Download Skin Cancer

Gwent Dermatology Patient Panel
Summary Notes taken at the talk
‘Skin Cancer – types, diagnosis and options for treatments &
medication’
th
on Tuesday, 28 April 2015 at Llanfrechfa Hospital.
Our speaker was Liz Freeman.
Liz explained that she had worked as a theatre sister for 20 years experience as a theatre sister
including laser treatments using a pulse dilator. This is designed to lighten red coloured skin marks,
such as port wine stain birth marks on children to get them ready for school. This triggered her
interest in dermatology and so she went on to do her Masters. Her role is quite mixed and she went
on to work in surgery, follow-ups and one stop clinics. She is a Skin Cancer Nurse Specialist. The
reason for the need for skin cancer nurses is that over the last decade the incidents of Skin Cancer
in the UK have risen year on year despite knowledge and education about prevention:
•
•
•
12,367 new cases of melanoma in the UK in 2010.
Now about 12,818 new cases of melanoma arise in a year of which 85% are non melanoma skin
cancer cases (i.e. Basal Cell Carcinoma (BCC) and Squamous Cell Carcinom (SCC). Squamous Cell
Carcinoma often affects the head, neck and hands. Although initially non-malignant they can
spread into the lymphatic glands and become serious.
Melanoma is now the most common cancer in young people aged 15 to 34 in the UK. It is twice as
common in young women as in young men. However, more men die from it.
Melanoma is also now increasing in those of us who are over 65 – firstly because as we are living
longer and have longer exposure to sunlight. Also because when young they were the first group to
be exposed to package holidays and did not know the danger or lying out in the sun.
As summer is with us Liz finished her talk with this list of 'must dos'. I've moved into the first
part of her talk.
Protect your skin from the sun and avoid skin cancer
• Wear brimmed hats and protective clothing.
• Seek shade from 11 a.m. - 3 p.m.
• Use sunscreen of at least SPF 30 that also has high UVA protection; reapply every 2 to
3 hours.
• Keep babies and young children out of direct sunlight.
• Tell your doctor about any change in moles so that you can get them checked out.
• Sunglasses with UV protection are a must.
Now please read on and be safe.
It is important to be aware of these MYTHS.
• Freckles are good for you and protect you from the sun - NOT TRUE.
The more freckling you have indicates the increased exposure to sun you get over your
lifetime.
• Sun creams stop you getting a suntan – NOT TRUE.
People often say they will start of the Factor 30 for the first couple of days and got down to
factor 15 or 5 so they have a tan to go home from their holiday with. The creams don't stop
you getting a sun tan if your skin is meant to tan. They just help to reduce the burning
1
•
•
•
caused by UVA and UVB that damage to the DNA mechanism that protects the skin. The sun is
strong enough to get through the creams. The creams need to be reapplied.
Sun beds are good for you. NO THEY AREN’’T. Thankfully there are a lot more regulations.
These are especially important for under 18 year olds who are encouraged to use them. The
people who operated them didn’t care as they were getting their £15 for 5 minutes. Like the
sun they burn your skin.
People don't die from skin cancer. YES THEY DO.
A sun tan will protect you from developing skin cancer. NO IT DOESN’T.
Skin Cancer and knowing what to look for
Dealing with cancer positively is dependent on early detection. This relies on each of us taking an
active role by learning how to check our body for potentially problematic lesions – those lumps and
bumps that suddenly appear.
Liz showed us slides to identify the different types of skin conditions explaining the treatments
given if necessary. She divided this section into two parts and started with Benign Lesions that
many people get on their skin. After these she went on to take us through different types of skin
conditions resulting in Sun Damage and Skin Cancer.
1. Benign Lesions
Skin Tags These are little pieces of skin that protrude from the body often
in the creases of the skin e.g. under the arms, in the folds of the skin, under
the arms, breasts or groin. These are benign but can irritate if they get
warm and hot.
Treatment – Some GPs will remove them if they are particularly troublesome
but these days the regulations suggest they are left alone. Use a moisturiser to keep comfy helps.
To remove them tie a piece of cotton around the base of the tag and they should drop off in about a
week to 10 days. Another method is to use strong scissors to cut it and spray some aftershave on it.
The alcohol in it will stop the bleeding. These are completely benign.
Seborhic keratosis These are harmless skin lesions and very common: also
called senile warts or ground warts. These vary from light brown to dark
brown spots on the skin and are nothing to worry about and can look like
you’ve got a squashed rice crispy on your skin and feel you would like to
remove them with your fingernail. Sometimes as they may have different
colours they may be referred to Liz as they could be a melanoma. She may use a dermatoscope or
visually be able to decide whether this is the case.
No treatment required - if itchy use a moisturiser as they are just keratin in the skin. Some can be
removed with your finger nail or a loofa can be used to get rid of rough bits. Some are raised (called
keratin pearls). Some G Ps will correct troublesome ones. This can run in families. Not associated
with sunshine. If you’re not sure check with your doctor.
