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Psoriasis and Psoriatic Arthritis
Psoriasis is an inflammatory skin condition that is typically chronic. It can vary from mild to very severe. It can be with or without joint pain.
Psoriasis is not contagious but can run in families.
Causes of Psoriasis

Exact cause is not known, but it is believed that the immune system plays a key role. The immune system activates T-cells (a type of white blood cell) and this causes the skin to grow too quickly. Skin typically replaces itself every 30 days, but in a person with psoriasis, the skin replaces itself about six times faster.
People typically have things that “trigger” psoriasis.
Common triggers:
  • Stress
  • Infection
  • Certain Medications
  • Cold, dry winter weather
  • Lack of sunlight
  • Injury – appears 10-14 days after

Types of Psoriasis

There are five major types of psoriasis:
  • Plaque Psoriasis

Most common type. Appears as patches of raised, red skin with silvery white scale. They are typically on the elbows, knees, lower back and scalp.
  • Guttate Psoriasis

These are small, red spots that usually affect children and young adults. Typically starts off as an infection.

  • Pustular Psoriasis

White pustules surrounded by red skin. Typically on the palms and soles.

  • Inverse Psoriasis

Smooth red lesions in skin folds.
  • Erythrodermic Psoriasis

Widespread redness with severe itching and pain. This can be life threatening.

Psoriatic Arthritis
Psoriatic arthritis develops in 10-30% of people with psoriasis. This is typically chronic joint pain. Medication can prevent joint problems if started early. Without treatment, permanent degeneration can occur
Treatment of Psoriasis
Psoriasis cannot be cured. Treatments can be very effective in controlling it, however.
Types of Treatment
  • Topicals

  • Corticosteroids
    Creams, ointments and lotions may clear the skin by reducing inflammation.
    Form of vitamin D that controls growth of skin cells.
    Coal Tar

  • Light Therapy

  • Ultraviolet light slows rapid growth of skin cells

  • Systemic

  • Methotrexate
    This is an anti-cancer medication that can clear psoriasis. Regular blood tests are needed because of the effects of the medication on the liver.
    This can cause dryness of the skin. It can be prescribed alone or in combination with UV light. Regular blood tests are needed.
    This medication suppresses the immune system and is usually used to prevent organ rejection in patients who have received a transplant. Regular blood tests are needed.

  • Biologic

  • These medications are typically given by injection or infusion. They are unique in that they pinpoint the exact part of the immune system that is involved with psoriasis.
    There are many different biologic medications that may be used, given at different intervals.



It is important to know what your moles look like.  Most moles are harmless but skin cancer can develop in or near a mole.  It can help to find and detect skin cancer earlier if you know what your moles look like.

Moles can be:

  • One color – usually brown but can be tan, black, pink, blue, skin toned or colorless.
  • Round or oval in shape
  • Flat or slightly raised
  • Look the same from month to month

Moles can differ in size, shape or color.  Moles can have hair.  Some moles can change slowly over time, possibly even disappearing.

Nevus is the medical term for a mole.  Nevi is the medical term for two or more moles.

Types of Moles

  • Common or typical mole (nevus)
  • Atypical mole (Dysplastic nevus) – This type can look like melanoma.  It is not melanoma but you have a higher risk for melanoma if you have 4 or more dysplastic nevi.
  • Congenital mole – This is when a person is born with a mole.  About 1 out of every 100 people have congenital nevi.  Having giant congenital nevi increases risks for melanoma.
  • Spitz nevus – This often looks like melanoma.  It can so closely resemble melanoma it can be difficult to determine whether or not it is a melanoma under the microscope.
  • Acquired mole – When a mole appears after a person is born; greater than 50 increases risk for melanoma


Familial Atypical Multiple Mole-Melanoma Syndrome (FAMMM)

This is a genetic condition in which people have many moles (more than 50).  Some are atypical.  There is also a blood relative with melanoma.  This increases your risk of developing melanoma


ABCDEs of Melanoma

abcdes-of-melanoma-large (1)  

Always get a pigmented lesion checked if there is any change at all.  There are typical things that you should look for in evaluating moles or lesions on the skin during self checks.  These are the ABCDEs.

A:  Asymmetry – One side is not like the other.  If you draw a line through the mole, the sides will not match.

