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

The average dermatologist in Arizona finds around 20 a year.

Of the roughly 8-10,000 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. Yeah, 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?”

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free sample of might appear gummies from [email protected]/dillon. It's the science back breakdown of exactly what's happening to your muscles as you age, and how to fight back. All right, everybody. Welcome back to the Dylan Jamelli 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 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 because 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 dermatopist recognized for his work in early melanoma detection, and he has been using evidence-based use of dermatopi 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. Now it's pleasure. Thank you for having me on, I appreciate it. I am stoked like I said to have you here, 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 Dormoscopy 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. 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 MP or PA, and you get a skin exam when they're looking over your skin, they shouldn't be just doing the

visual exam. They should look at every single mole with an every pink spot and every sun spot that you have in your body with a dermatoscope because things that can look normal like that little mole in your hand. I'm not saying that is harmful. It looks round regular. Looks like as even borders. But if I were just to look at that with my eye, I cannot tell you, and this is as an expert

“endermoscopy and a board certified dermatologist that that is normal. The only way that we can tell”

that this normal is if I put a dermatoscope on it. And if people are not using a dermatoscope, what does that create? It 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

you can imagine how many people go into 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 here in”

a can 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? 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 mammogram. 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 going to know that there

is disease? That is potentially there. There are many breast cancers that don't present as a lump, right? So women women would not be able to find it. Well, same as melanoma. They're not all irregular. They don't have symptoms. 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 is 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, 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. And signs that there is an increased bascular density within a mole, which is a sign of a melanoma, 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 a middle portion of your skin. And some of those structures like shiny white lines, orthogonal lines, those are features that you can see within an invasive melanoma, even though from the outside, it looks like completely normal. Okay. So it's like, it's almost like an x-ray vision tool, so to speak. Correct, right. It's a secondary image, imaging, to where you can think about it like this.

You get an x-ray, say you come in and hit your, you have a knee injury, your knees sore, maybe you feel like you tore your acel. You go get an x-ray of it. That x-rays actually not going to show you tore your acel. No, these it can't see it. And that is kind of what we want to do. 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 acel tear, while the x-rays not going to show you if the acel is torn, you need an MRI, right? And the MRI will be able to actually assess those structures, and we'll be able to say, oh yeah, clearly there's an acel tear or the acel is intact. You wouldn't try to assess an acel 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 questions. Some people have very few, and I actually maybe I need to look into a literature on that exact. Yeah, 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 eight typical moles. And that is a component when we look at risk 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

more popping up. 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. How to 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 are absolutely can be sun-induced. And getting new moles does not always mean that there is trouble associated with it. Yeah. 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 to

“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. Two weeks straight, have three and a half for our

layouts. That's when I noticed what about tanning, like in a tanning bed. Terrible. Yeah. So you tanning beds are actually UVA. Right. So when you're looking at getting sunlight, you're looking at obviously all spectrum visible infrared. UVC is actually thankfully filtered out. He'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 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 we started to get popular, I spent a lot”

of time in them. A lot. You know, like teenage years. Oh, I don't know two or three times a week for a while, and then I owned a bed in Vegas. I didn't, and it's funny. I owned it. I used it less than when I had a membership somewhere. Just sat there. But I haven't, you know, I stopped using tanning beds well over 12 or 13 years ago probably, but I definitely, it was a prevalent thing back then and not a lot of data. Absolutely. And in particular, tanning beds were, you know,

your 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. Mm-hmm. And you want to avoid that at all cost. 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 going to 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 going to help with your muscles. Yeah. It's going to help with your skin. Well, what is a dose? What were the studies done that showed that dose was helpful in are these companies and devices actually administering that dose? And so it's a, there is a dosometry that is associated with red light therapy. So if you're using it and I actually use it on my head to keep my hair

nice and full. So, 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. And I don't know the answer to this and I don't know how many different options there are 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 good ones and what should we avoid and what should we try to get? So UVA and UVB are the two forms of UV that you're going to

be getting from the sun. Right. 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. UVB is definitely of the two much more carcinogenic. So meaning it is one that has heavily associated with melanoma tumor genesis, looking at basal solar squamous cell carcinoma in the development of skin cancer. UVA is also associated with it is just that we get more the amount of UVB

that we get, the intensity of it is more and it is more toxic. Now, as a dermatologist, you know, getting any dose of UVB because UV ultraviolet radiation is a class one carcinogen and we know that

some dose to where it is, I don't want to say, not harmful, but the dose makes a poison. Right.

