Transcript of Episode #159: Your Mole Could Be Cancer And You Wouldn’t Know… Featuring EXPERT Board Certified Dermatologist and DERMOSCOPIST Dr. Michael Christopher!!

I find between 150 and 250 melanomas a year. The average dermatologist in Arizona finds around 20 a year. Of the roughly 8,000 to 10,000 people that die a year, they are actually diagnosed with what we consider early-stage melanoma.

How often do you find something that looks normal that is an actual melanoma?

Almost every week.

Oh shit.

I find so many skin cancers every day that you would not be able to see without using a dermatoscope.

So are there other ways to develop skin cancer melanomas without it being sun-related?

Oh, 100%.

And what are some of those?

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All right, everybody, welcome back to the Dylan Gemelli Podcast. So I am pumped today because I have a very well-educated, well-rounded guest that I hit it off with right away. But we're going to talk about something that I have not talked about yet, and I'm really happy to get into it because there are so many people that put content out on the sun and people that have put the fear of God into some people and then told others that everything out there is nonsense. And we don't get into the nitty-gritty about that and, and talk to somebody that's just straight science. But then the other aspects of what my guest does, especially when it comes to identifying melanomas and his way of going about it that I've never heard of and never seen. And so this is going to be a learning experience for everybody today, which I am just— I'm ecstatic to bring this to light 'cause the goal on the podcast is to always to bring new concepts and a good down-the-middle approach to giving everybody the best knowledge possible. So my guest today is a board-certified dermatologist and expert dermoscopist recognized for his work in early melanoma detection.

And he has been using evidence-based use of dermoscopy, and he identifies between 150 and 250 melanomas annually. And that is just, with the discussion we had back and forth, far more than you see on national state averages. So he's doing incredible work, he's doing something special, and I am super excited to introduce you guys, Dr. Michael Christopher.

You know, it's a pleasure. Thank you for having me on, I appreciate it.

I am stoked, like I said, to have you here. And, and we had a good discussion prior, and the things that you were telling me were Startling, troubling, but also I'm grateful that I met you so that we can get this out there and get people aware and start talking about things that I think they're not aware about that you do. So, let's get into the dermoscopy because I'm still having trouble saying that because I've never heard of it. Could you kind of get into what that is?

Yeah, absolutely. So, I brought a tool with me and I'm not sponsored. I don't work for any company. I just want people to be aware of that. Not that other people do, okay, but me personally, I don't work with anybody. This is what we call a dermatoscope. And so if you see a board-certified dermatologist or say an NP or PA and you get a skin exam, when they're looking over your skin, they shouldn't be just doing a visual exam.

Mm-hmm.

They should look at every single mole with, uh, and every pink spot and every sunspot that you have on your body with a dermatoscope because things that can look normal like that little mole on your hand, And I'm not saying that is harmful. It looks round, regular, looks like it has even borders. But if I were just to look at that with my eye, I cannot tell you, and this is as an expert in dermoscopy and a board-certified dermatologist, that that is normal. The only way that we can tell that it's normal is if I put a dermatoscope on it. And if people are not using a dermatoscope, what does that create? That creates melanomas that are identified much later. In their course, and there is a mortality association with it. In Arizona, you kind of stated some statistics. I find between 150 and 250 melanomas a year. The average dermatologist in Arizona finds around 20 a year, and that's kind of on the national average.

Mm-hmm.

So if there's that large of a gap, you can imagine how many people go in to get a skin check. And it's not that people are not trying, they're looking at your skin thoroughly, They are just missing stuff that is not obvious to your naked eye, and that's due to training and lack of utilization of this tool.

Why do so many people eyeball it and do that approach? I've never even heard of the scope and the tool that you have until I met you.

Yeah, great question, and I can't answer that, to be honest with you. Dermoscopy, the discipline, which is the study of the structures that you see within when you're using that tool, was invented in 1989. I was born in 1984, right?

Right.

So my whole medical career, actually what got me very interested in dermatology was the potential intervention at the earliest stage of cancer within dermatologic disease, and that is through dermoscopy. So it was foundational for my interest in the field, and I can't tell you why other people don't use it because I think it is the most important thing. When we give a skin check and we're doing a cancer screening, it's like women getting their annual mammograms.

Yeah.

After 40, that's what's recommended. And if you didn't do a mammogram, you just had a woman do a self-breast exam, how are we gonna know that there is disease that is potentially there? There are many breast cancers that don't present as a lump, right? So women, when a woman would not be able to find it, well, same as melanoma. They're not all irregular, They don't have symptoms, meaning they're not itchy, painful, they don't bleed, and we may not be able to see it. And we can see it when we utilize that tool.

Yeah, because everything I've ever learned, and when I go in, it's eyeball approach. And if it doesn't look irregular or doesn't show any of the things that you've talked about or that we kind of know in general, it's like, okay, move on. Now, when you use that tool, what does it show, like, in particular that you can't see with the naked eye?

What we see within the dermatoscope, you can see structures that you cannot see with your eye, and one of them is the pigment architecture. So that mole right there, which I'm just going to lay my dermatoscope on just to— yeah, I've looked at it enough times. Yeah, just to make sure it's fine. But it can show me the network that is present within it and if that is regular or irregular. It can show me angiogenic structures, so structures of blood vessels, uh, and signs that there is, say, increased vascular density within a mole, which is a sign of a melanoma.

Mm-hmm.

It shows me structures that we see within the skin. So you can actually— you're not just looking at the surface, you're actually looking within the dermis, which is the middle portion of your skin. And some of those structures, like shiny white lines, uh, orthogonal lines, those are, uh, features that you can see within an invasive melanoma. even though from the outside, it looks like a completely normal mole.

Okay. So it's almost like an X-ray vision tool, so to speak.

Correct, right. It's a secondary imaging to where, think about it like this. You get an X-ray, say you come in and you have a knee injury, your knee's sore. Maybe you feel like you tore your ACL. You go get an X-ray of it. The X-ray is actually not gonna show you you tore your ACL because it can't see it. And that is kind of what we wanna do Yeah. So a visual skin exam, if we're just doing it visually, you cannot see those structures I just outlined to you within the scope, the pigment architecture, the blood vessels that are present within it, the structures that are in the middle portion of the skin in the dermis. You need another tool. And the dermatoscope is that tool. As you're assessing, say, your knee for an ACL tear, well, the X-ray is not gonna show you if the ACL is torn. You need an MRI. And the MRI will be able to actually assess those structures and will be able to say, oh yeah, clearly there's an ACL tear or the ACL is intact. You wouldn't try to assess an ACL tear with just an X-ray.

