Neoplastic Skin Conditions

Moles, like warts, are benign neoplasms but are not contagious.  In this case, melanocytes secrete excessive amounts of melanin (the substance that colors the skin).  The small group of cells usually 6 mm or less is symmetrical, round or oval, unicolored with distinct round edges.  Moles, nevi, are not inherently dangerous, but some have a higher potential of becoming cancerous.  Congenital nevi, moles present at birth, have a greater risk of becoming cancerous if they are large and if they change their appearance.  Dyplastic nevi are moles that exhibit certain characteristics of skin cancer, which will be described in the next section on skin cancer.  Massage in not contraindicated unless the moles are irritated or torn.  Because many moles are on the back, massage therapists are in a unique position to observe moles and spot possible skin cancer.  Again, refer to the next section to learn how to tell the difference between a mole and skin cancer.

Psoriasis is a chronic condition in which the skin cells periodically grow too rapidly.  Normally skin cells reproduce every 30 days, but during acute psoriasis, the cells reproduce every 2-4 days.  Psoriasis appears as a build-up of scaly, itchy pink skin cells.  The cause of psoriasis is under debate, but acute flare-ups can be caused by emotional stress, sunburn or the lack of sun, hormonal changes, prescription drugs or immunosupression.  Although rarely a dangerous condition, if the skin breaks, an infection can ensue.  Psoriatic arthritis is a possible complication of psoriasis that causes inflammation in the joints similar to, but usually not as severe as rheumatoid arthritis.  Psoriasis is a local contraindication to massage because in its acute phase, it will only be exacerbated by massage.  Psoriasis is not contagious, nor can it be spread by massage and the relaxing benefits of massage may help decrease stress, often seen as a factor in acute flare-ups. 

Skin Cancer is uncontrolled skin cell replication causing tumors, which can possibly spread (metastasize) to other parts of the body.   Skin cancer is the common type of cancer and it is estimated that 40-50% of people over 65 will experience some form of skin cancer.  Early detection and treatment are the cornerstones of prevention and eradication of cancer.

Actinic Keratosis:  Precancerous Lesions
Actinic keratosis (AK) is not cancer, but 20% of these lesions can develop into squamous cell carcinoma.  AK lesions appear as sores that do not heal normally, but form a crust over and over again.  If you notice an AK lesion, bring it to the awareness of the client or patient and recommend they consult their doctor as soon as possible.  AK lesions do not contraindicate massage.

Basal Cell Carcinoma (BCC), accounting for 75-90% of all skin cancer cases, is the most common type of skin cancer.  It is a tumor of the basal cells in the epithelium that is slow-growing and non-metastasizing.  It is the least serious and easiest to treat skin cancer.  It sometimes presents as a small, hard pearl-colored lump on the face that has rounded edges and a soft center that may bleed.  The center forms a crust, or scab, but never heals.  Another presentation is on the trunk - flat sores that crust over and over, but do not heal.  Treatment, excision of the tumor, is effective due to the slow-growing, non-metastasizing nature of the tumor.  A BCC tumor is a local contraindication to massage.  It is not contagious and does not spread, but if left untreated, the tumor can erode local nerves or blood vessels.

Squamous Cell Carcinoma (SCC) is a malignant cancer of the keratinocytes in the epithelium.  Typically SCC tumors, which account for 20% of skin cancer cases, appear on the lips, ears or hands as hard, firm lumps with an open sore that does not heal.  The sore crusts over, but the crust falls off over and over again.  The longer this goes on, the deeper the cancer spreads into the skin.  Early detection is important to avoid the metastasis of the cancer to other parts of the body through the lymphatic system or circulatory system.  Because massage stimulates the lymphatic system and circulatory system, cancer can be a systemic contraindication for massage.  It is important to work with the healthcare team so that, as the therapist, you are providing treatment that maximizes benefit while minimizing risk. 

Malignant Melanoma (MM), accounting for 3-5% of all cancer cases, is the most dangerous.  It is responsible for 75% of all skin cancer deaths.  MM often begins as a mole, which then begins to change in color, thickness or size and may become itchy or bleed around the edges.  MM does not always start as a mole.  The ABCDE’s is a mnemonic to remember the main features of a malignant melanoma:
ABCDE’s for Identifying Malignant Melanomas
A:  Asymmetrical  While most moles are symmetrical – round or oval, MM is oddly shaped.   
B:  Border  While normal moles have distinct borders, MM has irregular borders.
C:  Color  While normal moles are consistent, MM are multi-colored and may change color.
D:  Diameter  MM is larger than normal moles, which are usually less than 6 mm.
E:  Elevated   MM is elevated from the skin.

Because this cancer grows rapidly, may spread into deep layers of the skin and can metastasize to other areas of the body through the lymphatic and circulatory system, early detection is important and treatment is aggressive consisting of excision of the tumor cells, radiation and chemotherapy.  As with SCC tumors, malignant melanomas can be a systemic contraindication for massage.  Again, it is important to work as part of the healthcare team.  In terminal cases, massage can be an important part of patient care.

Injuries to the Skin

Burns are graded in three levels of severity based on how deep they go, how much of the body they cover and what part of the body is affected.  A First-Degree burn affects the superficial epidermis and appears as reddened skin with associated pain, heat and sometimes pealing.  A superficial sunburn is a good example.  A Second-Degree burn affects all layers of the epidermis and goes down into the dermis.  Characteristics include redness, swelling, blisters and much more pain.  Third-Degree burns go through the dermis into subcutaneous tissue destroying sebaceous glands, sweat glands, hair shafts and free nerve endings.  Because the nociceptors are destroyed, third-degree burns can be less painful than second-degree burns.  Characteristics are charring, whiteness and leathery skin.  Third-degree burns can lead to fluid loss, shock and infection.  Most burns, even sunburns, are a local contraindication for massage.  It may feel soothing for the therapist to gently spread some cooling lotion on a sunburn, but any amount of pressure will be irritating.  Of course, deeper burns are not only a local contraindication, but may be a systemic contraindication.  When working with a healthcare team, massage can provide relief of pain and stress associated with deeper burns once the acute systemic threat is over. 

Decubitis Ulcers, also known as pressure sores or bed sores, are caused by inadequate blood flow to the skin, which causes the skin to break down.  The first symptoms of associated with decubitis ulcer formation are skin becomes red, itchy and painful.  If the decreased circulation continues, the skin becomes purple and skin cell death (necrosis) begins.  At this point, bacteria will often invade the necrotic tissue, which results in an infection.  Areas where the bones can pinch the skin between the contact surface are the most susceptible to ulcers.  These include greater trochanter, heels, sacrum and elbows.  Before decubitis ulcers form, massage can help increase circulation to the skin, but once the skin is broken down, decubitis ulcers, and all other open wounds, are a localized contraindication for massage due to the risk of infection. 

Scar Tissue is the body’s way of repairing itself after injury.  Fibroblasts, cells that lay down collagen, are stimulated into action during the fibroplastic stage of tissue repair.  In the acute phase of tissue injury, massage is a locally contraindicated.  In the subacute phase, massage can help to smooth scar tissue and reduce hypertrophic scarring.

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