Dematofibroma can be linked with an insect bite – a lump with brown
stain around the edges. These can be caused by a minor injury to the skin, an
insect bite or a prick of a thorn. If you squeeze it between your finger and
thumb it dimples. This is a benign skin condition. No treatment
2
Spider Naevi – given this name because they have a spidery
appearance that goes out from the central spot. If you press the
raised bit the colour goes. This can happen in pregnancy when your
blood vessels dilate.
Treatment – if they bleed a little they can be cortorised to stop the
the bleeding.
Campbell de Margan (also called Cherry angiomas) are red purpley spots in
the dormice of the skin. No treatment usually needed. Some people have
clusters of them. These bright red spots are common, and if you are prone
to them they can get very numerous as you get older. If necessary they can
be easily treated with a pulsed dye laser. This makes a bright flash of yellow
laser light which briefly heats up the angioma. It feels like the snap of an
elastic band when it is done. The angioma immediately goes dark purple, like a bruise.
-
Haemangioma – are a blood vessel that’s come up to the surface. It is a
noncancerous growth that had formed as a result of an abnormal collection
of blood vessels. Because they are congenital, most people develop them
before birth, while they are still in the womb.
Treatment -They can sometimes bleed so they can be cortorised.
Pyogenic gramuloma Very common and you can get these if you catch your
finger e.g. catch it on a bramble. Instead of it continuing to heal it over
heals, develops into a lump and can bleed profusely. It is benign. Treatment
- local anaesthetic is used along with a special tool with a metal ring to
scrape it off and cautorise the base. Hopefully it will go back to heal
normally.
2. Examples of Sun Damage / Skin Cancer Levels and how they are
Measured
Liz showed us a diagram with the skin’s three layers. The epidermis is on the
surface and affected by sunlight or the environment (phenotype). Within the
layers (the dermis and hypodermis) below the surface there may be genetic
causes for some skin conditions.
There are two levels of damage - Actinic Keratosis (also called Solar
Keratosis) – 80% are precancerous skin lesions; usually the result of too much sun exposure. If not
treated it could develop into a more invasive and potentially disfiguring skin cancer called
Squamous Cell Carcinoma.
Malignant transformation - If the melanoma has spread to another part of the body this is called
Secondary Cancer or Metastases. The seriousness of the cancer is measured in stages and each
stage describes how deeply it has grown into the skin, and whether it has spread. In the UK most
melanomas are found at an early stage and so the chance of curing it is very high. Doctors will test
to find the depth into the skin that a melanoma has reached in order to decide:
• The kind of treatment to prescribe
• The level of risk that the melanoma will return after treatment.
• Whether further tests are needed to see if the melanoma has spread into other parts of the
body e.g. the lymph nodes that may be close to the melanoma.
3
Melanomas - Determining whether it is benign or malignant. Development into Squamous Cell
Carcinoma will need to be considered if the following examples of changes in a mole occur:
Assymetry This benign mole is not asymmetrical. If you draw a
line through the middle, the two sides will match, meaning it is
symmetrical. If you draw a line through this mole, the two halves
will not match, meaning it is asymmetrical, a warning sign for
melanoma.
Border A benign mole has smooth, even borders, unlike melanomas.
The borders of an early melanoma tend to be uneven. The edges
may be scalloped or notched.
Color Most benign moles are all one color — often a single shade
of brown. Having a variety of colors is another warning signal. A
number of different shades of brown, tan or black could appear. A
melanoma may also become red, white or blue.
Diameter
Benign moles usually have a smaller diameter than malignant ones.
Melanomas usually are larger in diameter than the eraser on your
pencil tip (¼ inch or 6mm), but they may sometimes be smaller
when first detected.
Evolving Common, benign moles look the same over time. Be on the
alert when a mole starts to evolve or change in any way. When a
mole is evolving, see a doctor. Any change — in size, shape, color,
elevation, or another trait, or any new symptom such as bleeding,
itching or crusting — points to danger.
In addition they are at least 6 mm in diameter and more discomfort is experienced.
This is a useful website showing these changes http://www.skincancer.org/skin-cancerinformation/melanoma?gclid=CjwKEAjw7MuqBRC2nNacqJmIpT0SJABQXAOtKgb2TD4ALSxJW3
p8c1UVHhI-rJWAAnjz5ulX8i0UwhoCfqPw_wcB#panel1-1
Actinic Keratosis (also called Solar Keratosis) is the result of
cumulative UVR exposure of the skin in places that the sun reaches
e.g. the head (particularly when hair recedes, neck and back of hands
and forearms. Also it can affect scars, skin that has burned in the
past or has been ulcerated for a long time. It is common and forms
20% of the skin cancers diagnosed. The skin shrinks, atrophy
occurs, you can get white scaring and wrinkles develop. This
photograph shows the typical appearance of sun damaged scalp also
know as Field Change. The skin is changed by sunshine and is more common in fair skinned people.