Right. Here's a question for you. On a normal person, and obviously everybody's differentiating here, how many moles does a person tend to carry?

Oh God, great question. Some people have very few. And I actually, maybe I need to look into the literature on that exactly because it is so varied. Most people have moles. It's just how many do they have?

Yeah.

One of the risk factors actually for melanoma is the number of moles you have, and not just the number of moles you have, but if you also harbor atypical moles. And that is a component when we look at risks of melanoma that tie into familial or genetic risk factors. Not all melanoma is just created from the sun. Most of it is from the sun, but there are familial traits, we call them germline mutations, that increase your risk and odds of developing melanoma. Okay.

So, one of the things I've noticed on myself after too much time in the sun as I've gotten older is a few more popping up. How— like the one you see here, that was not always there. And, I've had certain ones, they all kind of look the same. I know that doesn't mean anything. What causes that to happen? Is it something as you age from being in the sun too long?

Moles are sun-induced, right? You can have genetic moles, but moles absolutely can be sun-induced. And getting new moles does not always mean that there is trouble associated with it, right? Until you're about 40 years of age. Once you hit 40, if you're getting a new mole, even if it looks normal, it should be evaluated. But there is an association with sun exposure and the number of moles that somebody does develop. So that is an important thing to pay attention to.

I noticed after long vacations on the beach, that they popped up. That's when it happened. Yeah, 2 weeks straight of 3.5, 4-hour layouts. That's when I noticed. What about tanning, like in a tanning bed?

Terrible. Yeah, so you— tanning, uh, tanning beds are actually UVA, right? So when we get— when you're looking at getting sunlight, you're looking at obviously all spectrums: visible, infrared. Um, UVC is actually thankfully filtered out because it's extremely toxic. But UVA is what you're getting through the tanning bed, and it is highly concentrated. And we have a multitude of studies that show what the increased risks are of melanoma associated with sun— with using a tanning bed.

So it's highly enhanced.

It is highly associated. And that is why places that have very good data on melanoma and melanoma prevention have actually outlawed tanning beds, like Australia. It is not allowed there.

When I was in high school, when they started to get popular, I spent a lot of time in them, a lot, like teenage years.

How much?

Oh, I don't know, 2 or 3 times a week for a while. And then, I owned a bed in Vegas. And, it's funny, I owned it, I used it less than when I had a membership somewhere, just sat there. But, I stopped using tanning beds well over 12 or 13 years ago probably, but definitely, it was a prevalent thing back then and not a lot of data.

Yeah, absolutely. And, in particular, tanning beds were— I know you're large into fitness and health.

Yeah.

It is heavily, you know, people tan like crazy because they want their— to have tone and definition, in particular for them on shows, right? But the big issue with tanning, burning in general, is acute intense UV, right? That acute intense UV is highly toxic, and you want to avoid that at all costs.

What about like the craze of red light beds and therapies? Does that have a negative effect?

So, no, it does not. That is not gonna induce skin cancer. So, from my scope of area of expertise, I have no concern with it.

Okay.

I do think that there are some benefits of using red light therapy and infrared, but you have to know the manufacturer. You need to look at the studies. A lot of people will say, oh, it's good for your mood. It's gonna help with your muscles. It's gonna help with your skin. Well, what is the dose? What were the studies done that showed that dose was helpful, and are these companies and devices actually administering that dose? And so, it's a— there is a dosimetry that is associated with red light therapy.

Mm-hmm.

So, if you're using it, and I actually use it on my hat— on my head to keep my hair nice and full. So, I do think that it is helpful, but you need to know the science behind the company that you are deciding to invest in.

So, and I don't know the answer to this, and I don't know how many different options there are or levels of this, but you hear UVA, UVB. How many different types of UV rays are there, and what are the negative ones, and what are the, the good ones, and what should we avoid, and what should we try to get?

So UVA and UVB are the 2 forms of UV that you're going to be getting from Uh, the sun, right?

Okay.

UVC is filtered out by our ozone, which is extremely toxic. UVA and UVB, and I will say this with— just understand that the dose matters, right, of everything.

Yeah.

Um, UVB is definitely, of the two, much more carcinogenic. So meaning it is one that has— is heavily associated with melanoma tumorigenesis, uh, looking at basal cell or squamous cell carcinoma and the development of skin cancer. UVA is also associated with it. It's just that we get more— the, the amount of UVB that we get, the intensity of it is more, and it is more toxic.

Okay.

Now, as a dermatologist, you know, uh, getting any dose of UV— because UV, ultraviolet radiation, is a class 1 carcinogen, and we know that it is a carcinogen across the board, so we know that it induces mutations in our body— but is there some dose to where it is I don't wanna say not harmful, but the dose makes the poison, right?

Mm-hmm.

A little bit of UVA. So for me, if the UV is less than 2, I don't wear sunscreen. I don't need to wear sunscreen. I am not worried about getting a skin cancer based on a UV index of less than 2. But as soon as UV index is above 2, based on my Fitzpatrick skin type, it means the color of my skin, I'm a Fitzpatrick 2, I absolutely make sure that I have sunscreen. Not only is that important of blocking UV radiation, but it also is helpful for photoaging, which photoaging is something that I also would like to prevent.

How do you know the level of UV that's in the sun? Is it just something that's measured that you can look up online?

You can look up online, or pretty much every weather app will have that. So if you go to your— I have an iPhone. If you open up your iPhone, go to the weather app, and it'll show you, say, you know, the heat for the day, if it's going to rain, you can click UV index, it's on there. And it'll show you the time of day when the UV is going to be higher than that too.

What determines the level of UV index?

So time of year, where we are with latitude. So from the equatorial line and time of year. So summer, winter, spring, fall.

That's what I was going to ask you. Closer to the— so closer to the equator, higher UV? Correct.

Yes. And you're looking at that all year long, right? So it's all— the closer you are to the equator, the more UV. you're going to be getting throughout the year.

So, does Iceland have a low level of skin cancer probably?

Interestingly enough, I've looked at this, the data is not great on that.

Really?

Yeah. But, there's a multitude of factors. So, looking at how they record skin cancer there, that is one issue, but it's not correlated the way that you would presume.

