Dermatology, Cosmetic Surgery, Mohs Micrographic Skin Cancer Surgery & Laser Surgery

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Category: Skin Cancer

Causes and Treatments of Skin Cancer: Are You at Risk?

3 Min Read

 

Skin cancer is easily treatable when diagnosed early.Skin cancer affects one out of every five Americans.

While skin cancer is easily treatable when it is diagnosed early, it can spread and become more serious—or even fatal—if the signs are disregarded.

What Are the Types of Skin Cancer?

Not all skin cancer is the same. There are three main divisions of skin cancer: basal cell carcinoma, squamous cell carcinoma, and melanoma.

  1. Basal cell carcinoma is caused by the uncontrolled growth and division of the basal cells (cells from the lower part of the epidermis that produce new skin cells). These are most often found on the face, neck, ears, shoulders, and back.
  2. Squamous cell carcinoma is caused by the uncontrolled growth and division of the squamous cells (cells from the outermost part of the epidermis that play a role in osmosis, diffusion, and filtration). These cancers are commonly found on the face, neck, ears, and scalp.
  3. Melanoma is caused by the uncontrolled growth of the melanocytes (the cells that produce pigment). This is the most severe form of skin cancer and can spread quickly if not treated.

What Are the Causes of Skin Cancer?

While the development of skin cancer can be influenced by genetics, moles, and lifestyle choices, it is most commonly attributed to being exposed to UV radiation. 

Ultraviolet rays due to sun exposure or tanning beds damage your DNA and alter the way that your cells reproduce, grow, and divide. Skin cancer can develop when the growth of these cells is not kept in check.

How Can I Identify Skin Cancer?

Skin cancer is commonly identified and diagnosed by changes in your skin or moles. 

For basal cell carcinoma, watch out for:

  • Open sores that do not heal
  • Shiny bumps or nodules
  • Slightly raised, pink growths
  • Reddish patches

For squamous cell carcinoma, watch out for:

  • Crusty skin sores
  • Thick, rough, or scaly patches
  • Open wounds or warts that do not heal

For melanoma, watch out for moles or skin patches that follow the ABCDEs:

  • Asymmetry (half of the mole does not match the other)
  • Border (uneven or ragged borders)
  • Color (more than one shade)
  • Diameter (larger than six millimeters)
  • Evolving (moles that grow or change in appearance)

How Can I Treat Skin Cancer?

There are several tissue removal options that can treat skin cancer—including melanoma. These techniques remove the visible tumor as well as a margin (a buffer rim of tissue around the cancerous cells).

Unfortunately, these excision techniques result in scarring, which may be visible if the cancer is located in an exposed area like the face, neck, hands, or arms. 

While there is no way to eliminate scarring, some techniques can reduce the amount of scarring. One of these techniques is Mohs surgery. 

Mohs surgery is a conservative but highly effective skin cancer treatment that removes cancerous tissue layer by layer (as opposed to the “chunk” of tissue that is removed with many other techniques).

By removing the tissue in layers, there is no unnecessary damage to the surrounding tissues, and this allows for better aesthetics and a more comfortable recovery. 

Once the skin cancer has been removed, the surrounding edges can be pulled together and sutured or covered with a skin graft.

How Can I Learn More About Mohs Surgery?

If you would like to learn more about Mohs surgery, contact Skin Physicians & Surgeons, Inc. and set up a consultation by calling (909) 981-8929.

You can also stay up-to-date with Dr. Sandra Lee by following Dr. Pimple Popper on Twitter or Instagram.

Do I Have a Mole or Skin Cancer?

Mole ExamFreckles, sun spots, fairy kisses… it doesn’t matter what you call them; most everyone has moles. When melanocytes grow in clusters on the skin, a mole develops, and sun exposure and hormones can cause them to take on the traditional dark color we associate with moles. Congenital nevi are moles present at birth, while dysplastic nevi are moles that occur after birth. Unfortunately, moles have the potential to be more dangerous than you think; both types of moles can turn into skin cancer over time. So, how do you know when it’s time to see your doctor?

