric ozone, which normally screens the earth from some UVB radiation. In the past two decades, ozone levels have, primarily from widespread use of chlorofluorocarbons (CFCs) — synthetic chemicals commonly used as refrigerants, solvents and foam-blowing agents. Less ozone means that more UVB radiation reaches the ground.

    Scientists are divided on just how much ozone depletion has contributed to the rise in skin cancer. They cite other factors, such as an increase in outdoor activities and sunbathing, as well as a trend toward skimpier clothing. Yet ozone depletion remains a serious concern.

    In addition, the amount of UVB light reaching the earth varies considerably from one geographic region to another. Rays are strongest closer to the equator and at high altitudes.

    But no matter where you live, your skin absorbs UV radiation whenever you're outdoors unless you wear protective clothing and sunscreen. What's more, exposure to occasional periods of intense sunlight puts you at greater risk of melanoma than spending long hours in the sun. An initial high dose of UV radiation will severely damage melanocytes, but not destroy them. When these damaged cells are subjected to further intense bouts of UVA light, they have little capacity to repair their DNA and so are more likely to become malignant.

    Chronic sun exposure doesn't explain all melanomas. Other factors that may lead to melanoma include:

    • Heredity. A small percentage of people who develop melanoma have a family history of the disease. Having a parent, child or sibling with melanoma greatly increases your risk. Damage to the tumor suppressor gene, p16, appears to play a role in inherited melanomas.

    • In addition, some families are affected by a condition called familial atypical multiple mole and melanoma (FAMMM) syndrome. The hallmarks of FAMMM include a history of melanoma in one or more close relatives and having more than 50 moles — some of which are atypical. People with this syndrome have an extremely high risk of developing melanoma. For that reason, screening for signs of skin cancer is crucial. Check with your doctor about getting a screening exam every 4 to 6 months.

    • Age. In general, your risk of developing melanoma increases with age. But younger people can also develop skin cancer, and melanoma is, in fact, one of the most common cancers in people under 30. Complicating matters further, the age at which melanomas tend to develop appears to be different for men and women. In general, women have a higher rate of melanoma than men do until age 40. After age 40, the rate for men rises dramatically. Researchers don't yet know the reason for the disparity, although they believe hormonal factors may play a role. After age 60, the melanoma rate for women once again increases. Overall, however, men have a greater lifetime risk of melanoma than women do.

    • Carcinogens. The American Cancer Society has identified several substances that may contribute to melanoma, including coal, tar, the pitch used in road paving, the wood preservative creosote, arsenic compounds in pesticides and radium.

    As with other types of cancer, it's likely that many melanomas result from a combination of environmental and genetic factors.

    Risk factors

    Factors that may increase your risk of skin cancer include:

    • Fair skin. Having less pigment (melanin) in your skin means you have less protection from damaging UV radiation. If you have blond or red hair, light-colored eyes and you freckle or sunburn easily, you're more likely to develop melanoma than someone with a darker complexion. Fair-skinned people of Northern European ancestry are particularly at risk. Queensland, Australia, has the highest skin cancer rate in the world because it has unusually high levels of UV radiation and because most of its inhabitants are of English or Irish descent.

    • A history of sunburn. Every time you burn your skin, you increase your risk of developing skin cancer. People who have had one or more severe, blistering sunburns as a child or teenager are at increased risk of skin cancer as an adult. For that reason, it's particularly important to protect children from the sun, not just with sunscreen but also with a hat, protective clothing and dark glasses. Although sunburns in adulthood are also a risk factor, the greatest damage seems to occur before you're 18. Infants are at greatest risk because the melanin in their skin isn't fully developed.

    • Excessive sun exposure. Exposure to UV radiation is the leading cause of all skin cancers, including melanoma. Many experts believe that the greatest damage may occur before age 18. For that reason, it's especially important to make sure children wear sunscreen or protective clothing when they're outdoors.

    • Sunny or high-altitude climates. Living in a sunny climate exposes you to more UV radiation than does living in a cool, cloudy climate. Skin cancer is far more common in Arizona than in Minnesota. If you live at a high elevation, where the sun is stronger, you're also exposed to more UV radiation.