4
Treatments
1. Solarese Gel or cream is a 60 -90 day treatment that has a 76% response rate that local skin
reactions tolerate reasonably well. It makes the area look worse as the area gets inflamed but
then it work well. So it will be important to use this treatment when you are not going to a social
event and want to avoid the treated area being seen. This involves Primary Care only as GPs can
prescribe this so no Secondary care with a consultant is necessary.
2. Fluerouracil ( Efudex) is 5% cream used to treat superficial basal cell carcinoma when
conventional methods are impractical, such as in the case of multiple lesions or difficult treatment
sites on the face or scalp. It is also used to treat Bowen’s Disease, actinic keratosis (also called
solar keratosis), which can lead to more serious invasive squamous cell carcinoma if left untreated.
Treatment regimes - 3 weeks with an 86% success rate & avoids operation on legs. You get the
inflammation during the first week. Some people use it once a week some twice a week. Liz advises
patients not to cover the whole scalp as they may get too sore but to treat different areas.
When the melanoma reaches deeper into the skin an over production of keratin raises the skin into
a heaped up dome. It can develop in 6 to 8 weeks. Some are slower growing and affect legs, arms,
head - where the sun reaches.
Treatment then can involve cutting it out with a 5 mm margin followed by a skin graft from e.g.
shoulder for face with follow up in 2 years and special dressing for 5 to 8 weeks to heal. At this
stage there is a high risk of the disease spreading to the lymph nodes in the head and neck.
Here is a good website on treatments
http://www.cancer.gov/cancertopics/pdq/treatment/skin/HealthProfessional/page4
Bowen's disease - these are sometimes called pre cancerous lesions on arms and legs as
sometimes they can develop into a skin cancer. However, when the abnormal cells have not spread
further than the epidermis there is no sign of an invading cancer.
Treatment - photo dynamic
therapy: a 3 to 4 hour process
using red light to destroy the
lesion.
Superficial basal cells BCC are non invasive and move across surfaces of the skin: also called
rodent ulcers as the edges
have a 'gnawed' appearance. It
is a malignant cancer of the
skin on faces and legs. The
second photograph from the
left shows an advanced
Nodular Basal Cell Carcenoma.
Treatment - they are cut our and repaired using Mohs' surgery. This involves the removal of all of
the cancerous tissue and as little of the healthy tissue as possible. This method is used to remove
large tumors, those in hard-to-treat places.
5
Pigmented Basal Cell Carsenoma can get a larger e g. on the face due to exposure to the sun.
Many patients need reconstruction surgery.
Treatment - Mose Surgery. The patient may need recontructive
surgery.
Cutaneous Horn is composed of compacted keratin. The base of the horn may be flat, nodular, or
crateriform. Around half of horns have a benign base, and half are
premalignant or malignant.
Treatment
Cutaneous horns are usually excised with appropriate margins, dependent of
the nature of the lesion.
Lentigo Maligna - a dark blotch that may not be a problem for many years but need to do
something about it - pre malignant.
Treatment - Aldara Cream (imiquimod) is an immune response modifier.
Aldara is used to treat actinic keratosis (a condition caused by too much
sun exposure) on the face and scalp. It’s important to realise the effect
of the cream and crusting information. Treatment lasts for 6 weeks. Once
stopped Vasaline is used to get the crust off. Left with a pale scar
Local Medical News
There
•
•
•
•
has been huge progress in the last 10 years in developing new drugs with:
encouraging results so far,
Clinical trials at Velindre that is the National Centre for coordination.
Ongoing international research.
Drugs able to latch on to clusters of cells
Vitamin D Advice
There is evidence related to health effects of serum Vitam D levels, sunlight exposure and Vitamin
D. Individuals who avoid sunlight may be at risk of reduced serum Vitamin D levels.
Some people recommend having levels checked. The sun can increase their intake of food with high
Vitamin D levels.
Liz's
•
•
•
role is multi facetted
3-5 surgeries per week
nurse let surgery including flaps, grafts
nurse led follow up clinics
Tele-Dermatology
This is a new initiative now open to GPs to refer patients directly to a consultant. They can access
clinical photographs and / or take a photograph of the patient's skin to send it in for diagnosis by a
dermatologist. The patient then only needs one appointment t check back to see if it is right. The
GP is able to check his diagnosis with his Tele-Derm referral + with history of lesion against the
consultant’s diagnosis.
6
Patient / Nurse Education is focussing on:
•
How to recognise abnormal lesions
•
How to manage them effectively
•
How to reduce the risks
•
Work is going on in school.
Psychological support
Living with a life threatening illness can be very difficult for both patients and their families. This
is only available for skin cancer at the moment.
7