“A little bit of UVA, so for me if the UV is less than two, 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 the lesson too, but as soon as UV index is above two, based on my Fitzpatrick skin type, it means a color of my skin. I'm a Fitzpatrick too. I absolutely make sure that I have sunscreen. Not only is that important blocking UV radiation, but it also is helpful for photo aging, which photo aging 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, we'll have that. So if you go to your, I have an iPhone. If you open up your iPhone,

go to the weather app and I'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 I'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, it would 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”

cracks. Okay. And you're looking at that all year long. Yeah. So it's all the closer 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? You know, interestingly enough, I've looked at this, the data is not

great. Really. Yeah. So I, but there, there's a multitude of factors. So looking at like the, how they record skin cancer there, that is one issue, but it's not correlated the way that you it 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-son people in the world or 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 to buy it unless you have some sort of condition, right, which there are those. Yeah. And but the time of day matters. 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 UV index is a 10 based on your Fitzpatrick skin type you're a three. 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. When we get excess UV it causes cyclobutane permitting dimers, two 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 based on 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 in my writer.

It so depends. So that depends on the time of year. Right. So in for instance in Tucson, which is where I live in practice. By 10 o'clock, even in the winter time, the UV is going to be around three. So that's probably pretty good. But I was in Austin in April and I was surprised. It was eight thirty in the morning. UV index is already three. And I said to myself, it's only, you know, it's spring. That's early. And it's already above that point. And the UV index was five until

after five p.m. So people say 10 to two. 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 your weather app. So does temperature play a role then in that?”

No. No. No. No. No. Think about going to San Diego right now. Yes. What's the temperature probably? 90. I don't know. You lower 80. 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 during the summer time and they all get burned. So like I was just so nice outside. I didn't think I needed to wear a 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 three weeks ago, and I like to go for walks in the morning. And in Phoenix now, I do treadmill walks in the morning. It's two damn hot. Because I don't start til 10. I do the sun like breath work in the pool right after something. You know, it's 10 minutes. But I was out there and it was so, I mean, it was instant sweat. In Miami. Yeah. Just instant. And so I'm wondering, since it's as close to the equator by the

ocean, then the UVs probably a lot higher in the summer there, right? Or it's probably I would say

would just be an ever based 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 and they're yard and then they move some rocks around. And instead of it being a two minute trip, it sounds 30 minutes outdoors and they burn. So it's the the unintended sun exposure that people are not aware of. And currently, they're, 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.

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 moment, they're not covering that. Correct. And there's and they're, 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

tape blood pressure. Yeah. 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. Yeah. If you sit in somewhere that is warm, you're going to release nitrous oxide until like sauna. So you don't have to get a something that is toxic. That is a grade one, class one 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 two, 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 to kind of like the red wine bullshit about, oh, it's got risk ferretrol and it will just take risk ferretrol

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? 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 one to a six. So as dark as you can be. Okay. And so 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 some 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 feel melanin is present and how much pigment is present. But yes, grossly, you can look to see, you know, what color is that individual skin and compare it to that scale and you can categorically fit where somebody falls. So are there other ways to like develop skin cancer melanomas without it being sun related? Oh, 100%. And what are some of those? Yeah. They're genetically related. Right. So there is germline mutations.

“When you ask me about the moles, right? Like, you know, how many moles somebody has to do? Do you know?”