Right. So, I'm just curious because there's so many people on both sides of the fence that are either just most anti-sun people in the world are people that are like, man, you need to be in the sun all the time. And, I'm one of those that's like, you need to get 10, 15 minutes of sun daily. Let's not go crazy. Let's get what we need though and not be frightened by it unless you have some sort of condition.

Right, which there are those.

Yeah.

But, the time of day matters, right?

Okay.

So, if you are getting 10 to 15 minutes of sun, we're in Phoenix right now.

Yeah.

So, in Phoenix, if you're getting 10 to 15 minutes of sun, and the UV index is a 10, based on your Fitzpatrick skin type, you're a 3, that is harmful for you.

Okay.

You are causing UV radiation, and you can measure— or you are causing UV radiation to cause DNA mutations in your cells, and you can measure that. Uh, when we get excess UV, it causes cyclobutane-pyrimidine dimers to form in our DNA, and that is something that is measurable. And we know that that is toxic, and that is a signature that we see within skin cancer. In melanoma, basal cell carcinoma, squamous cell carcinoma.

My assumption here would be don't go out in the sun after like 10 o'clock because it's so strong. Am I right?

Or— It— so it depends. So that all— that depends on the time of year, right? So in, for instance, in Tucson, which is where I live and practice, uh, by 10 o'clock, even in the wintertime, the UV is going to be around 3. So that's probably pretty good. But I was in Austin in April and I was surprised. It was 8:30 in the morning, the UV index was already 3. And I said to myself, it's only, you know, it's spring, right?

Yeah.

That's early and it's already above that point. And the UV index was 5 until after 5:00 PM. So people say 10 to 2, it actually is not, that is not a sensitive way to measure what the UV index is, but we have a way to measure it, or you have a way to get the information accurately. And that's through, um, your weather app.

So does temperature play a role then in that, or—

No, no, not at all. Think about going to San Diego right now. Yeah, what's the temperature? Probably 90, I don't know, lower, usually 70 to 80. I mean, even maybe even a little bit under that, right? So people— I see a lot of patients who, they love to go to Coronado Island, you know, during the summertime, and they all get burned. So like, it was just so nice outside, I didn't think I needed to wear sunscreen. the temperature is not correlated. You could burn. So, it is not— temperature does not equate to UV index.

Okay. All right. Because I was in Miami and the other, what, 3 weeks ago, and I like to go for walks in the morning. In Phoenix now, I do treadmill walks in the morning. It's too damn hot because I don't start till 10. I do the sun, like breathwork in the pool right after or something. It's 10 minutes, but I was out there and it was so— I mean, it was instant sweat.

Oh, just in Miami?

Yeah, just instant. And so, I'm wondering since it's closer to the equator by the ocean, then the UV is probably a lot higher in the summer there, right?

It's probably— I would say it's probably higher for sure because it is closer to the equator. I would assume so.

All right. But, it would just be in everybody's best interest to check if you're going to spend any time outside.

Correct. And, most of the time, the issue where things come up is that people, they don't plan on going outside.

Yeah.

Like where I see a lot of people where they get a sunburn, they have— they went outside to get their mail and then they go and, you know, they look at a plant in their yard and then they move some rocks around. And instead of it being a 2-minute trip, it's now 30 minutes outdoors and they burn. So it's the unintended sun exposure that people are not aware of. And currently, There, as you said, there's a lot of people who are on one side of the fence right now telling you to go out and get your UV because it's healthy for you. Uh, and so they're getting that information and not worrying about the downstream consequences.

Yeah, it's like partially right and partially not because it's not really gauging and looking at the actual rays right at the, the moment. They're not covering that.

Correct. And there's— and there they utilize— people utilize data to say, hey, Well, you asked me a question earlier about UV radiation. Well, is there— what, what is there some benefit? Well, looking at UVA, it causes nitrous oxide to be released in your skin. That is a vasodilator, and that will reduce, say, blood pressure. So systemic vascular resistance. Well, we already know there's a ton of other things that do that, excluding medications.

Yeah.

If you exercise, you're going to release nitrous oxide. If you sit in somewhere that is warm, you're gonna release nitrous oxide. So like sauna. So you don't have to get something that is toxic, that is a grade 1, class 1 carcinogen to have a health benefit. With that being said, a small dose of UV, as I said, for me, if the UV index is less than 2, I don't worry about it. So I'm not worried about that level of radiation getting into my body because the dose makes the poison.

Well, when people want stuff to work out, they kind of pick and choose what they want, kind of like the red wine, bullshit about, oh, it's got resveratrol in it, we'll just take resveratrol and forget all the other stuff that goes with red wine.

Exactly.

I always tell people that. It's like, come on, like, what are you talking about here? I mean, just because you want the wine. So, you were bringing up something about a Fitzpatrick scale. You said it multiple times now.

What is that? That's looking at from as light as you can be, which is a 1, to a 6, so as dark as you can be.

Okay.

And so, we— when you look at that, there is a relationship obviously with that in your risk for potentially developing melanoma because you don't have as much natural— you can think about melanin as sun protection in your body to protect yourself from UV radiation and UV light.

Okay, so it's just all determined on skin tone?

That is a gross way to assess it.

Okay.

You can do skin biopsies and look at how much like pheomelanin is present and how much pigment is present. But yes, grossly, you can look to see, what color is that individual's skin and compare it to that scale, and you can categorically fit where somebody falls.

So, are there other ways to develop skin cancer melanomas without it being sun-related?

Oh, 100%.

And what are some of those?

They're genetically related, right? So, there's germline mutations. When you asked me about the moles, right? Like, how many moles somebody has, do you know? Well, we know, for instance, if you have a set number of dysplastic nevi or harbor dysplastic nevuses, Those individuals without UV exposure are just, they harbor an increased risk of developing a melanoma because they develop excess moles that are already irregular, right? So they don't have to get sunlight per se to develop a melanoma.

Mm-hmm.

They have a familial history of it and they have mutations, they're called germline mutations that are present, that are inherited from their parents. It's like a balding gene. You say both of your parents were bald, women go bald as well, and you inherit the balding trait. Unfortunately, that means that you have a probability that you will be bald. It's not 100%, but it's very similar for, say, melanoma risk. You may inherit a CKDN2A mutation. That mutation increases your risk of getting melanoma without sun exposure, but the UV radiation in itself can propagate that as well. Okay. Wow.

