Basal Cell Carcinoma - a doctor's self report

I squeezed the 'pimple' on my face a couple of times and just blood came out. I picked the scab. It was hard not to pick at it.  For a couple of weeks I used antibiotic cream but nothing changed.  It seemed a mm or two bigger.  A month went by.  I was going for dinner with  a friend who is a great family physician. I did the thing doctors hate people to do.  I'm a doctor. I know how rude this is.  But I did it anyway. I'd made my own diagnosis.  I wouldn't want anyone to know I was scared but I was 'uneasy'.
"What do you think this is?" I asked.  He was concerned.  Only the coffee and bread had arrived at our table.  Chez Michel, the fashionable Parisian West Vancouver restaurant.  Only a couple of tables taken this early in the evening. No one close by.  Beautiful view of English Bay.  Daylight savings. The sun still bright outside.
"Stand up and let me look at that  in the light." Skin is best viewed in bright sunlight.  I moved so he could position my head. He's taller than me.  A big man.  A doctor who served the far north for years in his youth.  A doctor's doctor. His practice as full of the rich and famous as well as the common man.  He doesn't differentiate when it comes to people. "All God's children'.  he says.
"It looks like basal cell cancer." he said finally as we sat down to eat our rolls.
"That's what I thought." I answered.
"It's hard to be certain." he said.  "It's raised with the typical edge."  We talked some more about what to do. Matter of fact.  We're friends. Both doctors. He could see I was concerned.  I could see he was concerned. I didn't want to worry him more than necessary.
"Aldara" is a new antineoplastic cream. You could try that.  Can cure basal cell carcinoma by enhancing your own immune response."  he told me. I'd not heard of this.  But that night on the way home from the meeting we'd attended together I drove to an all night pharmacy and got some. $400 for 23 treatments. I've not got extra health care coverage.  Self employed I pay for everything myself.  If I'm sick no money is coming in.  Worse these days, there's  no one  left to cover my practice.   I know the constant daily stress is getting to me.  My fingers were shaking when I put the first dab of cream on my face.
The first appointment with a Canadian dermatologist was given as 3 months away.  I thought the cancer could have entered my brain by then or I'd be psychotic.  Without the cream I'd not have slept thinking about this foreign alien thing gnawing up my face.  Basal Cell is also called 'rodent cancer'. That day I asked a couple of doctors I worked with what they thought.  As doctors we all like looking at physical disease. Improves our skills of recognition. Besides they'd been looking at me already discretely wondering what that thing was on my face.  They too thought it was basal cell carcinoma too. Can't be sure. Need to see a dermatologist. I'm clinging to a thread now that it's just a bad blemish.  My friend phones a good old boy and he'll see me the next week. There's a cancellation.  We phone back the first dermatologist and cancel the original appointment.
I suspect I'll survive. But I'm prone as anyone to catastrophise. Sometimes looking in the mirror I consider fascial mutilation of the cancer itself or the possible surgery. Surgery is usually the answer. . Other times I think of the rare case of metastases. They're not supposed to but I imagine myself the exception that proves the rule.  
Mostly I hope it's not that but now I'm sick with the flu like symptons the Aldara can cause.  It's a minor concern but I don't feel well. I go to work and care for others but I don't have a whole lot of hope myself.  It seems too that in the Canadian culture the sick are brutalized and  marginalized. Show weakness and this society hits you harder where it hurts. Canada is a culture that caters to the rich. I'm thankful that I can afford Aldara.
"Have you had that looked at? Doctor?" a patient points at my face.  "Oh yes, it's taken care of .  Just a little infection,  I'm putting cream on it."   I can't say Cancer. It's not Cancer. It's not the big "C" word.   It's not the modern leprosy.  People still back away from people with cancer despite all the education and science we know today.
I think how I used to work on television. I have to confront my own vanity.  I think what's important about a face. I wonder how much money my fairly okay face till today has made me.  I've felt sorry for those born with deformity.  Genetic deformity diseases and now I'm going to have an Acquired deformity disease.I think of Leonard Cohen's song,  with the words, "I want a new face, one not covered up in shame and pain".  Something like that.
 I imagine a hole in my face. I don't want anyone to know but then I tell my patients its best to share.  We live in walls here frightened of the advantage people take of the sick and suffering. Only the psychopaths and sociopaths seem to thrive. It's all about corporate economics today.  The sick are less valuable. The beaurocratic "in" words are abortion and euthanasia.  Doctors committed to healing are marginalized.   I'm becoming cynical with fear.  I have to pray more. As the Third Day song goes, "There's a light at the end of the tunnel."
"Did you not wear sunscreen?" a friend asks.  I tell him yes.  I'm fair skinned , a sailor and an out doors man.  And I've always worn sunscreen. But the question is like one that Job in the Bible was  asked by his friends.   I reply  " Personally I think I've got cancer because I masturbated."   We both laugh.  He's Catholic so he knows that is the root of all evil.  
My nurse friend says I should look on the bright side, "Maybe you can get a face lift thrown in."  I imagine myself with half a face lift, all the Canadian health care would provide. I'm the old geaser then in the nursing home with half a turkey neck.
It's silly. I'm not thinking very sanely.  I wall the thoughts off during the day enjoying the distraction of routine but at night I'm alone with my fears.  I wake from sleep seeing the pictures I've seen in textbooks and the faces of patients I've seen working overseas.  The time moves slowly.  I am a patient. Patients must have patience.
It's nothing really.  Just a little lesion.  I'll be okay.  I'm thankful for Aldara.  Even if it were just a placebo I apply it religiously and think it's working. It's keeping me sane at least till I see the dermatologist.
In Bellingham USA a dermatologist will see you next day for $150.  It's a small price to pay but then if I cross the border as a patient I couldn't return here as a doctor in good faith.
I pray more.   Anxiety is a measure of one's distance from God. Cancer is that which you can say in no other way.  My family physician friend is a poet. Maybe his dermatologist friend will have a way with words.