Well, we know, for instance, if you have a set number of dysplastic nearby harbor dysplastic nervous syndrome, those individuals without UV exposure are just they harbor an increased risk of developing a melanoma because they develop excess moles or are already a regular. Right. So they don't have to get sunlight per se that to develop a melanoma. They have a familial history of it and they amutations are called germline mutations that are present that are inherited from their parents. It's

like a balding gene. You say both your parents were bald. Women go bald as well. And you inherit the balding trait. Well, 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 CKDN to a mutation. That mutation increases your risk of getting melanoma without sun exposure. But the UV radiation and itself can propagate that as well. Wow. Is there any other ways or those

the two ways? Spontaneous and sporadic. So unfortunately, things just occur. 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 7 signature, which is a UV-related signature

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? It's all, I mean,”

well, because some people are modest in there. You know, but it's just look. It's all, when you're a physician, it is all, it's, if looking at gen general skin is like looking at a toe ear. 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, I get lost there with people. I get it. I guess to an extent, but not when you get older, man. I know, monacy is gone. And it really,

it should not be there when you're getting evaluated, because how do you know what's, not there last year, I found three melanomas on the butt. Three melanomas. You know, people not, they didn't use canning beds. It's just spontaneous acre. Yeah. And you wouldn't even know there's anything even there. Correct. Yes. You would not, I mean, that is on the easy area to look. You're no. Okay. So what are the, like, 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 dermatoscopist, right?

I said, so for me, what got me into dermatology, my interest in it in particular, as I've always

“been interested in kind of longevity medicine and living a healthy life is one of the pillars of”

living long is 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 zero, nobody dies from it. All you have to do is remove it. Just write it off. You cut it off and you're good to go. If you find melanoma at stage one, you actually have a high rate of survival. So if you look at the NCCN or HACC, you know, they'll give you, you know, what the five-year survival rate is. And it's like 98 to 99%. But there's a lot of

people that are diagnosed with a stage one melanoma of all the melanomas. And so of the

roughly eight to 10,000 people that die a year, they are actually diagnosed with what we consider

early stage melanoma. So objectively, if you can find it as early as possible, you shouldn't worry about it. So when I call a patient and tell them, hey, you have a melanoma inside too. 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 the later stage as you say it has traveled to the lymph node

“in its stage, even three-eight micro deposits. That ratio of either you're good, nothing, right?”

You're 100% survivorship or even looking at stage one at like 98%. Now you're at like 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 were if they had or would they even know? Nothing at that point. Nothing. Nothing. Correct. Which is unfortunate. That is why it is kind of one of those more to me like scary cancers. It's not like,

oh, I got a stomach ache or I have headaches. You can have something that's migrating through the stages, like stage three, three-eight. That means you have a micro deposit 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 for? Not necessarily yet. But there, we are, 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 stage zero. Okay. Meaning it would have to be stage one, stage two, stage three for a circulating tumor DNA for it to be found in your blood. So how long can one sit there in stage zero? Could it sit there for a long time? We don't know. So we could. Yeah, absolutely. And I'm sure that there

there are some that do that. Yeah. But if I could tell you that, I would be a trillionaire. Right. And I hope something he does figured 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, it's, you know, 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

excision for a, 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 six months, I'll send you a photo”

that you want, you'll just see that there was a line. There'll be no color. That's great there. This is recent. Yeah. And so you'll look, you'll look at it 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 verse, what is the risk of that going from a stage zero to something that kills you? Yeah. Right. To me, the balance is where we are. We don't know 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, she had healed them like a week. And I felt good. I didn't have to worry about it. Correct. Yeah. Super easy to do. Get it removed. 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 rest and what is the data on it. And then it is a very, to me, straightforward process. How many

and do you can't say exactly? But how often do you find something that looks normal? That is an actual melanoma. Does it have almost every week? Yeah. Yeah. Yeah. So almost every week. Wow. Not even. So, you know, 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 look like normal little bumps on the skin.

And it's a basil song. And something like that, say it's on the nose. It's a small, say a small basil 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, you can get a very tiny scar versus losing your whole, say, tip your nose. Yeah. How quick does that thing show? Does it show what it is? Yeah. Yeah. I mean, you know, there are certain things dynamic rotation.

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 showing you structures that are inside this 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. And so when I have learners who I really just have board certified dermatologists who will fly in to see me to learn, they, if they ever do a 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 can 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'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, you know, it sounds, you know,”

rudimentary, the length of time. But a mole, two to three seconds. I tried to count mine and I'm like, in my head, I'm thinking, like, what is average? I'm trying to count my wife. Yeah, but it's not just moles. It's every sun spot. So every lentigo, somebody has, I have to look at what the dream is. 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 going to take long. And that's okay,

but look, that's always signed up for. Yeah. It's to make sure that you were okay. Yeah. Oh, yeah.