Is there any other ways, or are those the 2 ways?

Spontaneous and sporadic, right? So unfortunately, things just occur.

Okay. Right?

So when you look at melanoma that occurs on the underside of your foot, so on the bottom of the foot, a lot of that is sporadic, spontaneous. And unfortunately, those are not— we can tell you the genetics in the melanoma itself, and we can tell you, do they harbor this, you know, a class VII signature, which is a UV-related signature within the DNA? They don't. So, we know that they are not induced. We know that there are certain cutaneous melanomas that are induced from the sun, and that is majority of them. And then, there is a small fraction that are not. That is why when you get a full skin check, it should be a full skin check. That means everything you're comfortable with. So, for me, that's the whole body.

Yeah.

Oh, yeah.

I think same. You should definitely— I mean, why wouldn't you?

I mean, well, because some people are modest and they are— but to me—

Just look.

When you're a physician, it is all— it's— if looking at genital skin is like looking at a toe or— yeah, it is the same thing.

Yeah, that's, that's something I would recommend getting over quite quickly if you're going to get something checked. I, I—

you—

I get lost there with people. I get it, I guess, to an extent, but not when you get older, man.

I know, modesty is gone. And it really, uh, it, it should not be there when you're getting evaluated because how do you know what's not there? Last year I found 3 melanomas on the butt. 3 melanomas. People, they didn't use tanning beds, it just spontaneously occurred. Yeah.

And, you wouldn't even know there's anything even there.

Correct, yes. I mean, that is not an easy area to look yourself.

No. Okay. So, what are the stages of melanoma and how severe is each stage?

So, if you find melanoma early, which is my objective, that is why I'm a dermoscopist, right? I said, so for me, What got me into dermatology, uh, my interest in it in particular, as I've always been interested in kind of longevity medicine, uh, and living a healthy life, is one of the pillars of living long is, uh, preventing things that can take us out early. And cancer, unfortunately, is one of those things that can do that. If you find melanoma at stage 0, nobody dies from it. All you have to do is remove it.

Just cut it off.

You cut it off and you're good to go. If you find melanoma at stage 1, you actually have a, a high rate of survival. So if you look at the NCCN or AJCC, you know, they'll give you, you know, what the 5-year survival rate is, and it's like 98 to 99%. But there's a lot of people that are diagnosed with a stage 1 melanoma of all the melanomas, uh, and so of the roughly 8,000 to 10,000 people that die a year, they are actually diagnosed with what we consider early stage melanoma.

Oh, wow.

So objectively, If you can find it as early as possible, you shouldn't worry about it, right?

Mm-hmm.

So when I call a patient and tell them, hey, you have a melanoma in situ, it's not a big deal. We cut it out, you're good to go. You truly are good to go. You just have to have continual skin surveillance, right? Because you made a melanoma, that means that you have an increased risk. Compare that to somebody who has later stage disease, say it has traveled to the lymph node, and it's stage even 3A microdeposit. That ratio of either you're good, nothing, right? You're 100% survivorship or even looking at stage 1 at 98%, now you're at 73%, 74%. So, that is substantially different. And, the difference between how that may present on the body is not much, which is important.

What kind of side effects would someone have if they had or would they even know?

Nothing at that point.

Nothing.

Nothing, correct, which is unfortunate. That is why, uh, it is kind of one of those more, to me, like scary cancers. It's not like, oh, I got a stomachache or I have headaches. Uh, you can have something that's migrating through the stages like stage 3, uh, 3A. That means you have a microdeposit in the lymph node. You would have no symptoms. So, but it's already moved from the skin into a lymph node.

Would it show on blood work or anything at all, like any sort of blood things that you would look Not necessarily yet, but there are tools that are looking at that.

So, you're looking at circulating tumor DNA in your blood to assess to see, say somebody had a melanoma, it would have to be already past the top layer of the epidermis. That's stage 0, okay? Meaning, it would have to be stage 1, stage 2, stage 3 for a circulating tumor DNA for it to be found in your blood.

So how long can one sit there in stage 0? Could it sit there for a long time?

We don't know. So yeah, we could.

Yeah, absolutely.

And I'm sure that there's— there are some that do that.

Yeah.

Um, but if I could tell you that, I would be a trillionaire, right? And I— and I— and look, I hope somebody does figure that out because then we can say, hey, we know definitively that this is okay. Yeah. Because there are some dermatologists who actually believe that. They think, oh, it's, you know, an early stage, you know, cancer. And same with patients, this is okay, you can watch it like a prostate cancer, right? But we don't have the data to support that.

Yeah.

When we do, I will support it. One caveat, it is very easy— now, this is a scar on my arm, not from a melanoma, it was a severely dysplastic mole— having a small excision for a, uh, if it is, say, a melanoma in situ, is not a big deal. It is very easy to do. You can knock it out. The morbidity from this is nothing. In 6 months, I'll send you a photo that you want. You'll just see that there was a line. There will be no color.

Oh, that's recent.

This is recent. Yeah. Um, and so you'll look at— you'll look at that and be like, what's the morbidity and mortality of that, of doing a small procedure on somebody's skin? Nothing. It is so little. Uh, versus what is the risk of that going from a stage 0 to something that kills you. Yeah, right. To me, the balance is where we are, we don't know, uh, how to predict that, just remove it.

I had that done once and they cut it right off and then it was nothing, but they still cut it off and said you're okay. And I was like, well, shit, it healed in like a week and I felt good. I didn't have to worry about it. Correct.

Yeah, super easy to do, get it removed. Um, and if somebody has a different discussion and they say, hey, look, I don't want to do that, I would go through what are the risks and what is the data on it. But it is a very, to me, straightforward process.

How many— I know you can't say exactly, but how often do you find something that looks normal that is an actual melanoma?

Does it happen almost every week? Oh shit. Yeah, so almost every week. And not even— so, you know, I, I preach on melanoma because melanoma has the mortality associated with it.

Yeah.

I find so many skin cancers every day that you would not be able to see without using a dermatoscope.

Really?

Yeah, they're just— they're— they look like normal little bumps on the skin, uh, and it's a basal cell. And something like that, say it's on the nose, it's a small, uh, uh, say a small basal cell. Your nose, any area of tissue is space occupying, and so you want to identify stuff as small as possible visually To where you can't even see it, so that the treatment, uh, you can get a very tiny scar versus losing your whole, say, tip of your nose. Yeah.

