VIEWS: 231 PAGES: 39


                  Dr F Bhatti
                  Pennine VTS
                  Sept ‘08

 GPNotebook

 Dermnet

 Atlas of Dermatology

 eMedicine
       Benign Conditions

. Ephelide
.   Melanotic Naevi
.   Granuloma Telangiectaticum
.   Haemangioma of skin
.   Dermatofibroma
.   Papilloma
.   Seborrhoeic Keratosis
.   Squamous Cell Papilloma
.   Warts
Premalignant Conditions

   Bowen’s Disease
   Keratoacanthoma
   Marjolin’s Ulcer
   Paget’s disease of the Nipple
   Senile Keratosis
Malignant Conditions

   Basal cell Carcinoma
   Squamous cell Carcinoma
   Malignant Melanoma
   Mycosis Fungoides
   Kaposi’s Sarcoma
Basal Cell Carcinoma
   Locally invasive carcinoma of the basal layer of the
    epidermis. It almost never metastasizes but it may kill by
    local invasion

   Commonest skin cancer

   Middle aged or elderly, related to sunlight exposure, fair
    skinned people, M:F approximately 2:1

   Lesions occur in exposed areas of the skin (75% occur in
    the head and neck)‫‏‬

   Gorlin's syndrome. Patients with this condition appear to
    have a great tendency to develop basal cell epitheliomata
ed.. BCC

      Common sites are in normal and sun damaged skin on
       the face, in a region above a line drawn between the
       corner of the mouth and the lobe of the ear

      The initial lesion is a small pearly-white nodule with
       visible (telangiectatic) blood vessels; early lesions may
       bleed and ulcerate and then heal again

      Red nodule forms which expands to leave a
       characteristic rolled edge with central ulceration
       ('rodent ulcer')

      30% multiple, invasion is usually local. Metastasis is
       rare - metastatic rate is 0.0028%
 Clinical subtypes

1.Nodular BCC
   Most common type on the face
   Small, shiny, skin coloured or pinkish
   Blood vessels cross its surface
   May have a central ulcer so its edges
    appear rolled
   Often bleeds spontaneously then seem
    to heal over
   Cystic BCC is soft, with jelly-like
   Rodent ulcer is an open sore
   Micronodular and microcystic types may
    infiltrate deeply
2.Superficial BCC
   Often multiple
   Upper trunk and shoulders, or anywhere
   Pink or red scaly irregular plaques
   Slowly grow over months or years
   Bleed or ulcerate easily
    Continued …BCC

3. Morphoeic BCC
   Also known as sclerosing BCC
   Usually found in mid-facial sites
   Skin-coloured, waxy, scar-like
   Prone to recur after treatment
   May infiltrate cutaneous nerves (perineural spread)

4. Pigmented BCC
    Brown, blue or greyish lesion
    Nodular or superficial histology
    May resemble melanoma

5. Basisquamous BCC
    Mixed basal cell carcinoma (BCC) and squamous
     cell carcinoma (SCC)
    Potentially more aggressive than other forms of
Differential diagnoses
Nodular BCC                      Pigmented BCC
.   Fibrous papule               . Malignanat Melanoma
.   Naevus                       . Pigmented Seborrhoeic
.   Seborrhoeic keratosis             keratosis
.   Amelanotic melanoma          . Traumatised naevus

Superficial BCC                  Morpheaform BCC
.   Nummular eczema              . Scar
.   Psoriasis                    . Localised scleroderma
.   Extramammary Paget Disease
.   Bowen’s Disease
Basal Cell Carcinoma
More BCC
High Risk BCC
   They have a high recurrence rate after treatment.
   Histological sub-type / features
   Sites – Head & Neck area.
   Size – greater than 2 cm.
   Immunosuppressant.
   Genetic disorders e.g.Gorlin’s Syndrome.

Low-Risk BCC
   Size – Less than 2 cm.
   Site – Torso, Limbs.

