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

0:00I find between 150 and 250 melanomas a year, the average dermatologist in Arizona finds around 20 a year. Of the roughly 8 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. Yes, 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%. What are some of those? Your biology may not be the same in your 40s as it was in your 20s, but your standards and goals can be even bigger. We're at a time where we have more tools and methods to not just live longer, but also healthier with better results as we age. Aging is no longer viewed as a decline. It's about optimization and time efficiency. Training smarter and more efficient is a new standard, and we now know how to get more from the workouts we are already doing. Now, chances are your supplement stack

1:01is missing a much healthier foundation. So enhance it with mydapeer, a targeted supplement that revitalizes your mitochondria, the powerhouse of your cells. Myda-chondria are crucial to overall health, not just energy production. Protein builds muscle, creatine supports power, mydapeer helps support the cellular engines that power both. When your cells thrive, everything follows. So claim your free aging muscle protocol guide and free sample of mydapeer gummies from timeline at timeline.com slash Dylan. 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 Dillinger Mellie 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

2:03and 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 give everybody the best knowledge possible. So my guest today is a board-certified dermatologist and expert dermatocapist 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.

3:04So 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 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. 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 Bortert-Fighter metologist or say an MP or PA

4:06and you get a skin exam when they're looking over your skin, they shouldn't be just doing a 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 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 Bortert-Fighter metologist, that that is normal. The only way that we can tell that is 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 immortality 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. So if there's that large of a gap,

5:06you 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 here in Aikonai. 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.

6:08Because 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. 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 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

7:10naked 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 time to just make sure it's fine. But it can show me the network that is present within it. And if that is irregular or irregular, it can show me angiogenic structures. So structures of blood vessels and signs that there is a increased vascular 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 a completely normal mole. Okay. So it's like, it's almost like an x-ray vision tool, so to speak. Correct, right? It's a secondary imaging to where,

8:11think about it like this. You get an x-ray, say you come and get your knee injury, your knees sore, maybe you feel like you tore your ACL. You go get an x-ray of it. That x-ray is actually not going to show you your ACL. Bees that can't see it. And that is kind of what we 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 ACL tear, well, the x-ray is not going to show you if the ACL is torn. You need an MRI, right? An 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

9:13here. 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 that I've noticed on myself was 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,

10:15they all kind of look the same. I know that doesn't mean anything. How did what causes that to happen is it something that 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. 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. Two weeks straight, have three and a half four hour layouts. That's when I noticed what about tanning, like in a tanning bed. Terrible. Yeah. So tanning beds are actually UVA, right? So when you're looking at getting sunlight, you're looking at obviously all spectrums, visible infrared. UVC is actually thankfully filtered out. It's extremely toxic. But UVA is what

11:22you'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. 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. You know, like teenage years. How much? Oh, I don't know, two or three times a week for a while. Then I owned a bed in Vegas. I didn't. It's funny. I owned it. I used it less than when I had a membership somewhere. I 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. Yeah. Absolutely. And in particular, tanning beds were, you know, you're large into fitness and health. Yeah. It is heavily, you know, people tan like crazy. Because

12:26they 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 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 for 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 the 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

13:29red light therapy. So if you're using it and I actually use it 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 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 is heavily associated

14:35with melanoma tumor genesis looking at basal solid 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 than tens of it is more and it is more toxic. Now as a dermatologist, you know, getting any dose of UV because UV ultraviolet radiation is a class one 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 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 less than two. But as soon as UV index is above two, based on my Fitzpatrick skin type means to color my skin, I'm a Fitzpatrick two. I absolutely make sure that I have sunscreen. Not only is that important

15:39blocking 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's just something that's measured that you can look up online or 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 I'll show you say 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 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. Okay. And you're looking at that all year long. Right. So it's all the closer to the equator,

16:40the 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 have looked at this. The data is not great. Really? Yeah. So I but there are 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 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 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 a sun daily. Let's not go crazy. Let's get what we need though and not be frightened about 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 a sun, we're in Phoenix right now. Yeah. So in Phoenix, if you're getting 10 to 15 minutes a sun and the UV index is a 10 based on your Fitzpatrick skin type,