How quick does that thing show? Does it show right away?

Yeah, yeah. I mean, instant. Now, there are certain things, uh, dynamic rotation, uh, so there's a lot of stuff that you'll do when you're analyzing the skin, but you always want to have it in polarized mode. The polarized mode, that is what's showing you structures that are inside the skin, and it's your brain, right? It's what you're understanding within it. And so for me, I am an expert in this, uh, and so when I have learners who— I really just have board-certified dermatologists who will fly in to see me, uh, to, to learn, um, they— if they ever do an exam or look at an arm quicker than I could look at an arm, they're doing it too fast.

Okay.

So people always ask, how long is the skin check should be? I don't know, it depends on what's on your skin, but it should not be faster than I could do it because that means you have not assessed everything.

Yeah, because I mean, I'm thinking in my head, wow, if you're doing a full exam and someone's got 30 moles or something like that, it's going to take a little bit of time, right?

A little bit of time, but 30 moles, 30 moles should be pretty quick to go through.

Okay.

You should be able to analyze— I know it sounds, you know, rudimentary, the length of time, but a mole, 2 to 3 seconds.

I've tried to count mine and I'm like, in my head I'm thinking like, what is average? I've tried to count my wife's and—

Yeah, but, but it's not just moles, it's every sunspot.

Oh, wow.

So every lentigo somebody has, I have to look at with a dermatoscope. Every pink spot that somebody has. For you, you have tattoos. I will march through the tattoos to see, because unfortunately that creates camouflage on the skin.

Yeah.

But I will march through that area to see what is going on within it. So for you, it's gonna take longer. And that's okay. But look, that's what we signed up for.

Yeah.

Right? It's to make sure that you are okay and healthy. Yeah. Oh yeah.

I'd sit there all day for the, you know, But some people are in too big of a hurry, I guess, for their life.

They— yeah, you know, unfortunately. And I think, you know, people, they have a different opinion on— everybody can have a variable opinion on what they want to do with their health. But when you are getting your skin cancer screening, it should be the best screening.

Yeah, I agree. I think with any screening you do of any kind, heart, whatever, I think you should always try to do the most, you know, extensive to where it's not going to hurt you.

Correct. The difference is with a lot of that stuff though. So for instance, mammography for breast cancer screening, that's standardized, right? So for the most part, people, when you go get a mammogram, not you, men mostly don't get mammograms, right? I hope not. It does occur. I mean, men do get breast cancer. I actually diagnosed one last year on a person came in, they had a lump right underneath their areola, did a biopsy, it was breast cancer in a male. So it does happen, but it is rare. So you wouldn't just standardize mammograms in men, but as a discipline, mammography is standardized. What is not standardized is dermoscopy, right? I finished my residency in 2019. I had 2 lectures on dermoscopy, how to utilize that tool. And even though we utilize it in clinic every day, that does not mean people understand what they're seeing.

Yeah.

And for me to create the level of expertise I have had, when people talk about, how many hours of work you've put in on the backend, tens of thousands of hours of analyzing images with the histology, meaning the pathology, and correlating the structures of what we see on what we call the horizontal surface of the skin and the vertical surface that's within the skin. And that's a pathology. And that stuff is there, unfortunately, even all the books that are out there, all the lectures that are provided, the content needs to be developed curated, and then, uh, instructed very well.

I see. And this is one of those things, so I'll relate it to chiropractor. When I— because I've been in rehab for 20-some-odd years with my back, and I found a place that had what's called the Cox table, which is very hard to, to get certified for. And so most people opt to not get it, but it's like a dream as opposed to just getting thrown around and whipped around and popped and cracked. This actually manipulates your back and it helps it. And that's kind I'm relating it to this to where it's like, that's more of an unknown. It, it's like, oh, I've gotta go get another certification, or, oh, I've gotta take time to study this. How much does the tool itself cost?

So this one costs a little under $2,000.

Okay.

Okay. As a, as a cost in whole.

Mhmm.

But some of the, you know, lower cost ones are around $500. So it really shouldn't be— the cost in itself shouldn't be a big deal. for your dermatologist or dermatology provider to purchase. Yeah.

That's why I asked because I'm like, okay, is there a hurdle here to doing it? So, second question would be then, how difficult is it to read what that tells you?

It is much more difficult than people would like to lead on.

So, that's probably the problem.

That's the issue. So, a lot of stuff that people may presume is normal is abnormal. Uh, and then things that are, um, say normal, uh, they will biopsy because they think it is abnormal. Now, that occurs no matter what. I can go through, uh, the second part on at length, uh, because there are a lot of things that will create essentially interference or noise in the skin, and you need to actually take the tissue sample.

Okay.

If you get a— what I try to instruct is if you biopsy something, excuse me, that is normal, but you knew the exact reason why, and you have the data to show it, you should always biopsy.

Right.

Shiny white structures within a pigmented lesion that's papular requires a biopsy. It comes back as a normal mole, fine. But because that, those shiny white structures could be dermal fibrosis in a melanoma that is invasive. So you have to take it off. But the understanding, the disconnect, There is a disconnect with the level of knowledge people have in that area.

So that's the big problem.

That's the issue. Yeah. And we— that's what— with this, that is what we need to change.

Is there a certification or anything that you take to do that, or is that just to learn it?

And yeah, so there are courses, right? So there are multiple courses. Um, you know, I was in Utah in May presenting at their state, uh, meeting. I gave, uh, 4 lectures on it, right? Uh, I'll be in Colorado presenting at their annual conference. discussing dermoscopy. Uh, so there are ways to get the information, but I try to tell people, you— there's a canvas every single day, and that is the patient. And I want to look at, you know, a learning opportunity, but you have the ability to learn because you're, you are actively doing it as you see skin.

I don't want to put words in your mouth. I'm going to ask you, would you say it's an active hope of yours to help get that into more dermatologists' hands?

That is my goal. So my goal is for the public to be aware that dermoscopy is required for your skin cancer screening. It is required. As soon as the public on a whole becomes aware of that, then it will push the institutions to start to change the instruction.

Yeah.

I'll give you kind of a little, tidbit of like how we train. So in our— to become a board-certified dermatologist, you go through med school and then you do 4 years of residency. At that time, when you sit for your board examination, around 15 to 20% of the questions are pathology, meaning what the structures look like underneath the skin, which is good. You need to know it. And we had lectures every single week on dermatopathology. However, in practice, most dermatologists do not actually read their own pathology. You have a fellowship, a dermatopathologist that is reading the slides. So clinically, the dermatopathology training that is required, people don't utilize as much, right?