I'd sit there all day for the, you know, but some people are in two big of a hurry, I guess, for their life. 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 have any kind of 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. And so for the most part, people, when you go get a mammogram, not you, mostly don't get mammograms, right? It does occur. Yeah. And then, then, do you get breast cancer? Yeah. I actually diagnosed one last year on a, a person came in at a lump, right, right underneath their area, uh, did a biopsy,

was breast cancer in a male. Uh, 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 two lectures on, uh, dermoscopy that have utilized that tool. And even though we utilize it in clinic every day, that does not mean people

when people talk about how many hours of work you've put in on the back end, 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, um, 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. Yeah. My back, and I found a place that had what's called the cox table, which is very hard to get certified forward. So most people opt and I get it, but it's like a dream as opposed to just getting thrown around or whipped around and popped and cracked. This actually manipulates your back and it helps it. And that's kind of, I'm relating it to this to where it's like, that's more of an unknown. It,

it's like, oh, I've got to go get another certification or I've got to 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 and whole, but some of the, you know, lower cost ones are around 500 bucks. 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 what I asked because I'm like, okay, is there a hurdle here to”

doing it? So second, 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 read on. So that's probably the problem. That's the issue. So a lot of stuff that people may presume as normal is abnormal. And then things that are, say, normal, they will buy apps, because they think it is abnormal. Now that occurs no matter what, I can go through the second part on at length, because there are a lot of things that will create essentially interference or noise. Sure. And the skin and you

need to actually take the tissue sample. Okay. If you get a, what I try to instruct is if you buy apps, see something, excuse me, that is normal, but you knew the exact reason why and you have

the data to show it, you should always buy apps. Shiny white structures within a pigmented

region that's popular requires a biopsy comes back as a normal, fine. But because that, those

“shiny white structures could be a normal 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. And 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 you just go and learn it? Yeah. So there are courses, right? So there are multiple courses, you know, I was in Utah and may presenting at their states meeting, I gave four lectures on it.

I'll be in Colorado presenting at their annual conference discussing Dermoscopy. 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 learning opportunity, but you have the ability to learn because 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 a public on a whole becomes aware of that, then it will push the institutions to start to change the instruction. Yeah. It'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 four years of residency.

At that time, when you sit for your board examination around 15-20% 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 a 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. But when we look at what is required for Dermoscopy on my exams 2019, I don't think I had a single question that was Dermoscopy related. When we look at that ratio

of 15-20% being dermatopathology, I think we need to learn it. But if we're not going to be

in clinic. And that is like learning something procedurally, right?

Well, this is a procedural process, what you're analyzing. We should 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 not pick up a scope, but being 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 in real life situations and circumstances? It's kind of like taking fucking seven 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 my whole, and I'll relate this to the supplement industry is when when I'm around something and I see it's clean, label projects 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 by 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 to do what you do to make a difference. 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 and what they do, but I want you to have a purpose. So I mean, that would be the my, 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? Sure. Yeah. I mean, that's, I mean, that's a 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, the matter what's no matter how what the level of achievement people decide to get to, they're going to be people that are going to do what is standard. Yeah. And that is not wrong. That is what, what are governing bodies have, you know, established as this is the standard grade. This is what is expected.

But to me, because I see the difference in that is life. Like, 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 institution to learn dermatology. Most of the dermatologists say are used a dermatoscope, right? So they had that held 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 doing with it. So like, obviously, the dermatology would be the core like things. So that would just be like a subset of what you're learning basically. Correct. But this applies, you know, think about what are most people go to dermatologists for, right? Skin cancer, skin MEIC patients for all the other stuff. You know, acne, psoriasis, a topic dermatitis, or exima. But in general, you know, and obviously 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 of other questions. Since since we did so many melanoma and given that

you have so many other things that you're able to, I've always had this curiosity about certain

skin issues like psoriasis, like exima, what 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 a great question. There are absolutism of trying to say that there is no association with stuff is not where I'm at. There is definitely a gut access. There is a mental health aspect that is associated. And I think they actually play off each other. People that are itchy, they make their itch. Honestly, I feel like can drive people mad. Again, you're itchy. You get a bug

or exima. In your 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, and some of it's inflammatory, right? You know, we know that psoriasis, technically, is an autoimmune process. You have a overperliftative condition if we're just looking at the skin. This is not breaking down tissue. It's causing excess growth to cause plaques that are thickened on the skin. When you look at psoriotic arthritis, so that's essentially looking at that disease

and psoriasis, some people get arthritis with it. Other people do not, but when you have psoriotic