Know Your ABCDEs

You should monitor any suspicious mole once a month and contact your health care professional if you believe any of your moles are abnormal. A simple ABCDE rule will help you evaluate your moles for possible skin cancer. The following may be a cause for concern:

  • Asymmetry – one half of your mole doesn’t match the other
  • Borders – your mole has an irregular border rather than smooth, round edges
  • Color – your mole is a color other than brown or has inconsistent coloring such as various shades of brown
  • Diameter – your mole has a large diameter or approximately 6 mm or more
  • Evolving – your mole changes in size, shape, or color at any time

Avoid Developing Skin Cancer

While you can develop skin cancer without being born with moles, congenital nevi can develop into cancer. The key for any skin type is to avoid prolonged exposure to the sun. UVA and UVB rays can mutate your natural skin cells, causing uncontrollable cellular growth (cancer). Don’t stay in the sun for long periods of time. Always wear a broad-spectrum UV sunscreen, and apply it regularly when exposed to the sun for more than a few hours.

See a Physician

If you believe that you have a questionable mole, schedule a consultation with a board-certified dermatologist at Skin Physicians & Surgeons. We provide in-office screenings of possible skin cancers. We diagnose and treat all of our patients. Removing cancerous moles before they spread is the best way to keep you healthy.

Remove Unsightly Moles

Even if your mole isn’t cancerous, you can still have it removed to ensure beautiful, flawless skin. Mole removal is a simple procedure performed in our medical office. We exam all removed moles to ensure they aren’t cancerous. Great care is taken to minimize scar development to maintain the beauty of your complexion.   

 
To schedule your dermatology appointment with a doctor at Skin Physicians & Surgeons, call us at 909-981-8929 or contact us online.

Battling Sun Damage Head On: Protect Your Hair and Scalp

Almost everyone knows that wearing sunscreen is important for protecting your skin. But have you ever stopped to think about protecting your head? Wearing sunscreen on your face isn’t enough; your hair and scalp can also receive sun damage if they are not protected. It’s easy to forget this, but the risk of sun damage and skin cancer on your scalp is very real. Here is how to protect your hair and scalp using quality Skin PS sunscreens and skin cancer treatment.

Protecting Your Hairbikini woman in hat sitting in beach chair

The sun can damage your hair as well as your scalp. If you spend a lot of time out in the sun, you may have noticed your hair turning lighter. This is because strong UV rays dry out your hair, bleach it, break it down, and make it brittle and less manageable. Ideally, you should wear a hat to protect your hair and scalp when you’re out in the sun. However, if this is not an option, apply a leave-in conditioner with UV filter protection or a hydrating hair mask with UV protection to protect your hair from damaging rays of the sun.

Protecting Your Scalp

Your scalp is somewhat protected by your hair, but it is still vulnerable to sun’s ultraviolet rays. Before exposing your head to the sun, apply water-resistant zinc oxide or titanium dioxide sunscreens to your part line or over your whole head if you have fine hair or thinning hair. To prevent premature aging, dark spots, increased blood vessels, skin cancer, and more, use a broad-spectrum sunscreen with an SPF of 15 or greater. Apply this at least 30 minutes before going out into the sun and reapply it every couple hours, especially if it’s a hot day or if you’ve been sweating or swimming. At Skin Physicians & Surgeons, our experts recommend Melashade SPF30 and Antioxidant Facial Sunscreen SPF30 to prevent and reverse sun damage.

Treating Skin Cancer

If you already have signs of sun damage on your scalp, there’s a possibility you may have skin cancer. Know how to recognize the signs of skin cancer as well as what to do if you suspect a problem. At Skin Physicians & Surgeons, we can examine a concerning area or conduct a complete skin examination for you. If skin cancer is detected on your head or neck, Dr. Sandra Lee at our practice offers Mohs Micrographic Skin Cancer Surgery. This procedure is a specialized treatment created specifically for skin cancer on the head or neck, and it has an extremely high cancer cure rate (96 to 99 percent) with minimal skin removal.

For more tips on how to protect your skin from damaging UVA and UVB rays, to find out how to get our recommended professional sunscreens, or to schedule a cancer treatment consultation, call us at 909-981-8929 or fill out our online contact form.

Holy Moley! (Mole Removal)

Also known as “nevi,” moles are groups of darkened (pigmented) cells that can appear on various areas of the body. Moles come in many sizes and can be smooth, raised, or wrinkled. The average person has about 100 of these spots on their body! (Holy moley!)