B:  Border – The borders of an early melanoma may be uneven. The edges may be scalloped or notched.

C:  Color – Having a variety of colors is another warning signal. A number of different shades of brown, tan or black could appear. A melanoma may also become red, blue or some other color

D:  Diameter – Melanomas usually are larger in diameter than the size of the eraser on your pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected.

E:  Evolution – Any change — in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching or crusting — points to danger.


Melanoma is one of the fastest growing cancers in the U.S. and worldwide. Consider:

  • One in 50 Americans has a lifetime risk of developing melanoma
  • People under 30 are developing melanoma at an alarming rate – the incidence soaring by 50% in young women since 1980
  • Melanoma is the most common form of cancer for young adults aged 25-29 & the second most common cancer in adolescents and young adults aged 15-29
  • In 2009, nearly 63,000 people were diagnosed with melanoma in the U.S., resulting in about 8,650 deaths
  • The American Cancer Society projects that nearly 77,000 will be diagnosed and 9,500 will diefrom melanoma this year
  • Every eight minutes, someone in the U.S. will be diagnosed with melanoma
  • Every hour of every day, someone will die from the disease

Actinic Keratosis


Actinic Keratoses (AKs) are very common. They are one of the most common reasons for office visits.  They are sometimes called solar keratoses because they are caused by years of sun exposure.

AKs are considered precancerous.  If they are left untreated there is a high likelihood of progression to squamous cell carcinomas

What Do AKs Look Like?

Most are dry, scaly and rough textured.  Some are skin colored and more difficult to see.  They are usually sandpaper like and are in groups that cover large areas of skin.  Some can appear as red bumps, thick red scaly patches or growths or crusted growths varying in color from red to brown to yellowish black.

Sometimes AKs grow rapidly upward from the skin and develop a growth that resembles a horn.  When this happens, the AK is called a cutaneous horn.  Horns vary in size and shape.  They are common on men’s ears.  They are typically considered cancerous as the base of the horn has a higher likelihood of cancer.


Treatment of AKs is important to prevent development into skin cancer.

Risk Factors For AKs

  • Blond or red hair color
  • Blue, green or hazel eyes
  • Skin that freckles or burns when in the sun
  • 40 years of age and older
  • Fair skin people
  • People who have had a lot of sun exposure
  • Using a tanning bed or sun lamp

Where Do AKs Form On The Body

AKs typically form in areas that receive the most sun.

  • Face, forehead and scalp, especially a bald scalp
  • Ears
  • Neck and upper chest
  • Back
  • Arms and hands
  • Lower legs, especially in women
  • Border of the lip – actinic chelitis

Actinic Chelitis:


Treatment Options

  • Cryosurgery:  This is the most common treatment.  This involves freezing the AK with liquid nitrogen, which will make the skin blister and flake off.
  • Chemical Peeling:  A chemical solution is applied to the sun to peel away the AK.
  • Chemotherapy for the skin:  A prescription called 4-fluorouracil can be written. This is a cancer fighting cream that you apply to the AK to destroy it.
  • Immunotherapy for the skin:  A prescription cream called imiquimod cream – works with the body’s immune system to help destroy AKs.
  • NSAIDs for the skin: Sodium diclofenac gel is a medication that destroys AKs.


Melanoma is the most serious form of skin cancer.  It is important to find and treat melanoma before it spreads.  With early diagnosis and treatment, melanoma has a high cure rate.

Causes of Melanoma

Exposure to UV rays plays a role in developing melanoma, especially in fair skinned people.  Many sunburns, especially blistering sunburns, raises the risk of getting melanoma.  Not all melanomas are caused by UV radiation. There are other risk factors that increase the likelihood of a person getting melanoma.

Risk Factors for Melanoma

  • Fair, sun sensitive skin that tans poorly or burns easily
  • Red or blond hair
  • Blue or green eyes
  • 50 or more small moles
  • Unusual looking moles that are often larger than normal and have uneven edges (may be called dysplastic nevi or atypical moles)
  • Past sunburns or indoor tanning
  • Past history of melanoma or other skin cancer
  • Blood relatives who have had melanoma
  • Weak immune system, due to disease, organ transplant or medicine
  • Age 50 or older

Being younger than 50 does not mean that you cannot get melanoma.  It is the most common cancer for young adults age 25-29 years old and the second most common cancer in adolescents and young adults.

