Download If its dry wet it, if its wet dry it Ummm Not always!

If its dry wet it, if its wet dry it Ummm Not always! Alastair Dickson, Jess Gilmour & Tonya de Bique >Ğƚ͛ƐƚĂůŬĂďŽƵƚƐŬŝŶĐĂŶĐĞƌ http://youtu.be/qnp-­‐4AGeXs8 The skin ‡ Epidermis ± Flat squamous cells ‡ Basal cells ± Round cells in epidermis ± Below squamous cells ‡ Melanocytes ± Scattered amongst basal cells ± Reside deepest part of epidermis ‡ Dermis ± Below epidermis ± Multiple types cells + structures ± Include glands, blood + lymph vessels ± Sweat + sebum reach skin surface through pores Types of cancer cells ‡ Pre-­‐cancerous lesions ± Aktinic keratoses ‡ Benign growths ± Non-­‐invasive ± Typically rĞŵŽǀĞĚнĚŽŶ͛ƚƌĞƚƵƌŶ ± viz moles ‡ Malignant ± Maybe threat to life ± Often can be removed but can grow back Common types of skin cancer ‡ Basal cell skin cancer (BCC) ‡ Squamous cell skin cancer (SCC) ‡ Melanoma Frustrated grandparent ‡ Loves the outdoors. Does lots of hiking. ‡ Fed-­‐up with his dry, wrinkly skin. ‡ Now grandchildren questioning why ŚĞ͛ƐŐŽƚŚŽƌŶƐ͍ ‡ Is this normal? ‡ Is it cancerous? ‡ tŚĂƚ͛ƐLJŽƵƌƚŚŽƵŐŚƚƐ͍ ‡ tŚĂƚ͛ƐLJŽƵƌƉůĂŶ͍ ‡ Any suggestions for skin care/prevention? Aktinic keratoses ‡ ͞dŚŝĐŬĞŶĞĚ͕ƐĐĂůLJŐƌŽǁƚŚĐĂƵƐĞĚďLJƐƵŶůŝŐŚƚ͟ ‡ Occur on sun exposed areas of skin ± Esp back hands, face namely nose, cheeks, upper lip, temple + forehead ‡ Multiple flat or thickened, scaly or warty, skin coloured or reddened lesions. ± Can develop into a cutaneous horn ± Cells show characteristic UV-­‐induced gene mutations ‡ Risk factors include sun exposure, tanning booths. ‡ Be suspicious if see signs sun damaged skin ± Dry, discoloured, wrinkled skin ‡ Most lesions do not progress to malignancy but increased risk of SCC Ulcerous dog bite ‡ Retired farmer, from highlands of Scotland ‡ Annoyed with his ulcer. Wants it freezing off. Blames his terrier for biting him after had been chasing rats. ‡ What are your thoughts? ‡ What hx would you take. ‡ Describe the lesion ‡ DDx? ‡ Plan? BCC ‡ Also known as Rodent ulcer ‡ Typically looks like small inflamed crater with a raised edge ‡ Starts basal layers of skin ‡ Typically occurs in sun-­‐exposed areas of skin ± Commonest place is face ‡ Commonest type skin Ca in caucasians ± More common closer to equator, high altitudes ‡ Age ± 5 times more likely in people aged than in 50-­‐55 year old ‡ Rarely metastasises A bad case of dermatitis ‡
Retired cleaner ‡
Lots of dermatitis in past. ‡
Worried cos this seems different. Worse than before and now getting joint pain. ‡
What do you think/your concerns? ‡
Is it dermatitis/something else? ‡
What questions are relevant here? ‡
Describe the lesion? ±
Any worrying features? ‡
What examination would you do? ‡
tŚĂƚ͛ƐLJŽƵƌƉůĂŶ͍ ‡
What are you going to tell the patient? ‡
What are their likely top questions/concerns? SCC ‡
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Affects squamous cells Appearance: ± Typically starts as small crusted or scaly area of skin with red or pink base. ± May grow into lump looking like a wart. ± May ulcerate or bleed intermittently-­‐ i.e. It ĚŽĞƐŶ͛ƚĂƉƉĞĂƌƚŽŚĞĂů͘ ± Left untreated will grow + damage nearby structures possibly eroding them completely ‡
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Most common type skin Ca in dark skinned persons Dark skinned persons affects non-­‐sun exposed skin ± Legs or feet ‡
Caucasians typically affects sun exposed skin ± Head, face, ears + neck ‡
Sometimes metastasises ŽǁĞŶ͛ƐŝƐĞĂƐĞ ‡
Early form of SCC ‡
Also known as precancerous dermatitis or precancerous dermatosis ‡
Risk factors include prolonged exposure to arsenic + HPV16, HPV2 ±
Query if factory worker, esp chemicals industry ‡
Occurs on sun-­‐exposed areas of skin ‡
Older white men esp prone ‡
Appearance reddish, scaly or thickened patch of skin ‡
Requires treatment to prevent it growing deeper into skin ±
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Topical 5-­‐fluorouracil cream Imiquimod 5% cream on lower limbs Unsightly freckle ‡