Suspicious Moles

Unfortunately, a lot of these “beauty marks” aren’t very appealing, and some can even pose a health risk. Although most moles are initially benign, they can potentially become cancerous. Therefore, it is important to perform a self-exam once a month and have a full body skin exam every two to three years (or yearly if you have a family or personal history of skin cancer). These exams check for suspicious moles to help identify potential skin cancers so they can be addressed as soon as possible.

ABCDEs of Melanoma

Be on the lookout for the following (ABCDE) mole characteristics that may be warning signs of skin cancer: 

    • A: Asymmetry
    • B: Borders that are uneven or notched
    • C: Color variations (more than one color, or red, white, or blue)
    • D: Diameter larger than a pencil tip eraser (¼ inch or 6mm)
    • E: Evolving in any way (size, shape, color, elevation, itching, bleeding, etc.)

 

Famous Moles

Some celebrities have had their famous moles removed to ensure their safety. Ewan McGregor had several moles removed, and one of them proved to be cancerous. Enrique Iglesias had his trademark mole removed after his doctor told him it could become cancerous. Although Iglesias was nervous about having his mole removed, the quick procedure was done in five minutes.

A Simple Removal Process

We commonly perform mole removal procedures in our medical office. Mole removal is a very safe, simple, and painless process when performed by a professional. The area is numbed with a local anesthetic, and the mole is removed flush with the skin. If necessary, an excision technique and sutures may be used. We then have the mole examined to determine whether or not it is cancerous.

If you’re concerned about a mole for cosmetic reasons or suspicious characteristics, call us at (909) 981-8929 or fill out our online contact form for more information. Board-certified dermatologist Dr. Sandra Lee looks forward to helping you achieve peace of mind and a more attractive appearance.

What Is Cryotherapy?

Cryotherapy may sound like a term coined for a superhero power, but it is a simple cosmetic treatment that permanently eliminates abnormal and diseased tissue. By utilizing non-toxic liquid nitrogen that is about -200º C, this non-invasive treatment instantly freezes the cells inside of the affected tissue.

How Is Cryotherapy Treatment Performed?

Once the targeted area is cleaned, cryotherapy is performed with a handheld device that delivers short pulses of liquid nitrogen directly to the skin. After the skin is properly treated, ointment is applied, and a bandage covers the treated area. Over the next few days, the area may blister and scab as it heals.

What Skin Conditions Are Treatable With Cryotherapy?

Cryotherapy effectively treats a wide range of common skin imperfections, including:

Wartswarts on hand

Warts are small, rough growths caused by the human papillomavirus (HPV). Although most warts are not painful, their appearance on the face, hands, or feet can cause a person to feel self-conscious about their appearance.

Skin Tags

Skin tags are small flaps of overdeveloped tissue that are typically found on the neck, chest, or armpits. Skin tags often cause irritation when they come in contact with clothing.

Solar Lentigines and Actinic Keratosis

These skin lesions are gray or brown spots that usually appear on the face, hands, and arms. These spots can either develop as a result of the aging process or as a result of prolonged sun exposure (hyperpigmentation). In some instances, they may also be precursors to skin cancer.

Skin Cancer

Cryotherapy can also treat some skin cancers, but only if the lesions affect the epidermis (top layer) of the skin. A consultation with Dr. Sandra Lee will determine if cryotherapy can be an effective treatment for your skin cancer lesion.

To find out if you are a good candidate for cryotherapy, feel free to contact our board-certified dermatologist Dr. Sandra Lee today. Dr. Lee has years of experience with the most technologically advanced laser and light-based procedures to help you achieve an appearance about which you can feel confident. Call (909) 981-8929 today, or fill out our online contact form for more information. We look forward to seeing you soon!

 

How to Get a Great Sunless Tan

A woman's tan legs on a white backgroundPopular culture has labeled tan skin as desirable, and many women go to great lengths to achieve a sun-kissed glow. However, those who achieve bronze skin from indoor tanning beds and the sun’s natural rays are putting themselves at a high risk for developing melanoma, the deadliest form of skin cancer. The ultraviolet radiation from sunshine and tanning beds causes DNA damage to skin cells, which can lead to genetic defects that develop into cancerous tumors. Not only is tanning detrimental to your health, it also leads to significant signs of aging, such as wrinkles, fine lines, and sun spots.

Fortunately, a natural-looking tan can be achieved safely with sunless tanning products. Follow these simple tips to get a great sunless tan.