“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 psoriasis, you can look at certain inflammatory markers to assess what is their level of inflammation as it elevated or not. Once they're about 10% body psoriasis, 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 there's the seven drugs, turn on your TV, which I really don't watch, but turn on and look at

they're just numerous drugs that work, and good thing is it actually works. A lot of the, a lot of the drugs that we have psoriasis, psoriasis, are exceptionally good, and they're low risk, which is great. Examine a little bit different. We have good drugs for atopic dermatitis, much better than what we had 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, and nothing with pharma. I prescribe things that work for

people. I've had quite a few pretty highly intelligent guests when here, but they'll come on and say, oh, this cure psoriasis and this does this, and I've yet to really see that come to fruition, and that's why I ask 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 in what I don't,

even though in my severe, it's more frowned upon to get behind stuff like that. I am a realist.

“Yeah, which is good. I think that you should have that, I think 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, which when you look at evidence for interventions, and you look at studies that remove, say they peel off the epidemiology component. Well, 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 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. But ultimately, you want to do stuff that is safe, and you want to take care of yourself. Yeah, 100%. I got fascinated with psoriasis. One of 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 about it, and learning that, because I didn't even really know what it was at the time, 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? So there is a kind of a bimal distribution with psoriasis, but I definitely would say I see it more, you know, 35, 40 years old, 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, already, habits, 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're psoriasis, maybe they have just a teeny little pink spot on their skin. They don't even think anything on it. But then they become overweight, drink access, alcohol, smoke cigarettes, and boom, they're coming to the dermatologist. I got this itchyness in my scalp, or I'm getting these sick bumps on the back of my arms, and they were, they already

had it, but they're, they're, their metabolic health was under good control. 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, go zampic and, you know, looking at some agglutide, trezzepatide, these GLP medications, well, what have I seen in my own culverts of patients who are on those? Not me prescribing them,

you know, which is awesome. You know, I'm happy for them along the way. Yeah. So, so there is

association with that. Okay. So, when it comes to like acne issues, yeah, is that a hormonal

“problem, or what is a general cause there? So, hormones absolutely play a role, right? So, that's why”

when you look at like pre-puberty, if a, if a child comes in before puberty, before they say, if women starts having their men's disease, right? You, you 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, those oil glands become activated or grow with endrogens and your body, so things like testosterone. And so, that 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 build up that direct. 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, something greasy or potato chips, you're going to

“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 more muscle, so there are very few things

that are going to impact that level. So, yeah, for me, I don't really, you know, I try to recommend just clean eating with, for with my patients. Is acting more of a prevalent problem for younger people than it is older people? It is, but I definitely have, I mean, I have a 86-year-old on acutine. You know, I've multiple older 80-year-olds on, uh, I so try to know. And at that point in time, it's not technically, uh, acne is what we call rhino-feminist rosatia, which is, you know,

look at rosatia, it's kind of a sibling of what acne is. Uh, and acutine-riys are trying to

notice unbelievably helpful for it. And these patients, they never want to go off of it.

Because they, if you look at, look at rhino-fima and look at what the nose looks like, it is not, it is not something you would want to have. So, if we could treat it, you want to treat it. So, you mentioned acutine. I spoke to you about that a little bit when we talked. So, I would like to just ask you, what is acutine? And is it dangerous? Obviously, people, if you miss using anything and do it in the wrong way, it's going to be dangerous. But what are you

notice with side effects? Why is on that? Because I've, I've seen some people have issues with it, but I also don't know how they're using it. Yeah. So, uh, I so try to know in, which is the actual drug, which is the brand is acutine. Yeah. Is a oral derivative of a vitamin A, right? So, it's a vitamin A derivative medication, uh, that works at the sebaceous gland in it causes those sebaceous glands, which are in their hormone responsive, uh, to shrink. And it causes some of them to actually

inbaloo and go away. As a dermatologist, it is one of the best drugs that you could possibly have for acne. And, you know, I can't imagine that not being universal among dermatologists. 99 out of 100 would tell you that 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?”

