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TaraL.Roberts,MSN,RN,ANP-BCNursePractitioner-GeneralSurgery

CentralTexasVeteransHealthCareSystemTNPFallConferenceSeptember9,2017

Objectives:

�Describeandrecognizebenignandcancerousskinconditionscommonlyreferredtosurgery.

�Discusssomemedical/surgicaltreatmentsforthesecommonskinconditions.

�Discusspharmaceuticalmanagementforthesecommonskinconditions.

OverviewofBenignSkinLesions� Acrochordon (skintag)� Angiomas� Dermatofibroma� EpidermalInclusionCyst(EIC)� Lipoma� Neurofibroma� Nevi� Seborrheic Keratosis(SK)� ActinicKeratosis(AK)� Hidradenitis

Acrochordon (skintag)

� Definition:pedunculated outgrowthofnormalskin;usuallyonanarrowstalk

� Occurinapproximately25%ofadults� Riskofdevelopingskintagsincreaseswithage� Mayhaveafamilialtendency� Occuratsitesoffriction(i.e.axilla,neck,inframammary andinguinalregions)

Acrochordon(Skintag)

Pedunculated skintagintheaxilla

(UpToDate2011:CopyrightLogicalImages,Inc.;www.visualdx.com)

Acrochrodon(Skintags)Typicalappearanceofmultiplepedunculated skintagsintheaxilla

(UpToDate2011:CopyrightLogicalImages,Inc.;www.visualdx.com)

Acrochordon(Skintag)

Irritatedskintag

(UpToDate2011:CourtesyofBethG.Goldstein,MDandAdamO.Goldstein,MD)

Acrochordon (Skintag)� TREATMENT

� Removalindicatediftheybecomeirritatedorpatientdesiresremovalforcosmeticreasons

� Afterapplicationofalocalanestheticskintagscanbe:� Excisedwithforcepsandscissors/scalpel(willrequirechemical

orelectrocautery tostopbleeding;largerlesionsmayrequiresuturing)

� Cryosurgerywithliquidnitrogen(effectiveforsmallerlesions)

� Electrodessiccation (effectiveforsmallerlesions)

� Informpatientstheywilllikelydevelopnewskintagsinthepredisposedareas

CherryAngioma (DeMorganspots)� Definition:Abenigngrowthontheskincomposedofmaturecapillaries

� Incidenceincreaseswithage� Mostcommonontrunk� Red/purpledomeshapedlesions0.1to0.4cmindiameter� Bleedeasilywhentraumatized� Alwaysblanchwithpressurealthoughfibroticlesionsmaynotblanchcompletely

CherryAngiomas

Usuallyoccurasmultiplelesionsonthetrunk

(UpToDate2011:CopyrightLogicalImages,Inc.;www.visualdx.com)

CherryAngioma

� TREATMENT� Notreatmentindicatedunlesslesionsarebothersome� Newlesionslikelytoformfollowingremoval� Afterapplicationofalocalanestheticangiomas canbe:

� Electrocauterized (smalllesions)� Shaveexcisionandelectrocautery (largerlesions)

Dermatofibroma� Definition:benignovergrowthoffibroblasts(cellsfoundin

connectivetissuethatproducecollagen)asaresultoftrauma,insectbitesorunknowncauses

� Firmhyperpigmented nodules0.3to1.0cminsize� Mostcommononlowerextremitiesofadults� Usuallyasymptomaticbutmayitchorbesubjecttorepeatedtrauma

� Non-tender� Dimplewhenpinched� Usuallynohistoryofchangeinappearance

Dermatofibroma

Firmhyperpigmentednoduleontheshin

(UpToDate2011:CopyrightLogicalImages,Inc.;www.visualdx.com)

Dermatofibroma

DimpleSign

(UpToDate2011:Goodheart,HP.Goodheart’sPhotoguide ofCommonSkinDisorders,2nd Edition,LippincottWilliams&Wilkins,Philadelphia2003.)