17:42you'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 yourself and you can measure that. When we get excess UV, it causes cyclo butane-perimating 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 carcinoma, squamous 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 right or it so depends. So that that depends on the time of year. Right. So in for instance, in Tucson, which is where I live and 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 830 in the morning, the UV index is already three. And I said to myself, it's only, you know, it's spring. Yeah. That's

18:42early and it's already above that point. And the UV index was five until after five 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 your weather app. So does temperature play a role then in that? No, no. No. No. 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 three weeks ago. And I like to go for walks in the morning. And Phoenix, now I do treadmill walks in the morning.

19:45It's too damn hot because I don't start till 10. Yeah. 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 instance what? You know, just imagine. Yeah, just instant. And so I'm wondering since it's as close to the equator by the ocean than 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 two-minute trip, it's now 30 minutes outdoors and they burn. So it's the the unintended sun exposure

20:46that 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. 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 engaging 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, 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 going to release nitrous oxide to like sauna. So you

21:47don'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 a 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 resparatrol and we'll just take resparatrol 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 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

22:52body 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%. What are some of those? Yeah. They're genetically related. So there's germline mutations. When you ask me about the moles, right? How many moles somebody has? Do you know? Well, we know, for instance, if you have a set number of dysplacic nearby or harbor dysplacic nevac syndrome, those individuals without UV exposure are just they harbor an increased risk of developing a melanoma because they develop excess moles or

23:54already are 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 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 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 2A mutation. That mutation increases your risk of getting melanoma without sun exposure. But the UV radiation and itself can propagate that as well. Okay. Wow. Is there any other ways or those the two ways? Spontaneous and sporadic, right? So unfortunately, things just occur. Right. So when you look at melanoma that it occurs on the underside of your foot. So on the bottom of the foot, a lot of that is sporadic, spontaneous.

24:57And unfortunately, those are not. We can tell you the genetics in the melanoma itself. And we can tell you, do they harbor this class seven 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? It's all, I mean, well, because some people are modest in their, you know, to me, it's all when you're a physician, it is all, it's looking at general 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 get lost there with people. I get it, I guess, to an extent, but

26:00not when you get older, man. I know. Monocity is gone. And it really, it should not be there when you are 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 just spontaneously occur. 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 dermoscopycer. 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 cut it off.

27:04You 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 AJCC, you know, they'll give you, you know, what the five year of survival rate is. And it's like 98 to 99%. But there's a lot of people that are diagnosed with the 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 as early as possible, you shouldn't worry about it, right? 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 later stages, you say it has traveled to the lymph node on its stage, even three, eight micro deposits. That ratio of either you're good, nothing, right? You're 100% survivorship

28:12or 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 that 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 meet 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 A. That means you have a micro deposit in the lymph node. You would have no symptoms. 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 we are, there are tools that are looking at that. So you're looking at circulating tumor DNA in your blood

29:13to assess to see say somebody had a melanoma. It would have to be already past the top layer of that pydarmus at stage zero. 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. How long can one sit there in stage zero? Could it sit there for a long time? We don't know. We could. Absolutely. I'm sure that there are some that do that. But if I could tell you that, I would be a trillion there. And I look, I hope somebody does trigger that out because then we can say, hey, we know definitively that this is okay. Because there are some dermatologists who actually believe that. They think, it's an early stage 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. When we do, I will support it. One caveat. It is very easy. Now this is a scarmer. I'm not from a

30:17melanoma. It was a severely dysplastic mole. Having a small 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. This is recent. Yeah. And so you'll look at, you'll look at 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, shit, it peeled 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

31:18would 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? Is it happening every week? 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're, they look like normal little bumps on the skin. And it's a basal cell. And something like that, say it's on the nose. It's a small, 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, 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. I mean,

32:23instant. Now, 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 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. 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 does 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 and know it sounds, you know, rudimentary,

33:23the 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 does average? I'm trying to count my wife's and. Yeah, but it's not just moles. It's every sun spot. So every when to go somebody has, I have to look at with the 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 would just going to take long. And that's okay. But look, that's what we 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 too 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