   Surgery, Local Radiotherapy, Cryotherapy, or Curretage.
   Up to 85% superficial BCCs are cured by Photodynamic
    therapy, with excellent cosmetic results. It is less successful
    for other types
   Curettage and cautery with histology is only adequate for
    small lesions.
   Systemic chemotherapy is ineffective, though topical 5-
    Fluorouracil cream may be helpful, particularly for multiple
   Imiquimod cream . The cream is applied to superficial BCCs
    three to five times each week, for 6 to 16 weeks. results in
    an inflammatory reaction, maximal at three weeks. Up to
    85% of suitable BCCs disappear, with minimal scarring.
   Recurrence is common (0.15 - 15%)‫‏‬
        Squamous Cell Carcinoma

Malignant tumour of the epidermis in which the cells, if differentiated, show keratin
formation. Invasive SCC refers to cancer cells that have grown into the dermis.

Associated with:

. Excessive sunlight exposure and pre-existing solar keratosis

. Exposure to chemical carcinogens such as coal tar products

. Chronic irritation/ inflammation (Marjolin's ulcer)e.g. margins of
                          osteomyelitic sinuses/ long-standing ulcers

. Patients with immunosuppression e.g.Renal transplant patients

. Genetic predisposition e.g. Xeroderma Pigmentosum , Albinism

. Pre-malignant conditions e.g. Bowen's disease, Leukoplakia

Rare in patients under 60 years of age unless immunosuppressed

Men - scalp and ears                     Women - lower legs
          Both sexes - back of hands, face
    Continued …SCC

Differential Diagnosis

       Basal cell carcinoma
       Keratocanthoma
       Malignant melanoma
       Solar keratosis
       Pyogenic granuloma
       Infected seborrheic wart

Clinical features

       Rapidly expanding painless, ulcerated nodule rolled indurated margin. May
        have a cauliflower-like appearance with areas of bleeding, ulceration or serous
       About 55% of lesions occur in the head and neck region. About 25% of lesions
        occur on the hands and arms.
       Metastasis may occur via local draining lymph nodes and beyond.
Contd… SCC

   . 5% of SCCs metastasise.

   . More likely if the original SCC was on the lip or ear; or if it was
   large, deeply invading or involving nerve fibres (perineural spread).

   . 80% of cases, the metastases develop in the nearest lymph glands.

   . Metastases are more difficult to treat than the original skin lesion.
   Increased risk if the immune system is functioning poorly e.g.
                Organ transplantation
                CLL
                Alcoholism
                Multiple skin cancers
                Genetic defect in skin repair e.g., xeroderma pigmentosum
SCC of different types/Sites

When confined to the epithelium is called SCC in situ ,Intraepidermal SCC or
    Bowen’s disease.
SCC in situ of mucosal surfaces includes:
   Oral leukoplakia
   Vulval intraepithelial neoplasia
   Penile intraepithelial neoplasia
   Bowenoid papulosis
There are some special types of invasive SCC of the skin:
   Keratoacanthoma (pseudocancer)– a rapidly growing keratinising skin
    nodule that may resolve without treatment. BUT appearances can be
    deceptive so still refer… unless you’re a dermatologist.
   Carcinoma cuniculatum (‘verrucous carcinoma’), a slowly-growing warty
    tumour found on the sole of the foot

    Invasive SCC types/sites include
   Vulval SCC
   Oral SCC
Bowen’s Disease
Pigmented SCC
Other SCC

            Oral SCC-

        Superficial BCC

. Depends upon size, location, number to be treated & the preference of the doctor

. Established lesions
          .Physical treatment e.g. cryotherapy, curettage, local excision
          .Topical treatment options include:
                               . Topical Cytotoxic preparations (e.g. 5-fluorouracil),
                               . Topical Retinoids
                               . Salicylic acid in Emulsifying Ointment
                               . Topical Diclofenac Gel (this is licensed for Rx of Actinic
                                 Keratosis in UK)
                               . Imiquimod 5% cream used 3 times per week for 16
                                 weeks is an effective treatment for Actinic Keratoses
                               . Systemic treatment may be given for extensive or
                                 resistant lesions e.g. Systemic Retinoids
 . Screening - for other skin lesions more common in patients with marked sunshine
     exposure e.g. SCC, BCC,Melanomas
• Urgent referral if :