Dermatofibroma� Treatment

� Generallynotreatmentindicatedunlesssymptomatic,increasedsize,changeincolororbleeds

� Forlesionsthatareraisedandeasilyirritatedd/trepeatedtraumaconsidercryotherapy,shaveexcisionw/cautery orcompleteexcision(iflesionischanging)

� Lesionsmayrecur� Scarfromremovalmaylookworsethanthelesion� Rarelydevelopintomalignantlesionscalleddermatofibrosarcoma protuberans

EpidermalInclusionCysts(EIC)� Definition:discretenodulesundertheskincomposedofnormalepidermisthatproducekeratin;mayoccuranywhereonthebody;mistakenlycalledsebaceouscysts (thereisnosebaceouscomponent)

� Theepidermisthatcomposesthewallofthecystmaybecomelodgedinthedermisd/ttraumaorstartasa“blackhead”(opencomedone)

� Cystscanremainstableinsize,increaseinsizeorhavespontaneousinflammationwithrupture

� Diagnosisisbasedonclinicalappearance:thenodulesareusuallydiscrete,sometimesmobileonpalpationandgenerallyhaveavisiblepunctum

� Differentiatefrompilar cystsofthescalpandfacewhichforminhairrootsheaths

EpidermalInclusionCyst(EIC)

WithVisiblePunctum/Sinus

(CourtesyofTaraL.Roberts,NP)

EpidermalInclusionCyst(EIC)Raisedsubcutaneousnodule

Novisiblepunctumassociatedwiththiscyst(EIC)(UpToDate2011:Stedman'sMedicalDictionary.Copyright©2008LippincottWilliams&Wilkins.)

EpidermalInclusionCyst

Inflammed/InfectedEIC

(UpToDate2011:CourtesyofBethGGoldstein,MDandAdamOGoldstein,MD.)

EpidermalInclusionCyst(EIC)� Treatment

� Notindicatedunlessinfectedordesiredbypatient� Infectedcysts

� EmpirictreatmentwithoralABXsuchasAugmentin500/125mgor875/125mgPOBIDorKeflex500mgPOTID(tetracyclineorerythomycin aresometimesusedfortheirantiinflammatory properties)

� Incisionanddrainageusinglocalanesthesia(obtainculture;changeABXasneedbasedonC&Sresults)

� WoundcareuntilI&Dsiteheals(washsitedailywithsoapandwater;packwounddailywithiodoform orplaingauzestrip,coverwith4x4’sandpapertape)

� CystsmayrecurfollowingI&D;recommendformalexcisionwhennotinfected

Lipoma� Definition: benignneoplasms composedofmaturefatcellsusuallyencasedbyathinfibrinous capsule

� Angiolipomas aresimilartothetypicallipoma butarecommonlypainfulandcontainvascularstructure/cells

� Canoccuranywhereonthebodywherefatcellsexist/combine� Etiologyisnotwellknownorunderstood(geneticvs.environmental?)

� Usuallysuperficialinthesubcutaneoustissuesbutmayinvolvethefasciaorbefoundintramuscularly

� Usuallysoftorrubberyandmobile;asymptomaticanddonotgrowrapidlybutmayincreaseinsizeslowlyovertime

� Ifsuspectedlipoma ispainful,growsrapidly,restrictsmovementorisfirmorhasareasoffirmnessconsiderbiopsy

� Malignanttransformationtoliposarcoma israre

Lipoma

Multiplelipomas ontrunk

Scarsfrompriorexcisionsvisible

(UpToDate2011:Goodheart,HP.Goodheart's Photoguide ofCommonSkinDisorders,2ndEdition,LippincottWilliams&Wilkins,Philadelphia2003.Copyright©2003LippincottWilliams&Wilkins.)

LipomaSinglelipomarightmidlowerback

(CourtesyofTaraL.Roberts,NP)

Lipoma� TREATMENT

� Surgicalremovalforpain,cosmesis,ortissuediagnosis� Dependingonlocation,sizeandsuperficialvs.intramuscularremovalisdoneinminorproceduresettingusinglocalanestheticvs.ORwithsedationorgeneralanesthetic

� Potentialsideeffectsofsurgeryinclude:scarring,hematoma,seroma andoccasionallyrecurrence

� Ifpatienthasmultiplemasseswithsimilarappearance/texturethatareasymptomatic;biopsyonefordiagnosisandwatchothermasses;removeastheybecomesymptomatic,groworchange

LipomaLipoma excisedfromtherightlowerback.