Mm-hmm.

But when we look at what is required for dermoscopy, on my exams in 2019, I don't think I had a single question that was dermoscopy related. When we look at that ratio of 15 to 20% being dermatopathology, I think we need to learn it.

Yeah.

But if we're not gonna be applying dermatopathology, we really need to be learning what we're doing every day on the skin in clinic. And that is like learning something procedurally, right? Well, this is a procedural process, what you're analyzing. That should be so foundational in dermoscopy education. And in my opinion, if you're a nurse practitioner or a physician's assistant and you're just starting right out, And you go, you're now, you're working in a dermatology clinic. There really should be certification before you can pick up a scope, you know, or be, not pick up a scope, but be in a clinic and providing care for patients because the knowledge that it takes to get there is not low. It is a lot.

One of my personal frustrations when I talk with people and I learn what they're learning in school and everything is it doesn't correlate to real world and real life situations and circumstances. It's kind of like taking, fucking 7 years of history in school when you need to be taking courses on how to fix your credit and build your credit, balance your checkbook, things that are real-life circumstances. And so, like, my hope, and I'll relate this to the supplement industry, is when, when I'm around something and I see it's clean label, Project Certified, you know, if you're into the seed oil, seed oil-free certified, like, they get these real certifications, they go the extra mile. And it's normally cost-related why they don't. This isn't cost-related. This is more— time-related or desire to learn more. My hope would be that we could encourage more people to learn more, to be the best at what they do. They, they do what you do to make a difference, right? You know, you did this to make a difference, not to make a paycheck. You did it to make a significant difference.

Correct.

You know, of course I want everybody to make a lot of money at what they do, but I want you to have a purpose. So I mean, that would be the—

my—

I'm, I'm speaking for you on your behalf. That would be my argument because I deal with it every day.

Right.

And I've learned over time that if you're not doing stuff for other people, what are you doing?

True.

Yeah. I mean, that's the whole purpose, really. We should be helping everybody out, right?

Well, everybody.

In medicine, you should be, you're doing the best, you should be providing the best care. But with anything, standardization matters. Requirements matter. And if the requirement is not there, unfortunately, no matter what, no matter how— what level of achievement people decide to get to, there are going to be people that are going to do what is standard.

Yeah, of course.

And that is not wrong. That is what our governing bodies have, you know, established as this is the standard grade, this is what is expected. Uh, but to me, because I see the difference, and that is lives— like, I, I firmly believe if everybody was a dermoscopist as a dermatologist that we would reduce melanoma mortality.

I don't know if you have an exact percentage on this or not, but what percentage of dermatologists use that?

I would say majority of them use it, and I would say it's probably majority is loose. It's at least over half. Okay, but the training, right, almost every attending— I went to University of Wisconsin, it was a very good, uh, institution to learn dermatology, most of the dermatologists there used a dermatoscope, right? So they had that handheld tool, but the knowledge within it, this is just based on lectureship and what I know, it's just not there.

Yeah.

And that is what needs to be implemented. So people can harbor a tool, but if the understanding of those structures are not present, then even if you're utilizing something, It is not going to help you as much if you actually knew what you're, you're doing with it.

So, like, obviously the dermatology would be the core, like, thing. So that would just be like a subset of what you're learning, basically?

Correct. But this applies, you know, think about what do most people go to dermatologists for, right? Skin cancer screening. I mean, I see patients for all the other stuff, you know, acne, psoriasis, atopic dermatitis, or eczema. Um, but in general, you know, And obviously my, my specialty, my area of expertise is finding skin cancer. That is, people are coming in to get their skin examined to make sure that they're okay.

I want to utilize a couple other questions then, since we did so many melanoma, and given that you have so many, um, other things that you're able to— I, I've always had this curiosity about certain skin issues like psoriasis, like eczema, What—

what's—

is it— is it cellular? Is it nerves? Is it something mental? Is it gut health? What are some of the main culprits that cause these problems?

So great question. Uh, their absolutism of trying to say that there's no association with stuff is not where I'm at. There is definitely a gut axis. There is a, um, uh, mental health aspect that is associated, uh, and I think they actually play off each other. People that are itchy They may— their itch, honestly, I feel like can drive people mad. Like, if you're itchy, you get a bug bite, it's itching.

Yeah.

Like, imagine your whole body itching, you know, you have atopic dermatitis or eczema and you're scratching your skin constantly. That would drive me nuts, right? So there is some association, I think, in particular of driving the level of severity or symptoms of it, uh, and some of it's inflammatory, right? You know, we know that You know, psoriasis technically is an autoimmune process. You have an overproliferative condition. If we're just looking at the skin, it means it's not breaking down tissue. It's causing excess growth to cause plaques that are thickened on the skin. When you look at psoriatic arthritis, so that's essentially you're looking at that disease entity as psoriasis. Some people get arthritis with it, other people do not. But when you have psoriatic arthritis, you're actually destroying the joint. You have to treat it. if you don't treat, say, skin psoriasis and you have less than 10% body surface area, you can look at certain inflammatory markers to assess what is their level of inflammation. Is it elevated or not? Once they're above 10% body surface area, there is a signal of— you can look at blood-based markers and say, hey, look, they have internal inflammation, you need to treat that.

And that's where you have their systemic drugs. Turn on your TV, which I really don't watch, but turn it and look at— there are just numerous drugs that work. And good thing is they actually work. So a lot of the, a lot of the drugs that we have psoriasis— for psoriasis are exceptionally good, and they're low risk, which is great. Um, eczema, a little bit different. We have good drugs for atopic dermatitis, much better than what we had, you know, even 10 years ago. But the drugs for psoriasis—

and I don't work for any drug companies at all, I don't sell drugs, nothing with pharma, I prescribe things that I've had quite a few pretty highly intelligent guests on here, but they'll come on and say, oh, this cures psoriasis and this does this, and I've yet to really see that come to fruition.

Yeah.

And, that's why I asked because I'm one of those people, I don't love conventional medicine, but I'm certainly not against it because I use some and I know the efficacy of some and I know the benefits. It's like anything else, something good comes along and it gets screwed up along the way because somebody tries to make a lot of money off of it. It's just like anything else. It's not just medicine. So, I'm always temperate in terms of what I believe and what I don't, even though in my sphere, it's more frowned upon to get behind stuff like that. I'm a realist, right?

