En español | Last February, Thomas Knox noticed a skin growth on his right hand, between his thumb and index finger. The 79-year-old Philadelphia resident didn't think much of it at first. But it grew larger and was causing some pain — that's when he decided he needed to see a doctor.
Unfortunately, the coronavirus pandemic was sweeping through the country by then, and most clinics were closed to help keep patients and staff home and healthy. Knox's doctors, however, had a workaround. A team of dermatologists at Penn Medicine instructed Knox to take a few pictures of his hand, including one next to a ruler so they could see the exact size and characteristics of the lesion; they even had a surgeon weigh in on the image.
Then, over a conference call, they told Knox he needed to come in for a biopsy. Within 90 minutes of his appointment in an otherwise empty medical office, Knox had the cancer, which had grown to the size of a nickel, examined, biopsied and removed.
"Instead of having three appointments, four appointments, I only had one,” Knox said.
Photos, video help to triage urgent skin cancer cases
The tele-triage system Knox experienced is one that many dermatologists have adopted in response to the coronavirus outbreak, which has sidelined routine medical care, including cancer screenings. Instead of in-person visits, skin experts are turning to photos and video to help determine which concerns are in the clear — or at least can wait — and which need more immediate attention.
The goal is “to weigh the risks against the benefits,” explains Cerrene Giordano, a dermatologic surgeon and assistant professor of clinical dermatology at the University of Pennsylvania's Perelman School of Medicine. “Leaving some of these skin cancers such as melanoma untreated, especially if they are at a more aggressive stage, could potentially be more life-threatening than the risk of COVID-19,” she adds.
Even with some doctor's offices and clinics resuming in-person appointments, cancer screening rates for 2020 are far behind where they should be. A report from the health care technology company Komodo Health found that colonoscopies and biopsies performed to diagnose colon cancer declined by nearly 90 percent between January and mid-April, compared to the same period last year; cervical cancer screenings were down by more than 68 percent.
How to do an at-home skin check
- Stand in front of a full-length mirror and study your skin, front and back.
- Look at your underarms, forearms and palms.
- Look at the back of your legs, the soles of your feet and between your toes.
- Use a hand mirror to examine the back of your neck and scalp.
- Finally, use a hand mirror to check your back and buttocks.
- Contact a board-certified dermatologist if you notice any new spots on your skin, spots that are different from others or spots that are changing, itching or bleeding.
Source: American Academy of Dermatology
"We looked at all of our biopsy results from March 14, which is when all our clinics closed down, through the end of April and they all just plummeted,” says Carrie Kovarik, a dermatopathologist and associate professor of dermatology at the University of Pennsylvania's Perelman School of Medicine. “And it was really shocking to see how few melanomas and non-melanoma skin cancers we were diagnosing when we know that they're still out there.”
Dermatology, however, has an advantage over other specialties when it comes to detecting a potential cancer. It's a “visual field,” explains Julie Karen, a New York City-based dermatologist and clinical assistant professor of dermatology at New York University Grossman School of Medicine. And high-tech imaging equipment and invasive procedures are not always needed to let doctors know that there's cause for concern.
"There are things that we look at by telemedicine and say, ‘That's definitely cancer.’ You know, some things you can still tell,” Kovarik says.
Causes for concern
Even still, tele-dermatology has its limitations. Full body skin exams, which doctors regularly perform during in-office visits to identify suspicious spots, are not conducive to video appointments and phone calls. Instead, dermatologists are asking patients to do their own skin checks at home and to reach out with any concerns — at least until normal appointment loads resume.
When going over your skin, keep the children's story “The Ugly Duckling” in mind, Giordano says. “People tend to have spots that look the same on their body, and so if they have a spot that all of a sudden doesn't quite look like the other spots, or doesn't quite fit in,” it could be a warning sign of cancer, she explains.
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Dermatologists also use the first five letters of the alphabet — ABCDE — as a guide to help people recognize a melanoma, with A standing for Asymmetrical; B standing for uneven Borders; C standing for multiple Colors; D standing for Diameter (it's a warning sign if the size of the spot in question is larger than a pencil eraser — about 1/4 inch); and E standing for a spot that is Evolving.
If you notice a marking on your skin that fits this criteria, contact your doctor right away. Other warning signs that warrant a call to a dermatologist include itching, pain or bleeding on the spot in question. Finally: Don't neglect proper sun protection this summer. Wear sunscreen and reapply it often, Giordano says. And seek out shade during the sunniest points of the day.
Looking at his hand now, Knox says he can hardly tell a nickel-sized skin cancer was removed just a few months ago. The whole ordeal was the first time he used telehealth, but it won't be the last. Knox has already rescheduled upcoming in-person medical appointments to online visits.
"It saves me a trip,” he says. When you go into the office, “they make you sit around for a half an hour, 45 minutes. If you do telemedicine, at least you're at home, getting things done,” he adds.