34:24you 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, mostly don't get mammograms, right? It does occur. I mean, men do get breast cancer. Yeah. I actually diagnosed one last year on a person came in that a lump right right underneath the urela did a biopsy with 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 germoscopy, right? I finished my residency in 2019. I had two lectures on germoscopy that have utilized that tool. And even though we utilize it in clinic every day, that does not mean people understand what they are seeing. Yeah. And for me to create the level of expertise I have had, when people talk about how many hours of

35:25work 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 developed, curated, and then instructed very well. I see. And this is one of those things. So I'll relate it to chiropractor. Because I've been in rehab for 20-some odd years from my back. And I found a place that had what's called the cox table, which is very hard 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 of, I'm relating it to this to where it's like that's more of an unknown. It's like, oh, I've got to go get another certification. Or oh, I've got to take time to study this. How much does the tool itself cost?

36:29So this one costs a little under $2,000. Okay. Okay. As a cost and hold. But some of the, you know, lower cost ones are around $500. So 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 ask 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. And then things that are, say, normal, they will buy app, see 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 in the skin. And you need to actually take the tissue sample. Okay. If you get a, what I try to

37:32instruct is if you buy up 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 up see shiny white structures within a pigmented lesion that's popular requires a biopsy comes back as a normal 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. 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 just don't learn it? Yeah. So there are courses, right? So there are multiple courses. You know, I was in Utah in May presenting at their state's meeting. I gave four lectures on it, right? I'll be in Colorado presenting at their annual conference discussing dermoscopy.

38:32So 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 were 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 dermatologist 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. 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 four years of residency. At that time, when you sit for your board examination, around 15, 20% of the questions are pathology,

39:37meaning the what the structures look like underneath this 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, a, a, a dermatopathologist that is reading the slides. So clinically, the dermatopathology training that is required, people don't utilize as much, right? 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. The, 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 applying dermatopathology, we really need to be learning what we were doing every day on the skin in clinic. And that is like learning something procedurally, right? Well, this is a procedural, you know, process at what you're analyzing. We should, that should be still foundational in

40:39dermoscopy 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 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 the like 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

41:42by the, 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 them. They 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 in 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? True. Yeah. I mean, that's the, 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, no matter what, no matter how, what level of achievement people decide to get to, there are going to be people that

42:45are going to do what is standard. Yeah. And that is not wrong. That is what what our 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 and that is life's like I, I firmly believe if everybody was a dermatologist, 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 we use a dermatoscope, right? So they had that hand held 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

43:48needs 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 sub-sector 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, skin, MEIC patients for all the other stuff, you know, acne, psoriasis, atopic dermatitis, or eczema. 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 exam and to make sure that they're okay. I want to utilize a couple other questions since we did so many melanoma 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 eczema. What is it cellular? Is it nerves?

44:56Is it something mental? Is it gut health? What are some of the main culprits that cause these problems? So 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 dry people mad. Like you're itchy, you get a bug bite, it's itching. Imagine your whole body itching, you know, you have a top of dermatitis or eczema and you're scratching your skin constantly. That would drive me nuts. 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 over proliferative condition if we're just looking at the skin. This is not breaking down to you. It's causing excess growth

45:57to 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 as 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 on and look at, they're 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, psoriasis are exceptionally good and they're low risk, which is great. X and Y is 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

47:03work 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 on 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, 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 severe, it's more frowned upon to get behind stuff like that. I'm a realist, right? Which is good. I think that you, 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

48:03you 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, 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. But ultimately, you want to do stuff that is safe. You want to take care of yourself? Yeah, 100%. I got fascinated with Saraias. One of my dad passed away and my mom, you know, obviously had a meltdown and she developed it. So I always, in 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

49:04at the time. Yeah. 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 bimonol distribution with Saraias. But I definitely would say I see it more 35, 40 years old where they start developing it more frequently. And then there are other things that are associated with Saraias, which look at your metabolic health. So obesity, alcohol consumption, smoking, those are all factors for people to develop. They say they're predisposed to 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. While they, their Saraias, this may be 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 access to alcohol, smoke cigarettes, and boom, they're coming to the dermatologist. I got this itchiness in my scalp or I'm getting these sick, you know, bumps on the back of my arms. And they were, they already had it, but they they're, their metabolic health was under good control.

