Think it’s just a freckle? Maybe, but it could be cancer

In the course of examining airmen for FAA medical certificates, aeromedical examiners sometimes see skin lesions of various kinds. Most are inconsequential, but we sometimes find cancerous growths. Any time the word “cancer” comes up, it is a scary situation.

The cancerous lesions we see most frequently are basal cell carcinomas and squamous cell carcinomas. Both are topical skin cancers, developed from repeated exposure to the sun and other causes. They are usually slow to develop and fairly slow growing. Other than through direct extension — growing to the surrounding structures — they are not too dangerous.

The scariest lesion we see is the malignant melanoma. They are seen less often, but they do pop up. Unlike basal cell carcinomas and squamous cell carcinomas, which only spread superficially in the skin, malignant melanomas can metastasize to remote sites, including the brain. They range from light brown to black. Because of the color variation, it is difficult to diagnose malignant melanomas visually; often the best way to identify them accurately is by lab analysis of a biopsy.

One interesting case involved an airman who flew for a major airline. During the course of his examination, I notice a spot on his forehead, about the size of a button on top of a retractable ink pen. When asked, he said it had been there since he was a child, and had been described by other doctors as a “freckle.” I thought it might be more than that — it looked a little darker than an ordinary freckle. I asked him to consult with his physician, since I was not on his insurance plan, and suggested he have it removed.

Six months later, on his return to my office, I noticed nothing had been done and again asked about it. I told him we could remove it in my office — it would not take very long, probably an extra 20 minutes, and at most require probably one or two stitches. He declined, stating that he would go back to his family physician or maybe consult a dermatologist.

A couple of months later, I received a phone call from the airman. He had returned to his family physician, and told him of my concern about the “freckle.” Feeling uncomfortable over the possibility that he had missed a diagnosis, the doctor sent the airman to a dermatologist who, again, suggested it might be just a minor discoloration, most likely a freckle. However, because of my insistence, he removed it and sent it to a lab for analysis. It turned out to be a malignant melanoma. When the results came back, the dermatologist called the airman back in. He removed an additional inch border around the site. That necessitated a skin transplant to cover the hole that was left. It was initially a little disfiguring, but later turned out okay.

The FAA has rules regarding malignant melanomas based on their thickness. Depending on the treatment, there may be periods during which the airman will be without a medical, followed by a short observation period afterwards.

If you have any skin discolorations, no matter how minor and how long you have had them, show them to your family physician for a careful diagnosis. And remember, malignant melanomas can fool a doctor. The safest approach is to ask for a biopsy.

Dr. Guy Baldwin is a family physician and Senior Aviation Medical Examiner in Tulsa, Okla. A member of the EAA Aeromedical Council, he has more than 4,000 hours. He owns a Harvard T-6, a Cessna 210 and an Extra 300, in which he flies in airshows and aerobatic contests. He can be reached at 918-437-4993.