    • Moles. Having just one dysplastic mole doubles your risk of melanoma. Having 10 or more increases your risk 12 times. But it's not only atypical moles that make you more susceptible to melanoma — having more than 50 ordinary moles also increases your risk.

    • A family or personal history of skin cancer. If a close relative, such as a parent, child or sibling, has had melanoma, you have a greater chance of developing it too. And if you've had melanoma once, you're more likely to develop it again.

    • Weakened immune system. People with weakened immune systems are at greater risk of many diseases, including skin cancer. This includes people who have undergone an organ transplant, have certain cancers or HIV/AIDS, or are taking medications that suppress the immune system.

    • Exposure to environmental hazards. Exposure to environmental chemicals, including some herbicides, increases your risk of melanoma.

    • Rare genetic disorder. People with xeroderma pigmentosum, which causes an extreme sensitivity to sunlight, have a greatly increased risk of developing melanoma.

    Screening and diagnosis

    The American Cancer Society (ACS) recommends skin examinations every 3 years for adults between the ages of 20 and 40 and yearly exams for everyone older than 40. These screening exams involve a head to toe inspection of your skin by someone qualified to diagnose skin cancer such as a dermatologist or nurse specialist. If you have risk factors for skin cancer — fair skin, a history of severe sunburns, one or more dysplastic moles, or a family history of melanoma — talk to your doctor about more frequent screenings. Some doctors believe that all close family members of a person with melanoma also should be screened.

    In addition, the ACS recommends monthly self-exams for everyone older than 18. This helps you learn the moles, freckles and other skin marks that are normal for you, so you can notice any unusual changes. It's best to do this standing in front of a full-length mirror while using a hand-held mirror to inspect hard to see areas. Be sure to check the fronts, backs and sides of your arms and legs; your groin, scalp and fingernails; and your soles and the spaces between your toes.

    If you notice a new skin growth, a change in an existing mole or a sore that doesn't heal in 2 weeks, see your doctor. He or she may suspect cancer by simply looking at your skin, but the only way to accurately diagnose melanoma is with a biopsy. In this procedure, your doctor or dermatologist removes all or part of the suspicious mole or growth, and a pathologist analyzes the sample. Sometimes more than one pathologist may examine the tissue to determine whether cancer is present.

    If your mole is small, your doctor is likely to perform an excisional biopsy such as a punch biopsy or an elliptical excision. In this procedure, the entire mole or growth is removed, along with a small border of normal-appearing skin. On the other hand, your doctor might use an incisional biopsy for large moles, or for those on your hands or face, where scars are more obvious. In that case, only the most irregular part of a mole or growth is taken for laboratory analysis.

    Staging
    If you receive a diagnosis of melanoma, the next step is to determine the extent, or stage, of the cancer. Melanoma is staged using these criteria:

    • Thickness and depth. A pathologist determines the thickness and depth of a melanoma by carefully examining it under a microscope. The depth of a cancerous lesion is the most important factor in deciding on a treatment plan. In general, the deeper the tumor, the more serious the disease.

    • Spread. It's also important to determine whether melanoma cells have invaded your lymph nodes. To do so, your surgeon may use a procedure known as a sentinel node biopsy. Until recently, surgeons would remove as many lymph nodes as possible to verify that the nodes didn't contain cancer cells. But this greatly increased the risk of lymphedema — severe swelling of the involved area — and other side effects. That's why a procedure was developed that focuses on finding the sentinel nodes — the first nodes to receive the drainage from malignant tumors and therefore the first to develop cancer. If a sentinel node is removed, examined and found to be healthy, the chance of finding cancer in any of the remaining nodes is small and no other nodes need to be removed. This spares you the risks of more extensive procedures.

    Melanoma is staged using the numbers 0 through IV:

    • Stage 0. This melanoma is also called in situ (in one place) melanoma. At this stage, the cancer is confined to the epidermis and hasn't begun to spread. Finding and treating a cancerous tumor at this stage offers the best chance for a full recovery.