Warning Signs of Melanoma


The most common warning sign of melanoma is change.  Melanoma may start in an existing mole.  A change in shape, color, diameter of a mole can be a sign of melanoma.  Other changes to watch out for are moles that begin to itch or bleed.

Not all melanomas start out in a mole.  Some melanomas begin suddenly on normal looking skin.  A sudden new growth could be melanoma.

You should perform skin self exams, at least yearly, to look for warning signs.  It is helpful to look for the ABCDEs of melanoma detection.

A:  Asymmetry – one half does not look like the other half

B:  Border – border is irregular, scalloped or poorly defined

C:  Color – color is varied from one spot to another; there are shades of tan, brown and black; sometimes, red, white or blue

D: Diameter – melanomas are most often greater than 6 mm or the size of a pencil eraser (but they can be smaller)

E:  Evolving – A mole or growth that looks different from the rest or is changing in size, shape or color.


The most likely place for melanoma to appear is on the upper back, torso, lower legs, face, scalp and neck, but can appear anywhere.  It can also begin under nails, inside the mouth or on the genitals, and even in your eye.

It is important to remember that melanomas can look different from each other, but the most significant observation is that they look different from your other moles.  You can often look for the “ugly duckling” – a mole that looks completely different than the other moles on your body.

If You Find a Mole That Concerns You

Make an appointment for a skin check.  If any of the moles are concerning, a biopsy will be performed.  During the biopsy, a very small needle is used to inject numbing medication into the skin surrounding the site for the procedure.  A sample of skin is then removed and sent to the pathologist for microscopic examination.  The pathologist will determine whether or not cancer cells are present and will typically tell what stage the cancer is.

Knowing the stage is important because different stages require different treatments.  To determine the stage, it is possible that you could have other testing performed such as ultrasound, x-ray, CT, MRI or PET scans.  Sometimes a surgical procedure known as a sentinel lymph node biopsy is necessary to determine the stage.  Near by lymph nodes are biopsied to determine whether or not the melanoma has spread.  Not all patients will need any or all of these procedures.

Stages of Melanoma

  •  Stage 0; in situ:  Melanoma is confined to the epidermis (top layer of skin)
  • Stage I-II:  Melanoma is confined to the skin, but has reached the second layer of skin (dermis) or beyond.
  • Stage III:   Melanoma has spread to nearby lymph nodes.
  • Stage IV:  Melanoma has spread to the internal organs, beyond the closest lymph nodes or to other lymph nodes or areas of the skin far from the first tumor.


Treatment of Melanoma

Treatment usually starts with excision (surgical removal) of the melanoma and some normal looking skin around it.  If taken early enough, this may be the only treatment necessary.  The sample is sent to the pathologist, who will determine whether or not cancer cells are in the surrounding skin.  If there are no cancer cells present, and the melanoma is in situ, cure rate is near 100%.

If the cancer has spread beyond the skin, more treatment will be needed.  This can be more surgery to remove the tumor and radiation or chemotherapy to kill cancer cells.  If melanoma is advanced, patients typically receive combination therapy.

Melanoma Can Return

Having melanoma increases your risk for developing new melanomas.  They can also recur or return.  Melanoma can spread.  Because of this, it is essential to keep all appointments and have regular skin checks along with self skin checks at home.

More Information

ABCDEs of Melanoma


The Sun and Your Skin

Performing Skin Self Checks

Squamous Cell Carcinoma


Squamous cell carcinoma (SCC) is the second most common type of skin cancer.  If this type of skin cancer is detected early, it can be cured with treatment.

What SCC looks like

SCC can appear in many different forms.  It  can be a bump that feels crusty and rough, a flat patch that is red and rough, a dome shaped bump that grows and bleeds or a sore that does not heal or that heals and returns.

Most of these types of skin cancer develop on sun exposed skin but they can develop in areas that are not exposed to the sun as well.

Some begin as a precancerous growth called an actinic keratosis (AK).  AKs are typically dry, scaly and rough.  They can be very small or even as large as a quarter.

Risk factors for SCC

Although SCC can develop on anyone with any skin type, there are certain risk factors that make it more likely for you to develop an SCC at some point in your life.  This is more common in caucasians.  UV radiation causes damage to the skin and makes it more likely that a skin cancer will develop.  As damage accumulates, risk increases.  Risk also increases with time because more exposure occurs over time.

