london dermatology centre and st mary’s...

Dr Ien Chan MD FRCP

Consultant Dermatologist London Dermatology Centre

and St Mary’s Hospital

Pre- skin cancers

Non-Melanoma Skin Cancers

!  Pre-cancers

"  Actinic (solar) keratosis

"  Bowen’s disease (squamous cell carcinoma in-

situ)

!  Basal cell carcinoma

!  Squamous cell carcinoma

Non-Melanoma Skin Cancers

•  Sun beds

•  Depletion of ozone layer

•  Ageing population

•  Immunosuppressants

•  Increase in outdoor activities (leisure, holidays)

•  Skin type

Risk factors:

Non-Melanoma Skin Cancers

High risk exposed sites

Actinic keratosis

ACTINIC KERATOSIS

!  Dry, scaly plaques on sun-exposed areas

!  Usually < 10mm

!  More common in middle-age and beyond

!  Skin types I, II and III

!  Outdoors workers and sports persons

Actinic keratosis

" Prevalence of AK varies with geography " UK prevalence - 5.9%-15.4% of population aged 40+

" Australian prevalence – 40% of the population

1.  Memon et al. Br J Dermatol 2000; 142: 1154-1159 2.  Green et al. J Am Acad Dermatol 1988; 19: 1045-1052

Actinic keratosis"

1. Adapted from Harvey I et al. Br J Cancer 1996; 74: 1302-1307"

"

ACTINIC KERATOSIS

!  Pre-malignant

!  Keratotic lesions occurring on chronically light-exposed adult skin

!  Carry a risk of progression to squamous cell carcinoma (6-10% in 10 years)

!  NICE recommends AKs can be treated in primary care

ACTINIC KERATOSIS

!  Histopathology: epithelial dysplasia; focal areas of abnormal keratinocyte proliferation

!  Rate of transformation into invasive SCC is very low (0.24% for each AK)

!  26% resolve without treatment over a 1-yr period

!  Prevention: sunscreens, hats, self-examination, follow-up

ACTINIC KERATOSIS

Field  damage:  •  mul,ple  AK  lesions  present   •  underlying   and   surrounding   area  

of  ac,nic  damage  likely   •  likely   to   be   scalp   or   other   sun-­‐

damaged  areas •  extent   of   area   of   ac,nic   damage  

may  not  be  evident  visually  or  by  physical  examina,on.

ACTINIC KERATOSIS

Treatment:

Cryotherapy

Solaraze gel

Efudix (5-Fluorouracil 5%)

Actikerall (5-Fluorouracil 0.5% + 10% salicyclic acid)

Aldara (imiquimod 5%)

Zyclara (imiquimod 3.75%)

Picato (Ingenol mebutate)

Photodynamic therapy (PDT)

Surgical (curettage and cautery; excision)

ACTINIC KERATOSIS

Disease-related factors: •  Duration

•  Number

•  Clinical course of lesions; localisation

•  Extent of disease

   Patient profile: •  Age

•  Co-morbidities

•  Other risk factors, e.g. immunosuppression

•  Pre-existing skin cancer

•  History of treatments for AK

•  Tolerability

•  Long term outcome

•  Personal preference of the patient

Healthcare system: •  Cost

•  Physician’s familiarity

•  Clinic facilities

The presentation of AK"

A few superficial “thin” AKs Many small but visible AKs, which may be palpated

Multiple “thicker” AKs many of which are quite hyperkeratotic

Pre and post Efudix treatment

Bowen’s Disease

BOWEN’S DISEASE

!  Solitary lesion, on a

sun-exposed area

!  Typically: lower leg of

elderly patient

!  Slowly enlarging

erythematous scaly

plaque with well-

defined boundaries

BOWEN’S DISEASE

Bowen’s Disease

BOWEN’S DISEASE

!  Histopathology: SCC in situ

!  Rate of malignant transformation: 5 - 10%

!  Spontaneous resolution does not occur

!  Treatment: excision, curettage and cautery, Efudix, Aldara, PDT, cryotherapy, radiotherapy

Summary

" UV radiation may lead to a range of skin lesions, both

pre-cancerous and cancerous

" Early diagnosis & intervention essential

" AKs can be managed in primary care

" Other lesions (SCC, BCC, melanoma) to be referred to

dermatologist

Date of preparation: April 2005 " " " " "036/0181"