Choose the Right Product

When it comes to self-tanning products, all sunless tanners are not created equally.

Daily moisturizers, such as Jergens Natural Glow, are great for beginning self-tanners. Even if a moisturizer is not applied perfectly, any blotchiness or streaking will be subtle and even out more quickly than with more intense sunless tanning products. These moisturizers have less of the active tanning ingredient so that they gradually create a natural-looking tan, and they are great for taking the place of your daily moisturizer to hydrate your skin.A woman applying sunless tanning lotion with her hair up in a towel

Lotions and creams are fitting for people just starting a self-tanning regimen as well as for more experienced self-tanners. These formulas show a hint of shading when they are first applied so that you can see any uneven areas, and they easily blend into the skin without drying too quickly.

Mousses and gels are ideal for people who are more experienced with self-tanning products because these lightweight formulas dry faster than moisturizers and creams. Sunless tanning mousses and gels can be layered to create more intense tans and custom contouring.

Cleanse and Exfoliate

Before applying your sunless tanning product, be sure to prepare your skin by showering and thoroughly exfoliating your skin each time. This will remove dead skin cells so that healthy skin will absorb the tanning formula more evenly and last longer. Be sure you are completely dry before you begin applying your sunless tanning product.

Apply Evenly With Gloves

Use disposable, powder-free gloves when applying tanning products to avoid staining your hands, and the smooth surface of the gloves will help you apply the product more evenly. Be sure to spread the product over your skin evenly in a circular motion, using it sparingly around your ankles, knees, and elbows.

Buff Uneven Areas

If you notice areas that are blotchy or have too much color the next day, take a damp washcloth and buff the area to even out the color. For spots or streaks that are difficult to remove, create a paste from water and baking soda and use a washcloth to gently buff these areas with the paste.

Moisturize

Once you have achieved the faux glow you desire, be sure to apply lotion to moisturize your skin after every shower to help the tan last.

At Skin Physicians & Surgeons, we offer a variety of cosmeceuticals to protect and heal the skin from sun damage. These include face and body sunscreens like MelaShade™ Antioxidant Facial Sunscreen SPF 30, as well as the TNS Recovery Complex, the Skin Medica Lytera, and topical tretinoins to improve dyspigmentation, wrinkles, and skin firmness. Our medspa also provides chemical peels and microdermabrasion to reduce wrinkles, fine lines, dark spots, and acne, and we have a variety of nonsurgical cosmetic procedures to improve signs of aging.

If you have signs of aging, whether from sun damage or the natural aging process, Skin Physicians & Surgeons in Upland, CA can help you achieve a more youthful appearance. Please call (909) 981-8929 or fill out our online contact form to schedule your consultation and discover the best treatment options for your individual needs.

The Dangers of Indoor Tanning

Summer is over and winter is almost here, meaning that the sun will be out even less in the coming months. With bikini season over, many teenage girls and young women are turning to indoor tanning beds to maintain their summer glow. Some may think they look more attractive and healthy with a tan, but the reality is that exposing their skin to harmful UV rays, whether from the sun or indoor tanning, causes serious damage that can make them extremely unhealthy and age prematurely.

A young girl laying down in a tanning bed, blue from the light

A consumer update by the FDA reports the serious repercussions of using indoor tanning beds. According to the update, people who use indoor tanning beds are 75 percent more likely to develop melanoma, the deadliest form of skin cancer, compared to those who don’t use the beds, and the risk increases with use. A special article published earlier this year in Pediatrics, the official journal of the American Academy of Pediatrics, stated that high-pressure tanning units may emit 10 to 15 times the dose of UV-A rays than the dose emitted by the sun midday. The lamps used in tanning beds can also be more dangerous than sunlight because they can be used at the same intensity all year, whereas the sun’s intensity varies depending on the weather and time of year. The FDA is proposing changes that would make the regulation of sunlamp products more strict, including premarket review, performance testing, and warnings against the use of them by minors.

The FDA also warns that exposure to UV radiation can cause eye damage, skin burns, and premature aging of the skin. Those who are concerned about having bronzed skin now will have more wrinkles, fine lines, and dark spots later if they continue to expose their skin to this dangerous radiation. In addition, they will not only have more signs of aging, but these signs will appear sooner than if they had refrained from tanning. The choice to stay away from UV rays now will help keep your skin looking youthful and beautiful.