Crack Cocaine "Sores"

Dermatological problems are common with crack cocaine users. At first I just thought the countless sores and cellulitis I was seeing among my patients was standard dermatitis.  Not so.  Crack cocaine causes 'ischemia' by vasoconstriction.  When I did emergency medicine work and was faced with severe nose bleeds I used cocaine on a medical q tip to dab the inner lining of the nasal pasages high up to induce vasoconstriction and stop the bleed.  Inhaling crack cocaine delivers the drug into the body and vasoconstriction occurs in the small vessels. On the skin vasoconstriction results in ischemia and 'infarct' beyond the point of blood stoppage. The tissue is deprived of oxygen and dies in small patches.  Similar small infarcts can be seen in muscles.  Even bigger infarcts can be seen when a person injects cocaine into the muscle and the surrounding tissue becomes ischemic and infarcts.  I imagine this process would occur in organs too but would need to do more research of pathology to confirm this.
The result is that crack cocaine use appears frequently with 'sores.  I mostly see this on the face because that is what is most commonly exposed to me.  Muscles of the neck, arms and buttocks  may be dappled and dinted from the retraction with scarring under the skin.  Further 'abscesses' are frequent.  The  increased inflammation and subsequent abscesses are a consequence of secondary bacterial infection.  It can actually lead to an early gangrenous process.  So much depends on the immune system's capacity to handle the horrendous insults.
Doxycycline 100 mg od or bid for 10 days is an oral medication that addresses the secondary infection of the skin. Fucidin Cream bid or tid (2x or 3x/day) for a week or two is a topical treatment affective for individual lesions (sores).  These medications certainly expedite the healing of the injuries.  The solution, of course, is abstinence but harm reduction is better than nothing for the person who is a slave to the drug dealer and the politics and religion of drug addiction.