The following is a list of risk factors for SCC:

  • Pale or light colored skin
  • Blue, green or gray eyes
  • Blond or red hair
  • Inability to tan
  • Significant exposure to UV light
  • Using tanning beds or sunlamps
  • Exposure to cancer causing chemicals
  • Smoked or used tobacco
  • Spending lots of time near heat, such as a fire
  • Previous diagnosis of AKs
  • Badly burned skin
  • Having an ulcer or sore on the mouth that has been there many years
  • Taking medicine that suppresses your immune system
  • Receiving an organ transplant
  • HPV infection
  • Receiving many x-rays
  • Many PUVA light treatments
  • Medical conditions – Xeroderma Pigmentosum, Epidermolysis Bullous or Albinism

Treatment Options for SCC

Early detection provides the best treatment options for SCC.  If it is not treated, it can spread to other areas of the body and make it more difficult to treat.

A biopsy must be performed to get an accurate diagnosis.  To have the biopsy performed, numbing medicine is injected into the skin surrounding the possible skin cancer.  A sample of tissue is obtained and sent to a pathologist to view under the microscope.

The diagnosis given by the pathologist will determine treatment options.  The options available depends on how deep the skin cancer is, how large it is, and whether or not it has spread to other areas.

  • Excision – Surgical procedure performed in office.  This is performed in the same fashion as the biopsy, with local injections of numbing medicine.  The area of skin containing skin cancer, along with normal looking skin is taken off and sent to the pathologist to look at under the microscope.  The pathologist will determine if any cancer cells are in the normal looking skin.  If there are no cancer cells, then we say that the margins are clear and no further treatment is needed.  If there are cancer cells present, more treatment will be needed.
  • Mohs Micrographic Surgery – Surgical procedure performed in the office under local anesthesia.  This means that injections are given into the skin and you will be awake for the procedure.  The surgeon will remove the area of skin that is affected by cancer and a small amount of normal looking skin.  He or she will then look at the sample under the microscope immediately to determine whether or not margins are clear.  If they are not clear, more skin is taken and the process is repeated until all margins are clear.
  • Radiation – When a person cannot undergo surgery to treat a skin cancer, they may be sent for radiation therapy.  A series of radiation treatments are used to destroy the cancer cells.
  • Medicine applied to the skin – If caught early enough, a prescription medication can be given to be applied to the skin at home to destroy cancer cells.
  • Cryotherapy – For superficial SCC, those just on the surface of the skin, liquid nitrogen can be used to destroy cancer cells.  A very cold air is applied to the skin, usually by spraying from a canister to “freeze” the cancer cells to destroy them.

Basal Cell Carcinoma


BCC is the most common form of skin cancer.  Millions are diagnosed each year and nearly all are cured with treatment.

What BCC Looks Like

  • Dome shaped growth with visible blood vessels
  • Shiny, pinkish patch
  • Sore that heals, then returns and repeatedly heals and returns
  • Brown or black growth
  • White or yellow waxy growth that looks like a scar

Most BCCs develop on sun exposed skin such as the scalp, neck and hands.  It is especially common on the face – on the nose, cheeks and forehead but can develop anywhere on the body.

Risk Factors For BCC

Anyone can get BCC, but there are risk factors that make it more likely that you will be diagnosed with BCC at some point in your life.  Lighter skinned people tend to develop BCC more frequently.  Damage to the skin occurs through UV exposure, either from the sun or from tanning beds.  Over time, this damage accumulates and increases the risk of developing skin cancer.  The risk does increase with age because the older you are, the longer you have been exposed to UV radiation.

Risk Factors:

  • Pale, light colored or freckled skin
  • Blond or red hair
  • Blue, green or gray eyes
  • Family history of skin cancer
  • A weakened immune system or are taking medications that suppress the immune system
  • Received radiation therapy
  • Used tanning beds or other indoor tanning devices

BCC is serious because it can grow deep enough to affect bone or other tissue.  It rarely spreads to other areas of the body, however.  A deep or invasive BCC can be difficult to treat.