As an alternative to indoor tanning beds, we suggest trying spray tans or self-tanning lotions to achieve a truly healthy glow. With the winter and cold weather approaching, lotion that has bronzing qualities will work double time to keep your skin moisturized and glowing. Also, don’t forget that your skin is still being exposed to UV radiation even when the sun is behind the clouds. Be sure to use a moisturizer with a broad-spectrum SPF of 15 or higher every day, rain or shine, on your face, neck, hands, and any other area of your body that is exposed to the sun.

If your skin is already experiencing signs of sun damage, Skin Physicians & Surgeons has several treatment options to restore beautiful, healthy skin. We offer skin cancer examinations, skin cancer surgery, as well as nonsurgical cosmetic procedures, such as fractional laser treatment, to minimize wrinkles, fine lines, acne scars, sun spots, and other signs of aging. Please call (909) 981-8929 or fill out our online contact form to schedule your consultation. We look forward to hearing from you!

What Is a Physician Assistant?

In honor of National PA week I thought I’d take a moment to explain exactly what a PA is and does.

A physician assistant is a licensed and highly skilled health care professional, trained to provide patient evaluation, education, and health care services. A PA works with a physician to provide medical care and guidance to patients. A PA must attend a specialized medical training program associated with a medical school, which includes classroom studies and clinical experience. I personally have a bachelors degree in biology and also received my masters degree in physician assistant studies from the University of Southern California. I have been formally trained in dermatology by Dr. Rebish and Dr. Lee. Each PA must be supervised by a physician, and the supervising physician must always be available to the PA should the need arise.

A PA performs many diagnostic, preventative, and health maintenance services. As a physician assistant in dermatology, here are some services I provide:

  • Perform full body exams for skin cancer screening
  • Diagnose skin conditions, such as acne, psoriasis, skin cancer, rashes, etc.
  • Instruct and counsel patients on their medical conditions
  • Perform laser treatments, such as laser hair removal, VBeam laser for blood vessel removal, and sun spot removal with the MiXto laser
  • Perform minor surgical procedures
  • Write prescriptions
  • Act as first or second assistant during surgery
  • Perform cosmetic procedures, such as Botox, Dysport, Radiesse, Juvederm, and Restylane injections.

Frequently Asked Questions about Physician Assistants:

1. Are you a doctor? No, I am what is referred to as a mid-level practitioner, similar to a nurse practitioner. I am able to see patients, write prescriptions, and order tests.

2. Will you become a doctor? No, I have completed my formal training and passed national certification boards for physician assistants. I am not an intern or studying to be a doctor.

4. Are you a nurse or medical assistant? No, I have a bachelors degree in biology and have completed post-graduate training in a physician assistant program. I am board certified as a physician assistant.

5. What is the difference between a physician and a physician assistant?
The main difference between a physician and physician assistant is the amount of time spent in training. Physicians spend more time in school and also have to go through internships and residencies. Physicians can practice independently while PAs work with physicians and are ultimately under the physician’s supervision.

6. Do I have to see the PA? No. It is completely your choice on which provider you would like to see. 

7. What does PA-C mean? It means physician assistant-certified. It means the person has graduated from an accredited program and has passed testing by the National Commission on Certification of Physician Assistants (NCCPA).

8. Can you prescribe medications? Yes. I am able to recommend medications and write prescriptions.

9. How long have PAs been around? Since the 1960s physician assistants have helped expand the delivery of quality medical care.

erin small head shot

I absolutely love my job and could not imagine doing anything else.

I love being to work as a team with the physicians and other PA in our office to provide the best possible care for all of our patients.

Erin Jensen PA-C

 

If you are interested in any procedure or would like more information, feel free to schedule a consultation with our physicians or physician assistant by calling (909) 981-8929 or filling out our online contact form.

How To Protect Your Kids From The Sun This Summer

My daughter in her typical outdoor attire

The temperature is heating up, and your kids are spending more time outdoors. They’re sweating; they’re swimming. They need extra sun protection—and so do you!

The sun’s ultraviolet (UV) rays are at their strongest during the summer, and unprotected skin can be damaged in as little as 15 minutes. While applying a SPF (sun protection factor) 30 sunscreen is important throughout the year, taking extra sun-safety precautions during the summer is especially important.