So, they're going through puberty. Unfortunately, I've, you know, 11 and 13 year old, and I, kids are me, man. You know, unfortunately. And, you know, some kids are, you know, some kids are blessed. They have very few pimples and some kids are not. And you can, unfortunately, be such social pressures. They are very heavily impacted by how they look and what people say and do. And you can help reduce, uh, their acne and also reduce scarring with, to me, essentially,

no risk excluding the biggest risk with the acutane, the disclaimer, uh, pregnancy. We know it causes birth defects. That is a, uh, guarantee, and that is why the medicine is regulated extensively, because it will cause a birth defect, extremely important, excluding that. So, 30 days post acutane. So, like, tell my patients as females. 30 days post acutane. You want to have kids, say 27 year old, it's, there's no risk, no issue associated with it. Completely okay. But when

you're on the medicine and with the 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. But other in that,

lip balm, have a humidifier in your house, reduce the side effects that are associated with it,

“which are really sunsensivity and dryness or the two biggest things. It is very easy. So,”

if you were to talk to my patients, so, unfortunately, HIPAA cannot, but I'm sure they would actually line up and say, they would recommend it. Yeah. Because it works so well. Uh, and once you know how to utilize 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 rate questions. Yeah. A lot of people that will say the 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 like, 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 am hearing in society, right? So, from my patient population, I'm 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 were worried about, you know, oxy-benzone as one of the, one of the common ones that I hear daily. Like I say away from that, that's kind of 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 is absorbed into the skin, but something being absorbed does not mean it's going to cause harm. And I think that people need to be aware of that in general. It's like, we are concerned about chemicals 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 two hydrogen monides and one oxygen monides. And it is technically water can be harmful during too much of it right away, right? And you can actually die from that. But the studies that we have when it comes to actual chemical-based sunscreens that are currently on the market, okay? The, the amount of volume that you would have to utilize day and day out for not just our lifetime, meaning, you know, what is the average human

live? 80 years if we're lucky. But if you get to be a centenary 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 like at the endocrine disruptors

“of a rat uterus. And that's how they get, well, we know this is an occurring disruptor.”

Well, for potentially that to occur, you're looking at 130 years, 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 of literature comes out and shows me, hey, this is potentially harmful. I will, I will, I would like to have the chance to pivot and tell people don't use that. 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 parents, they don't want to 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, beam, beam of tricinol, which has been around for 26 years. In Europe, in Korea, we have very good safety profiles. It blocks, it's a photo-sable sunscreen. It has a large molecular weight, so over 500 Dalton, so the absorption is low into the skin. And it is actually

the first chemical-based sunscreen that is recognized, Grace won, 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 want to say it 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

That doesn't mean you need sunscreen on every day. You know, you may not need to.

You know, 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 want to get burnt ever again when I go to the beach or if I'm

“out and I put that shit on. You should. Yeah. 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 skin cancer. Well, how much did they actually use? You know, you can use a two-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”

of the sun exposure, it's a shot glass. It's an ounce of sunscreen. Yeah. People don't utilize that. Oh, I slather that on when I go to the beach. I got burnt too many times. Like, yeah. So you know, 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. Oh, man, I'd be happy to come on.”

You have been phenomenal. I mean, just everything and how quick the answers are. I can always

tell what 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 a what an asset to the community you are. I'm I'm really glad that I got to meet you, man. I appreciate. Thank you for having me on. Absolutely. Well, where can people follow you and then the, I mean, your clinics in Tucson, right? If somebody wants to actually see you in person.

Yeah. So Tucson Arizona, but Instagram is, I mean, I'm on all the outlets. It's just my name, Michael Underscore, Christopher Underscore, 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 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 Mortacom, Dylan Jamelli. Sign it off.