If caught and treated early, BCC is highly curable.  Treatment cures most BCCs.  To diagnose a BCC a biopsy will be performed.  This is the only way to diagnose any type of skin cancer.  The biopsy will be performed under local anesthesia, which means that the area of skin to be biopsied will be numbed with injections of lidocaine.  The tissue sample will then be sent to a pathologist to be examined under a microscope.  If the diagnosis is BCC, there are many factors that will determine the appropriate treatment.

Treatment Options for BCC

  • Excision – Surgical procedure to remove the BCC along with normal looking skin to ensure that all of the cancer cells have been removed.  This is sent to the pathologist for confirmation of clear margins, which means that there are no remaining cancer cells in that tissue that remains.  If the normal looking skin contains cancer cells, more treatment is necessary.
  • Mohs micrographic surgery – Mohs is usually performed at a medical office under local anesthesia while you remain awake.  The skin cancer, along with some normal looking skin is removed.  The sample is then examined under the microscope to determine whether or not cancer cells remain, and where those cells are.  This will direct the surgeon as to where to remove more skin sample, if necessary.  This process continues until there are no cancer cells remaining.
  • Radiation – When surgery cannot be performed, radiation therapy may be recommended.  A series of radiation treatments are performed to destroy the cancer cells.
  • Medication applied to the skin – When BCC is caught very early and is superficial, medication may be applied to the skin at home to destroy cancer cells.

What to expect from a TCA peel

TCA peels are typically performed during the fall and winter months.  It is advised to avoid sun exposure following the peel as this can cause hyperpigmentation.  We typically start performing TCA peels in the clinic in November for this reason.

This type of peel typically requires a down time of 7-10 days. Skin will be red and swollen. Blisters may form and break open. This will not leave scars, however. Skin will scale and peel within 7-10 days. We recommend moisturizing the skin immediately after and several days after the peel.

The day of the peel:

Avoid wearing makeup the day of the peel. If makeup is worn, you will be asked to remove makeup and wash with a mild cleanser. TCA solution is then applied to dry skin. During the peel, your skin will feel tingly, prickly and then turn hot. There is usually a fan running to cool your skin and ease the burning sensation. “Frosting” sometimes occurs – your skin may turn white during the procedure. This may look scary, but this is the area where your skin will turn brown and peel away the most.

After the peel has completed, you will be asked to wash your face very gently and apply moisturizer. Do not use any abrasive products and do not scrub skin after a peel has been performed.

Days Following the Peel:

Skin will be red in the beginning and turn brown and begin to peel away. It may even blister and break open. This will not leave scars. Continue to use moisturizer and stay out of the sun. You can use makeup at this point as peeling has typically not yet begun.

Everyone responds differently to TCA peels. Some people will have more peeling and redness and some will have less. Peeling typically begins on day 3 and may even peel for 10 days. Do not pick at skin or peel away layers. This can cause damage. Continue to use moisturizer and stay out of the sun.

What do TCA Peels do?

TCA peels are considered medium depth peels.  Strengths can vary, but we typically use two strengths: 25% and 35%.

TCA peels even out skin tone and can make your skin appear brighter. This type of peel reduces hyperpigmentation (dark spots) and other discoloration. TCA peels exfoliate the skin and clear out clogged pores. This type of peel also works well for fine lines and sun damage.

TCA peels will give results after only one peel, but more than one peel is typically required and results last about 6 months or so. You can supplement TCA peels with glycolic acid peels to make the effects last even longer.  

Tips for Managing Acne

  • Wash twice a day and after sweating with a mild cleanser.
  • Use fingertips to apply a mild, non-abrasive cleanser.  Using washcloths or pads can irritate the skin and make acne look worse.  Do not scrub your face.
  • Be gentle with your skin.  Do not use products containing alcohol.  Do not use products that irritate your skin such as astringents, toners and exfoliants.  This can make acne look worse.
  • Rinse with lukewarm water.
  • Shampoo your hair regularly to reduce oil buildup.
  • Let your skin heal naturally.  Popping and picking acne makes it take longer to heal and increases the chance of scar formation.
  • Keep your hands off your face.  Touching your skin can cause acne flare-ups.
  • Stay out of the sun and tanning beds.  Tanning damages the skin.  Also, there are some medications that make the skin more sensitive to UV light.
  • Make sure all sunscreens and cosmetics are oil free – labeled as non-acnegenic or non-comedogenic.
  • Shield your face when applying hair products.