Don’t pull a Tanning Mom on us. Try these tips on your next family trip to the beach, pool, playground, ballpark or amusement/water park.

1.  Sunscreen- Kids who are sweating or swimming need to reapply sunscreen more often. Remember that water, snow and sand can reflect UV rays and increase your child’s sun exposure and chance of getting a sunburn. A sunscreen with an SPF of at least 30 protects the skin from the sun. Apply one ounce of sunscreen (about the size of a ping pong ball) to all sun-exposed areas of the body. Don’t forget the ears, feet and behind the neck. Because sunscreen can take up to 30 minutes to go into full effect, it’s a good idea to apply it at home before you drive to the pool or beach.

2.  Lips and Eyes- Choosing the right sunglasses, hat and lip balm also can provide added UV protection for parents and kids. Apply a lip balm that offers SPF protection and reapply throughout the day. Choose wrap-around sunglasses that absorb at least 99% of UV rays to protect your eyes and the skin around your eyes. Choose a hat with a wide brim to give as much sun protection as possible.

3.  Wear sun-protective clothing- While most people usually know to use sunscreen and sunglasses, few are aware of the availability of sun-protective clothing. Many companies offer a variety of sun-protective clothing with as much as ultraviolet protection factor (UPF) 50. UPF indicates how much UV radiation can penetrate the fabric in clothing. For example, a shirt with UPF 30 means that just 1/30th of the sun’s UV radiation can reach the skin.

4.   Find or make shade- It’s always a good idea to have a place where you and your family can find shade from the sun. Plan ahead. Seeking shade is especially important between 10:00 a.m. to 4:00 p.m. when the sun’s ultraviolet (UV) rays are at their strongest. When outdoors choose parks with a covering over playgrounds, cary a large umbrella to the beach, put a tent up if you have space, or choose seating areas near trees.

5.  Make a travel size sun-safety kit- Summer time often leads to spontaneous plans. You never know what the day has in store. At the beginning of the summer, create a travel size kit with all the items you need to keep your family sun safe. Don’t leave home without it! Here are some basic, portable items to put in your kit:

  • Sunscreen with SPF 30 or higher
  • Lip balm with SPF 15 or higher
  • Hat with a brim or cap
  • Long-sleeved shirt
  • Sunglasses with UV protection

Summer is a gorgeous time of year, especially here in Southern California. We’re not asking you to become a hermit when it comes to summer time. Practicing these Sun safety tips will keep your family happy and healthy. Who likes dealing with a painful sunburn anyways?

Melanoma Monday

image courtesy of aad.org

What is Melanoma Monday? “Melanoma Monday” is observed on the first Monday of May and it is also termed as May Melanoma Skin Cancer Month. This day is also known as National Skin Self-Examination Day. People are advised and encouraged to undergo the examination of their skin for skin cancer. Of the different types of skin cancer, melanoma is the most deadly and accounts for about 75% of all skin cancer fatalities. Melanomas can also develop in other areas of the body such as the eye, underneath nails and inside the nose and mouth.

Melanoma Warning Signs: ABCDE

A – Asymmetry: is the mole asymmetrical? If you imagine a line drawn across the center of the mole, if the two halves do not match then they are considered asymmetrical.

B – Border: does the border or edge of the mole look uneven?

C – Color: is the mole one uniform color? If there are several colors or shades of a color within a mole this could be a warning sign.

D – Diameter: how big is the mole? Melanomas often have a diameter of 6mm (1/4inch) or more (diameter is the length across the mole).

E – Evolving: has the mole changed in shape, size or color? Have you noticed any other changes such as bleeding, itching or puss coming from the mole? These may be signs of a malignant mole so seek medical assistance.

Early Detection Is Crucial For Treatment Success
As with many other types of cancer, treatments are more successful when there is early detection. However, unlike most cancers, melanoma does normally not respond well to chemotherapy, radiotherapy or medication. When melanoma is at a later stage and has metastasized (spreading to other parts of the body), treatment options are limited and palliative care is the main course of action. Drug treatments for melanoma, when successful, do not provide a cure. They may extend life for a time measured in months not years. There will always be exceptions and some people with metastatic (stage 4) melanoma will live for many years after diagnosis. However, the prognosis for advanced melanoma is normally not good hence early detection is critical for success.

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