    • Stages I through IV. These cancers are invasive tumors that have the ability to spread to other areas. A stage I cancer is small and well localized and has a very successful treatment rate. But the higher the stage number, the lower the chances of a full recovery. By stage IV, the cancer has spread beyond your skin to other organs, such as your lungs, liver and bone. Although it may not be possible to eliminate the cancer at this stage, treatment with radiation or biological or experimental therapies may help alleviate symptoms the cancer is causing.

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  • Treatment

    The best treatment for you depends on the stage of cancer you have and your age, overall health and personal preferences. But in most cases, the standard treatment for melanomas that haven't spread beyond the skin is surgery to remove the cancer.

    When melanoma has spread to another part of your body, options may include surgery, chemotherapy, radiation therapy, biological therapy, experimental therapy or a combination. It's important to understand the different treatments and their potential risks and side effects. Don't be afraid to discuss any questions you may have with your treatment team. You may also want to consider seeking a second opinion, especially from doctors who specialize in treating melanoma. In some cases, after weighing your options you may choose not to treat the melanoma itself but rather to try to relieve any symptoms the cancer may cause.

    Treating early-stage melanomas
    The best treatment for early-stage melanomas is surgical removal (simple excision). Very thin melanomas may have been entirely removed during the biopsy and require no further treatment. Otherwise, surgery involves your doctor excising the cancer as well as a small border of normal skin and a layer of tissue beneath the skin. In almost every case this eliminates the cancer.

    At one time, surgery for more invasive early-stage tumors involved cutting out the cancer along with a large border of normal skin (wide local excision). This usually meant having a skin graft — a procedure in which skin from another part of the body is used to replace the skin that's removed. But taking smaller amounts of normal skin in some cases of invasive melanomas may be just as effective in treating cancer and may eliminate the need for skin grafts.

    Even so, you may be concerned about scarring. It may help to know that in many cases, the scar is a small line about 1 to 2 inches long that fades with time. If you need a skin graft, however, the scar will be larger and more noticeable.

    Treating melanomas that have spread beyond the skin

    • Surgical removal. Unfortunately, it's usually not possible to cure melanomas that have spread beyond the skin. But surgically removing a metastatic melanoma can often provide relief of symptoms — sometimes for years. Whether this is an option for you depends on where the cancer is located and how severe it is, as well as on your own wishes and overall health. 

    • Chemotherapy. This form of treatment uses drugs to destroy cancer cells. Two or more drugs are often given in combination and may be administered intravenously, in pill form or both — usually for 4 to 6 months. Although not as effective in treating melanoma as some other types of cancer, chemotherapy can help relieve symptoms in people with advanced metastatic melanoma.

    • Chemotherapy is generally a systemic therapy, which means that it can affect cancer cells throughout your body. But chemotherapy also affects healthy cells — especially fast-growing cells in your digestive tract, hair and bone marrow. This can cause side effects such as nausea, vomiting and fatigue. Not everyone has these side effects, however, and there are now better ways to manage them if you do.

    • Researchers are studying different ways to administer chemotherapy medications in an attempt to reduce their effect on healthy cells. One method under investigation is limb perfusion. It's used for melanomas on the arm or leg. In this procedure, the blood flow to the limb being treated is temporarily stopped with a tourniquet. High doses of chemotherapy drugs are then injected directly into the melanoma. Because most of the drugs stay in the limb, they're less likely to affect other parts of the body.

    • Radiation therapy. This treatment uses high-energy X-rays to kill cancer cells. It's sometimes used to help relieve symptoms of melanoma that has spread to another organ. Fatigue is a common side effect of radiation therapy, but your energy usually returns once the treatment is completed.

    • Biological therapy (immunotherapy). This form of treatment is designed to help your immune system fight disease. It involves the use of biologic response modifiers (BRMs) — substances your body normally produces in response to infection. BRMs such as interleukin-2 and interferon are now produced in laboratories for use in treating cancer and other diseases. Side effects include symptoms similar to those of the flu, such as chills, fever, nausea, vomiting and diarrhea. Often, these symptoms are so severe you need to be hospitalized. For that reason, researchers are searching for forms of immunotherapy that not only are more effective but also cause fewer side effects.