Yeah, which is good. I think that you should have that. You should do the things that you can do naturally.

Always.

That are healthy for you. Exercise, try to get good sleep, eat well. Those are healthy. Those are things that can help you. But if you There are things that you cannot say control, that is use pharmacology. You look at randomized controlled trials—

Yup.

Which when you look at evidence for— for interventions and you look at studies that remove, say they peel off the epidemiology component. Well, what— what else did this person have? How old were they? And you just look at, is this drug effective in these cohorts of similar people that are, you know, similar? And you can see what the data shows. That is why it is very expensive for pharmaceutical companies to bring a drug to the market. And, but ultimately you wanna do stuff that is safe and you wanna take care of yourself.

Yeah, 100%. I got fascinated with psoriasis when my dad passed away and my mom, you know, obviously had a meltdown and she developed it. So I always, and her correlation was to the stress and everything that just happened out of nowhere. So I got kind of fascinated with learning learning about it and learning that— because I didn't even really know what it was at the time.

Yeah.

You know, and so I studied into it and everything. Do you find that people that get those skin conditions, are they normally older or does it vary?

It— so there's a kind of a bimodal distribution with psoriasis, but I definitely would say I see it more, you know, 35, 40 years old.

Yeah.

Um, where they start developing it more frequently. And then there are other things that are associated with psoriasis, which look at your metabolic health, right?

Yeah.

So obesity, Alcohol consumption, smoking, those are all factors for people to develop. They say they're predisposed to already have it, but they have been in good health their whole life. You know, they don't smoke, they don't drink alcohol, and they're normal BMI, right? And they exercise. Well, they— their psoriasis, maybe they have just a teeny little pink spot on their skin, they don't even think anything of it, but then they become overweight, drink excess alcohol, smoke cigarettes, And boom, they're coming to the dermatologist. I got this itchiness in my scalp, or I'm getting these thick, you know, bumps on the back of my arms. And they were— they already had it, but they— their metabolic health was under good control.

Yeah.

Um, and there are a good subset of those patients. Like, there are a lot of— obviously, I'm sure you've— everybody is aware of like Ozempic and, you know, looking at semaglutide, tirzepatide. these GLP medications. Well, what have I seen in my own cohorts of patients who are on those? Not me prescribing them, taking care of their skin. They metabolically become healthier and their psoriasis is getting better, which is awesome. I'm happy for them along the way.

Yeah.

So, there is association with that.

Okay. So, when it comes to acne issues, is that a hormonal problem or what is the general cause there?

So, hormones absolutely play a role, right? So, that's why when we look at like pre-puberty, if, if a, if a child comes in before puberty, uh, before they say women start having their menses, right? Um, you, you would consider working up why that individual is getting acne, right? Because when do they start to develop acne? When they're going through puberty, right? You have sebaceous glands, these little oil glands.

Mm-hmm.

Uh, those oil glands become activated or grow with androgens in your body, so things like testosterone. Uh, and so that is is a primary driver of it, but there are other components that are associated with it.

Yeah, it's 'cause, for example, one major side effect with anabolic steroids, a lot of acne buildup fast.

Right, correct, yeah.

What about foods that, 'cause I mean, you know, and I say this, when you're a kid, it was always, oh, if you eat something greasy or potato chips, you're gonna get a zit. Is that true or is that just mythical BS?

So I would say that there, It depends. So if you— if there was something that you consumed, say it was dairy.

Yeah.

And every time you had dairy, you got pimples with it. Well, maybe for you dairy was a problem, but as a whole, it is a lower issue because it's not really adjusting your level of testosterone.

Yeah.

You know, think about foods that you can eat that are going to raise your testosterone. Everybody would be doing it, right, if they were trying to— if they wanted to get get more muscle. So there's very few things that are going to impact that level. Um, so yeah, for me, I don't really— you know, I try to recommend just clean eating with— for— with my patients.

Is acne more of a prevalent problem for younger people than it is older people?

It is, but I definitely have— I mean, I have an 86-year-old on Accutane. You know, I have multiple older 80-year-olds on, uh, isotretinoin. And that, at that point in time, it's not technically acne is what we call rhinophymatous rosacea, which is, you look at rosacea, it's kind of a sibling of what acne is. And Accutane or isotretinoin is unbelievably helpful for it. And these patients, they never wanna go off of it because they— if you look at— look up rhinophyma and look at what the nose looks like, it is not an— it is not something you would want to have. So if we could treat it, you wanna treat it.

So you mentioned Accutane. I spoke to you about that a little bit when we talked. So I'm— I would like to just ask you, What is Accutane and is it dangerous? Obviously, people, if you misuse anything and do it in the wrong way, it's going to be dangerous. But what do you notice with side effects-wise on that? Because I've, I've seen some people have issues with it, but I also don't know how they were using it.

Yeah, so, uh, isotretinoin, which is the actual drug, which is the brand is Accutane, yeah, is an oral derivative of vitamin A, right? So it's a vitamin A derivative medication. That works at the sebaceous gland, and it causes those sebaceous glands, which are in— they're hormone responsive, to shrink, and it causes some of them to actually involute and go away. As a dermatologist, it is one of the best drugs that you could possibly have for acne, and, you know, I cannot imagine that not being universal amongst dermatologists. 99 out of 100 would tell you They— it has saved so many patients' scars, um, reduced their depression, you know. And unfortunately, when a lot of kids get— when a lot of people get acne, teenage years, right?

Yeah.

So they're going through puberty. Unfortunately, I've, you know, uh, 11 and 13-year-old, and I— kids are mean, man, you know, unfortunately. And, you know, some kids are blessed, they have very few pimples, and some, some kids are not. And you can unfortunately, because of social pressures, They are very heavily impacted by how they look and what people say and do, and you can help reduce their acne and also reduce scarring with, to me, essentially no risk excluding the biggest risk with Accutane, the disclaimer, pregnancy. We know it causes birth defects. That is a guarantee and that is why the medicine is regulated extensively because it will cause a birth effect.

Yup.

effect. Extremely important. Excluding that, so 30 days post-Accutane— this is what I tell my patients as females— 30 days post-Accutane, you want to have kids, let's say 27-year-old woman, it's— there's no risk, no issue associated with it. Completely okay. But when you're on the medicine, within 30 days of it being discontinued, that risk of a birth defect is real. And that's because excess vitamin A will create a birth defect.

