HISTORY. Assess the patient for a personal or family history of skin cancer. Ask if the patient has an exposure to risk factors, including environmental or occupational exposure, at-risk

850 Skin Cancer medical conditions, or exposure to viruses. Note that outdoor employment and living in a sunny, warm climate such as the southeastern (Florida) or southwestern (New Mexico, Arizona, California) United States, Australia, or New Zealand place the patient at risk. Question the patient about any bleeding lesions or changes in skin color. Explore the history of nonhealing wounds or lesions that have been present for several years without any change. Question the patient about the presence of atypical moles, an unusual number of moles, or any noticeable change in a mole.

PHYSICAL EXAMINATION. Inspect the patient for additional risk factors, such as light skin and hair (red, blond, light brown), freckling, and light eye color (blue or green). Examine the patient's skin for the presence of lesions. Use a bright white light and magnification during the skin examination. Stretch the skin throughout the examination to note any nodules or translucent lesions. Examine folds or wrinkles in the skin. Assess the skin for ulcerations, sites of poor healing, old scars, drainage, pain, and bleeding. Because more than 70% of NMSCs occur on the face, head, and neck, closely examine these areas. Complete the skin assessment, considering that, in order of frequency, the remainder of NMSCs occurs on the trunk, upper extremities, lower extremities, and lastly, the genitals. Determine if the patient has precursor lesions of SCC, such as actinic keratoses (a hornlike projection on the skin from excessive sun exposure) and/or Bowen's disease (intraepidermal carcinoma). No assessment of precursor lesions for BCC is necessary because no equivalent lesions exist.

Assess for the characteristic lesions of BCC, which tend to be asymptomatic, grow slowly, be 0.5 to 1.0 cm in size, and have overlying telangiectasis (vascular lesions formed by dilated blood vessels). BCCs are classified as nodular (the most common type), superficial, pigmented, morpheaform, and keratotic. Nodular BCC appears as a translucent, nodular growth. Superficial BCC, frequently appearing on the trunk, presents as a scaly lesion with a distinct, raised, pearly margin. Pigmented BCC has a characteristic dark or bluish color with a raised and pearly border. The morpheaform BCC lesion is poorly demarcated, is light in color, and has a plaquelike appearance. Keratotic BCC lesions appear similar to ulcerating nodular BCC.

Assess for the characteristic lesions of SCC, which are usually found on sun-damaged skin. The lesions tend to be scaly, 0.5 to 1.5 cm in size, and likely to metastasize; they also grow rapidly. SCC lesions are usually covered by a warty scale surrounded by erythema that bleeds easily with minimal trauma. The tumor appears nodular, plaquelike, and without a distinct margin. When SCC is invasive, the lesion appears firm, dome-shaped, erythematous, and with an ulcerating core.

PSYCHOSOCIAL. Determine the patient's willingness to follow primary prevention strategies and to institute changes that decrease the risk of skin cancer or its recurrence. Of particular concern are patients who are adolescents and young adults who place a high premium on physical appearance. If the patient has metastatic disease, assess the ability to cope with highly stressful situations. Determine if the patient has support systems and the ability to cope with major lifestyle changes.

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