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  • Prevention

    The most heartening news about melanoma is that many cases of skin cancer can be prevented simply by following these precautions:

    • Avoid the sun between 10 a.m. and 3 p.m. Because the sun's rays are strongest during this period, try to schedule outdoor activities for other times of the day, even in winter or when the sky is cloudy. You absorb UV radiation year-round, and clouds offer little protection from damaging rays.

    • Wear sunscreen summer and winter. Sunscreens don't filter out all harmful UV radiation, especially the radiation that can lead to melanoma. But they play a major role in an overall sun protection program. Be sure to use a broad-spectrum sunscreen with a sun protection factor (SPF) of at least 15 when you go outside, summer and winter. Broad-spectrum products provide protection against both UVA and UVB radiation. Use sunscreen on all exposed skin, including your lips, the tips of your ears, and the backs of your hands and neck. You need to use about an ounce of sunscreen to adequately cover your entire body.

    • For the most protection, apply sunscreen 30 minutes before sun exposure and reapply it every 2 hours throughout the day. Also be sure to reapply it after swimming or exercising. Apply sunscreen to young children before they go outdoors, and teach older children and teens how to use sunscreen to protect themselves. Keep sunscreen in your car as well as with your gardening tools and sports and camping gear to remind yourself and your family to use it.

    • Be an educated sunscreen consumer. Most sunscreens provide physical protection, chemical protection or a combination of both. Knowing the difference can help you select the best product for you and your family.

    • Physical sunscreens contain ingredients such as titanium dioxide. These form an opaque film that reflects UV rays before they can penetrate your skin. Chemical sunscreens, on the other hand, absorb sunlight before it can cause any damage. Combination products do a little of both.

    • Even if you know what to look for, sunscreen labels can be confusing, and sometimes actually misleading. That's why the Food and Drug Administration has instituted new labeling guidelines. Among the changes is the elimination of the terms sun block (no product actually "blocks" UV rays), all-day (no sunscreen lasts all day) and waterproof (all sunscreens wash off in water to some extent — the new term is water-resistant). Sunscreens claiming an SPF higher than 30 are now labeled 30+, rather than 45 or 60, because tests show little difference among products with SPF factors over 30. Finally, make sure any product you use actually contains sunscreen — many tanning oils and lotions don't. Products that don't contain sunscreen are required by law to clearly indicate that on the label.

    • Wear protective clothing. Sunscreens don't provide complete protection from UV rays. That's why it's a good idea to also wear dark, tightly woven clothing that covers your arms and legs, and a broad-brimmed hat, which provides more protection than a baseball cap or visor. Some companies also design photoprotective clothing. Your dermatologist can recommend an appropriate brand. Don't forget sunglasses. Look for those that block out both UVA and UVB rays.

    • Avoid tanning beds and tan-accelerating agents. Tanning beds emit UVA rays, which may be as dangerous as UVB rays, especially since UVA light penetrates deeper into your skin and causes precancerous skin lesions.

    • Be aware of sun-sensitizing medications. Some common prescription and over-the-counter drugs — including antibiotics; certain cholesterol, high blood pressure and diabetes medications; birth control pills; nonsteroidal anti-inflammatories such as ibuprofen (Advil, Motrin, others); and the acne medicine isotretinoin (Accutane) — can make your skin more sensitive to sunlight. Ask your doctor or pharmacist about the side effects of any medications you take. If they increase your sensitivity to sunlight, be sure to take extra precautions.

    • Have regular skin examinations. See your doctor for a complete skin exam every year if you're older than 40, or more often if you're at high risk of developing melanoma.

    • Check your skin regularly and report changes to your doctor. Examine your skin often for new skin growths or changes in existing moles, freckles, bumps and birthmarks. With the help of mirrors, check your face, neck, ears and scalp. Examine your chest and trunk, and the tops and undersides of your arms and hands. Examine both the front and back of your legs, and your feet, including the soles and the spaces between your toes. Also check your genital area, including between your buttocks.

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