  . Histological Diagnosis of SCC
  . With non-healing keratinizing or crusted tumours larger than 1 cm with
  significant induration on palpation. They are commonly found on the
  face, scalp or back of the hand with a documented expansion over 8
  . Who have had an organ transplant and develop new or growing
  cutaneous lesions as squamous cell carcinoma is common with
  immunosuppression but may be atypical and aggressive

  **Use the 7-point weighted checklist for assessment of pigmented skin
  **There is controversy about Actinic Keratosis; whether its a premalignant
  condition or early SCC. In a study of 459 patients with cutaneous SCC, there
  were associated adjacent actinic keratoses in 97%. Reported rate of
  progression to invasive SCC varies but accepted as around 1 in 1000**
                       Malignant Melanoma

   Malignant tumour of epidermal melanocytes.Accounts for less than 1% of all
   Non-pigmented skin , exposed to excessive sunlight, especially if sunburn
   Spread occurs via superficial lymphatics to give satellite lesions, to regional
    lymph nodes via deep lymphatics, and via haematogenous spread to the lung,
    liver and brain. Haematogenous spread usually follows lymphatic.
   Range of colours and uniformity, often may bleed and ulcerate. It may cause
    pigmented lesions in the mouth.
   Malignant melanomas undergo two growth phases - radial and vertical. Vertical
    invasion is a poor prognostic sign.
   Different types :
        .   Superficial spreading (48%)
        .   Nodular (23%)
        .   Lentigo maligna (15%)
        .   Acral lentiginous including periungual (6%)
        . Amelanotic melanoma
Contd…Melanoma Types
Those that start off as flat patches (i.e. have a horizontal growth phase)
 Superficial spreading melanoma (SSM)
 Lentigo maligna melanoma (sun damaged skin of face, scalp and neck)
 Acral lentiginous melanoma (on soles of feet, palms of hands or under
    the nails – the subungual melanoma)
    They tend to grow slowly, but at any time, they may begin to thicken
    up or develop a nodule (i.e. progress to a vertical growth phase).

Melanomas that quickly involve deeper tissues include:
 Nodular melanoma (presenting as a rapidly enlarging lump)
 Mucosal melanoma (arising on lips, eyelids, vulva, penis, anus)
 Desmoplastic melanoma (fibrous tumour with a tendency to grow
    down nerves)
Combinations may arise e.g. nodular melanoma arising within a superficial
    spreading melanoma.
 Malignant Melanoma features:

Size:                . most malignant melanomas are greater than 10mm in diameter
                     . most benign tumours are less than 6mm
Symmetry:            . malignant lesions are usually asymmetrical with respect to cell
                       type, extension and degree of pigmentation

Dermoscopy:      Handheld device, relatively new technique, visualisation through stratum

       Without Dermoscopy
       resembles Seborrheic Keratoses

       With a Dermoscope, branched streaks
       at the edge of the and white areas within are
       visible, which suggests
       melanoma. A biopsy confirmed
       the lesion was melanoma
Superficial spreading melanoma

Typical SSMM

SSMM with

Amelanotic Melanoma
Lentigo Maligna Melanoma
sun damaged skin of face, scalp and neck

                                           Lentigo maligna melanoma

     Nodular melanoma in
     lentigo maligna

                                               Lentigo maligna
Acral lentiginous melanoma
Nodular melanoma

            amelanotic nodular melanoma
Differential Diagnosis (MM)

   Benign Naevi
   Dermatofibroma
   Pigmented Basal Cell Carcinoma
   Pyogenic Granuloma
   Kaposi's Sarcoma
   Vascular malformations
 Seborrhoeic Keratosis

   Surgery depends on the thickness of the melanoma and its site.
    Most thin melanomas do not need extensive surgery

   For thicker melanomas (those over 1 mm or so in depth), a much
    wider area of skin is cut out. Draining lymph node biopsies may also
    be needed.

Prognosis :

    Death is unlikely if a melanoma has a Breslow depth of less than one
    millimetre (T1). About half the patients are dead within 5 years if
    their melanoma is more than 4 mm thick (T4).
Moral of the story:

. Do an ABCDE/ 7 points assessment

. Appearances can be deceptive so if in
   doubt ask someone

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