50:09Yeah. 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 ozampic and you know, looking at some of Glutide, Terzepatide, 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 Saraiasis is getting better, you know, which is awesome. You know, I'm happy for them along the way. Yeah. So there is association with that. Okay. So when it comes to like acne issues, 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, when women starts having their men sees, right, you you would consider working up why that individual is getting acne, right? Because when do they start to develop acne when

51:11they're going through puberty, right? You have sebaceous glands, these little oil glands, those oil glands become activated or grow with androgens in 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 because for example, one major side effect with anabolic steroids, a lot of acne build up the rest. Correct. Yeah. What about foods that because 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. You know, think about foods that you can eat that are going to raise your testosterone.

52:14Everybody 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, 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 a 86 year old on acutene. You know, I have multiple older, 80 year olds on, Isochretinoin. And at that point in time, it's not technically acne. It's what we call rhino-fimicous rosacea, which is, you know, look at rosacea, it's kind of a sibling of what acne is. And acutene or Isochretinoin is unbelievably helpful for it. And these patients, they never want to go off of it because they, if you look at, look up rhino-fimic 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 acutene. I spoke to you about that a little bit when we talked. So I would like to just ask you,

53:16what is acutene? 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? Why is on that? Because I've seen some people have issues with it, but I also don't know how they were using it. Yeah. So Isochretinoin, which is the actual drug, which is the brand is acutene. Yeah. Is a oral derivative of a 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 the hormone responsive, to shrink and it causes some of them to actually imbalute and go away. As a dermatologist, it is one of the best drugs that you could possibly have for acne. And I can't not imagine that not being universal amongst dermatologists. 9, 9 out of 100 would tell you it has saved so many patients' scars, reduced their depression. And unfortunately, when a lot of kids get, when a lot of people get acne, teenage years, right? So they're going through

54:21puberty. Unfortunately, I've 11 and 13-year-old and I, kids are mean, man. You know, unfortunately, and some kids are, bless they have very few pimples and 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 acutain, the disclaimer, pregnancy. We know it causes birth effects. That is a guarantee and that is why the medicine is regulated extensively because it will cause a birth effect. Extremely important. Excluding that, so 30 days post acutain, so I tell my patients as females, 30 days post acutain, you want to have kids, and say 27 or only, 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 effect is

55:22real and that's because excess vitamin A will create a birth effect. 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 two 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'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, 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

56:22how 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'm 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 worried about, you know, oxybenzone as one of the common ones that I hear daily, like, you stay away from that. That's going to 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.

57:25We 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-moaties and one oxygen-moat. 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 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 centenary and you're 100, great. None of the studies show that there

58:29would 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 occurndisrupter. 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, I will, I will, I would like to have the chance to pivot and tell people don't use it. And if people say just use mineral sunscreen, I am completely fine with that. The 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 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

59:35blockers, there's a new one. And once again, I don't work for any company, BMatricinol, which has been around for 26 years in Europe and Korea. We have very good safety profiles. It blocks. It's a photo-stable 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 One, 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, getting in trouble, they utilize words to make things seem scarier than they are. They're organic. And my concern is somebody who I see skin cancer every day, I know what UE radiation does. My

1:00:39recommendation is you protect it when you need to. That doesn't mean you need sunscreen on every day. 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 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. I'm glad you do. 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 cancer. Well, how much did they actually use? You can use a two finger rule for your face. So put it, 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 of dabs there. You know, if you look at your body of the, the sun expose areas, 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 burnt too many times. 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

1:01:40ruined. You tend to not do it again. Yeah. So man, this has been so enlightening. I got like seven million more questions for you. We might have to do another dive. 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 what I'm talking to a real pro by how how they answer in the quickness and they don't dance like a politician. And you didn't turn 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 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

1:02:41much. 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 More to come. Dylan Jamelli signing off.