I see.

Um, but other than that, If you use sunscreen, sun protection in general, you moisturize your skin, you use, you know, lip balm, have a humidifier in your house, reduce the side effects that are associated with it, which are really sun sensitivity and dryness are the 2 biggest things. It is very easy. So if you were to talk to my patients, which unfortunately HIPAA cannot, but I'm sure they would actually line up and say they would recommend it.

Yeah.

Because it works so well and once you know how to utilize it, it, it's not hard. It's easy.

Okay, one more here about like not drugs, but I want your thoughts on sunblock in general because I, you know, once again you see a lot of people—

Great questions.

Yeah, a lot of people that will say, man, you better wear that every single day, and there's other people that will tell you it is like poison to wear it. I mean, literally. And I don't know how much social media you look at, but I mean, it is Don't go near it.

So, you know, in all honesty, over the past year, I've been trying to identify more sources for what I'm hearing in society, right? So from my patient population of telling me sunscreen's bad for you or the sun is good for you, and I'd be happy to go over some of these studies, which I think are actually very important for people to be aware of what the data shows. Now, when it comes to using sunblock and using chemical or physical-based sunscreen, I use both personally. I do recommend them both to my patients to utilize. The studies that we have, people are, you know, particularly worried about, you know, oxybenzone as one of the common ones that I hear daily. Okay, you stay away from that, that's gonna cause cancer, it's an endocrine disruptor. We have no human-based evidence or study that has shown that it actually does cause cancer or that it is harmful. It is absorbed. We know that it's absorbed into the skin, but something being absorbed does not mean it's going to cause harm. Uh, and I think that people need to be aware of that in general. It's like we are concerned about chemicals, uh, in general, you know, dihydrogen monoxide is water.

But if I were to say that to you and say, could you imagine putting that on your skin? People would say, oh, they would freak out because they don't know what it is. But that is 2 hydrogen moieties and 1 oxygen moiety. And it is technically— water can be harmful if you drink too much of it right away, right?

Yeah.

And you can actually die from that. Uh, but, uh, the, the studies that we have when it comes to actual chemical-based sunscreens that are currently on the market Okay? The amount of volume that you would have to utilize day in, day out for not just our lifetime, meaning, you know, what does the average human live? 80 years if we're lucky. But if you get to be a centenarian and you're 100, great. None of the studies show that there would be toxicity. This is looking at equivalent, like, animal models of where would it be toxic, or, you know, one of the animal studies looked at the endocrine disruptors. of a rat uterus, and that's how they get, well, we know this is an endocrine disruptor. Well, for potentially that to occur, you're looking at 130 years to like 250 years of use of sunscreen. We don't live that long. And because we don't live that long, and it's a theoretical risk, it is not actually a real risk, my concern is very low. With that being said, I always pay attention to literature. So if literature comes out and shows me, hey, this is potentially harmful, Mm-hmm.

I will, I would like to have the chance to pivot and tell people, don't use that.

Yeah.

And if people say, just use mineral sunscreen, I am completely fine with that, but mineral sunscreen for everybody does not always work. It makes their skin look white and chalky, right? And that is their appearance. They don't wanna look like they have toothpaste on their skin. And, you know, in particular, if you have, say, a darker skin tone, A lot of the chemical blockers, there's a new one. And once again, I don't work for any company, bemotricinol, which has been around for 26 years in Europe, in Korea. We have very good safety profiles. It blocks, it's a photostable sunscreen. It has a large molecular weight, it's over 500 Daltons. So the absorption is low into the skin.

Mm-hmm.

And it is actually the first chemical-based sunscreen that is recognized GRAS-1, generally recognized as safe and effective, by the FDA. The others are zinc oxide, titanium dioxide. So that is a chemical-based sunscreen. But just so people know, chemical-based sunscreens are actually organic. So they are organic compounds and physical-based sunscreens are inorganic. And this is where words, this is kind of where people, I don't wanna say get in trouble, they utilize words to make things seem scarier than they are.

They're organic.

And my concern as somebody who, I see skin cancer every day, I know what UV radiation does. My recommendation is you protect it when you need to. That doesn't mean you need sunscreen on every day. You know, you may not need to.

That's my stance on it where I feel like it's like, okay, it's too much. But I'll tell you this, I don't wanna get burnt ever again when I go to the beach or if I'm out and I put that shit on. You should.

I'm glad you do.

And the volume matters, right? So one of the things that we look at, because a lot of people are like, well, there was a study where they showed people who use sunscreen got more skin cancer.

Yeah.

Well, how much did they actually use? You know, you can use a 2-finger rule for your face. So put a strip of sunscreen on this finger, strip of sunscreen on that finger. That is how much sunscreen you need to utilize for your face. Most people do not do that. They put a couple dabs there. You know, if you look at your body, sun exposure is it's a shot glass. It's an ounce of sunscreen. People don't utilize that.

Oh, I slather that on when I go to the beach. I got burned too many times.

Yeah. So, you know what you need. Yeah. Oh, yeah. Yeah.

Trust me, get burnt once or twice and have your whole trip ruined, you tend to not do it again.

Yeah.

So, man, this has been so enlightening. I got like 7 million more questions for you. We might have to do another dive on this.

Oh, man, I'd be happy to come on. Absolutely.

You have been phenomenal. I mean, just everything and how quick the answers are. I can always tell when I'm talking to a real pro by how they answer in the quickness and they don't dance like a politician. And you didn't on anything. And I appreciate all of the insight and just your work in general. I mean, what an asset to the community you are. I'm really glad that I got to meet you, man.

I appreciate it. Thank you for having me on. It's a blast. Absolutely.

Well, where can people follow you? And then, I mean, your clinic's in Tucson, right? If somebody wants to actually see you in person.

Yeah, so Tucson, Arizona. But, uh, Instagram is— I mean, I'm on all the outlets. It's just my name, Michael_Christopher_MD.

Okay. Yeah, sweet. Thanks again for the time, brother. Absolutely. So valuable, such an asset, and it's been a real honor and pleasure to have you here.

Yeah, appreciate it. Thank you so much.

Absolutely. All right, everybody, I hope that you pay close attention to that and And this has been one of the most highly impactful conversations I've ever had. So, listen closely, take a lot from this, and stay tuned for plenty more to come. Dylan Gemelli, signing off.