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New GP Your next pt is 24 yr old lady w fair complexion + ŵƵůƚŝƉůĞ͚ĨƌĞĐŬůĞƐ͛͘ She is concerned about 1 of the freckles on her thigh which has become unsightly over past 9 months. No discomfort. What type of hx would you take? Describe the lesion What examination(s) would you do? What are your concerns? What is the patient likely to be worried about? What would you do next? Melanoma ‡ Occurs in melanocytes ‡ Can occur on any skin surface ± Men: typically head, neck, between shoulders + hips ± Women: typically lower legs, between shoulders + hips ‡ Rare in people with dark skin ± Different range of distribution in such persons ± Typically under finger or toe nails, palms of hand or soles of feet ‡ Commonly metastasises ± Typically fatal if does o ?post excision screening f/u worthwhile for re-­‐occurence ± New drugs available/forthcoming, variable estimates on effectiveness Symptoms of melanoma: ABCDE ‡ Asymmetry ‡ Irregular border ± Edges often ragged, notched or blurred ± Pigment diffusion into surrounding skin ‡ Uneven colour ± Shades of black, brown + tan ± May also see other shades: white, gray, red, pink or blue ‡ Diameter ± Change in size, typically larger (but not always) ± ĞƐƵƐƉŝĐŝŽƵƐŝĨĚŝĂŵĞƚĞƌшϲŵŵ;ϭͬϰ͞Ϳ ± But can be tiny ‡ Evolving ± Changing/changed over recent weeks/months Melanoma-­‐ Other ‡ More advanced ± Texture may change ‡ Skin surface may breakdown ±
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Scrapped look Hard or lumpy Oozing or bleeding surface Itchy, tender or painful Rationing + referrals ‡ Worried/concerned ± 2 week NHS referral rule ‡ Need 2nd opinion, no suspicion malignancy ± In-­‐house GPwSI ± Refer dermatology ‡ Cosmetic removal ± Private referral ± Primary or secondary care ± Multiple providers Diagnosis ‡ Initially via biopsy ‡ 4 types of biopsy ± shave biopsy ‡ No stitches required ± Punch biopsy ‡ Circle of tissue removed from abnormal area ± Incisional biopsy ‡ Surgical removal of part of lump or suspicious area removed ± Excisional biopsy ‡ Entire growth + margin of surrounding tissue surgically excised ‡ Most commonly used when suspicion of melanoma Staging of BCC & SCC ‡ Stage 0 ± Carcinoma in situ ± Involves only top layer of skin ‡ Stage I ± 'ƌŽǁƚŚчϮĐŵĚŝĂŵĞƚĞƌ;ůĂƌŐĞĂƐƉĞĂŶƵƚͿ ‡ Stage II ± 'ƌŽǁƚŚшϮĐŵĚŝĂŵĞƚĞƌ ‡ Stage III ± Cancer has invaded below the skin to cartilage, muscle or bone ± Or cancer has spread to adjacent lymph nodes ± No other spread ‡ Stage IV ± Metastatic spread ± More commonly SCC Staging of melanoma ‡ Stage 0 ± Only involves the top layer of skin ± Melanoma in situ ‡ Stage I ± dƵŵŽƵƌŝƐчϭŵŵƚŚŝĐŬнƐŬŝŶƐƵƌĨĂĐĞĂƉƉĞĂƌƐďƌŽŬĞŶĚŽǁŶ ± Tumour is 1-­‐2mm thick but skin surface appears intact ‡ Stage II ± Tumour 1-­‐2mm thick + surface appears broken down ± Thickness > 2mm (+ surface may appear broken down) ‡ Stage III ± 1 or more adjacent lymph nodes involved ± Invasion of adjacent structures ‡ Stage IV ± Metastasis has occurred WĂƚŝĞŶƚƐ͛ĨĞĂƌƐΘĞdžƉĞĐƚĂƚŝŽŶƐ ‡ What are patients worried about? ‡ How do you elicit their fears + concerns? ‡ How do you calm them? ‡ How do you make sense of it all? ‡ With increasing rationing, esp of dermatology, what back-­‐ƵƉƉůĂŶƐĚŽǁĞŚĂǀĞŝĨǁĞĐĂŶ͛ƚƌĞĨĞƌ͍ Prognosis ‡ All 3 types are curable if identified + treated early. ‡ Non-­‐melanoma skin cancers ± 95% cure rate ‡ Melanomas ± Low if metastasized ± Current estimates w existing Tx 10-­‐20% at 2 years [Robert et. al.; Ipilimumab plus dacarbazine for previously untreated metastatic melanoma; NEJM; 30/6/11; 364: 2517-­‐26] Prevention ‡ Important patients know what to check for + how http://youtu.be/TKyiWt4MH7o ‡ Important patients know how to protect themselves against further sun damage ± How do we do this? References ‡ http://dermnetnz.org/ ‡ www.dermis.net ‡ www.patient.co.uk ‡ Guidelines for the management of basal cell carcinoma, British Association of Dermatologists (2008) ‡ Multiprofessional Guidelines for the Management of the Patient with Primary Cutaneous Squamous Cell Carcinoma, British Association of Dermatologists (2002) ‡ The prevention, diagnosis, referral and management of melanoma of the skin, Royal College of Physicians and British Association of Dermatologists (September 2007) ‡ NICE Clinical Guideline; Skin tumours including melanoma. February 2006 and update 2011