Comment on “Skin Cancer Screening: The Paradox of Melanoma and Improved All-Cause Mortality”

To the Editor:

I was unsurprised and gratified by the information presented in the Viewpoint on skin cancer screening by Ngo¹ (Cutis. 2024;113:94-96). In my 30 years as a community dermatologist, I have observed that patients who opt to have periodic full-body skin examinations usually are more health literate, more likely to have a primary care physician (PCP) who has encouraged them to do so (ie, a conscientious practitioner directing their preventive care), more likely to have a strong will to live, and less likely to have multiple stressors that preclude self-care (eg, may be less likely to have a spouse for whom they are a caregiver) compared to those who do not get screened.

Findings on a full-body skin examination may impact patients in many ways, not only by the detection of skin cancers. I have discovered the following:

• evidence of diabetes/insulin resistance in the form of acanthosis nigricans, tinea corporis, erythrasma;
• evidence of rosacea associated with excessive alcohol intake;
• evidence of smoking-related issues such as psoriasis or hidradenitis suppurativa;
• cutaneous evidence of other systemic diseases (eg, autoimmune disease, cancer);
• elucidation of other chronic health problems (eg, psoriasis of the skin as a clue for undiagnosed psoriatic arthritis); and
• detection of parasites on the skin (eg, ticks) or signs of infection that may have notable ramifications (eg, interdigital maceration of a diabetic patient with tinea pedis).

I even saw a patient who had been sent for magnetic resonance imaging for back pain by her internist without any physical examination when she actually had an erosion over the sacrum from a rug burn!

When conducting full-body skin examinations, dermatologists should not underestimate these principles:

• The “magic” of using a relatively noninvasive and sensitive screening tool—comfort and stress reduction for the patient from a thorough visual, tactile, olfactory, and auditory examination.
• Human interaction—especially when the patient is seen annually or even more frequently over a period of years or decades, and especially when an excellent patient-physician rapport has been established.
• The impact of improving a patient’s appearance on their overall sense of well-being (eg, by ­controlling rosacea).
• The opportunity to introduce concepts (ie, educate patients) such as alcohol avoidance, smoking cessation, weight reduction, hygiene, diet, and exercise in a more tangential way than a PCP, as well as to consider with patients the idea that lifestyle modification may be an adjunct, if not a replacement, for prescription treatments.
• The stress reduction that ensues when a variety of self-identified health issues are addressed, for which the only treatment may be reassurance.

I would add to Dr. Ngo’s argument that stratifying patients into skin cancer risk categories may be a useful measure if the only goal of periodic dermatologic evaluation is skin cancer detection. One size rarely fits all when it comes to health recommendations.

In sum, I believe that periodic full-body skin examination is absolutely beneficial to patient care, and I am not at all surprised that all-cause mortality was lower in patients who have those examinations. Furthermore, when I offer my healthy, low-risk patients the option to return in 2 years rather than 1, the vast majority insist on 1 year. My mother used to say, “It’s better to be looked over than to be overlooked,” and I tell my patients that, too—but it seems they already know that instinctively.