(CourtesyofTaraL.Roberts,NP)

Neurofibroma� Definition: benigntumorsmadeupofcellsofneuromesenchymal origin

� Mayoccurassolitarylesionsorasmultiplesinthesettingofneurofibromatosis

� Cutaneous neurofibromas areususually asymptomatic,soft,fleshcoloredorhyperpigmented papulesornodulesthatarelessthan2cm

� The“button-hole”signiswhenpressureisapplieddirectlytotheneurofibroma anditretractsintotheskin(thisisnottrueforallneurofibromas)

Neurofibroma

Cutaneous,soft,fleshcoloredpapule/noduleconsistentwithasolitaryneurofibroma

(UpToDate2011:www.visualdx.com.CopyrightLogicalImages,Inc.)

Neurofibroma� TREATMENT

� Removalisnotnecessaryforcutaneous neurofibromas� Surgicalexcisionusinglocalanestheticsuchas1%lidocainewithepi canbedonetoremovethepapule/nodulewhentissuediagnosisisindicatedorpatientdesiresremovald/tdiscomfortorcosmesis

Nevus� Definition:abnormal/newgrowths(neoplasms)causedbyanincreaseofthepigmentproducingcellsoftheskin(melanocytes)

� Commonlyreferredtoas“moles”� Usuallypresentaspigmentedmacules,papulesorplaques� macules areflat(“junctional”)� papulesareelevated(“compound”)� plaquesareraised,rough,scalylesions

� Mayalsobefleshcoloredorpink(“intradermal”)

NevusIntradermal nevus(pink/fleshcolored)

(courtesyofPerri Dermatology,Dr.AnthonyJ.Perri)

NevusMelanocytic orDysplasticnevus

(courtesyofDr. Kopes-Kerr)

NevusJunctional Nevus

Flatpigmentedmacule

(CourtesyofTaraL.Roberts,NP2011)

NevusCompoundnevuswithcentralelevation,uniformpigmentationandregularborder

(UpToDate2011:CourtesyofJeanLBolognia,MD,andJulieVSchaffer,MD.)

Nevus� TREATMENT

� Generallynotindicatedunlessnevusisbothersomeforpatientorforcosmesis

� Ifthereisconcernformelanomaconsidershavebiopsy,punchbiopsyorexcisionusinglocalanesthesia

Seborrheic Keratosis(SK)� Definition:benignskinlesionscomposedofanovergrowthofimmaturekeratinocytes (cellscomposingtheepidermisoroutermostlayeroftheskin)

� Lesionsusuallyhavethefollowingcharacteristics:� hyperpigmented� scaly� wellcircumscribed� warty� “stuckon”

� Commonlyfoundonthetrunk,faceandupperextremities

SeborrheicKeratosisWarty,“stuckon”appearance(UpToDate2011:Goodheart,HP.Goodheart'sPhotoguide ofCommonSkinDisorders,2ndEdition,LippincottWilliams&Wilkins,Philadelphia2003.Copyright©2003LippincottWilliams&Wilkins.)

SeborrheicKeratosisPigemented keratosismaybemistakenformelanoma(UpToDate2011Goodheart,HP.Goodheart'sPhotoguide ofCommonSkinDisorders,2ndEdition,LippincottWilliams&Wilkins,Philadelphia2003.Copyright©2003LippincottWilliams&Wilkins.)

Seborrheic Keratosis(SK)� TREATMENT

� Generallynotindicatedbutifpatientdesirestreatmentforsymptomaticlesionsorcosmesis theycanberemovedbyoneofthefollowingmeans:� Liquidnitrogenforsmaller,thinnerlesions� Curettage,sniporshaveexcisionusinglocalanesthesia(1%lidocaine withorw/oepinephrine)followedbyelectrodessicationofthewoundbed

� Completeexcisionwithscalpelusinglocalanesthesiaifrulingoutapigmentedbasalcellcarcinoma,melanomaorothersuspiciouslesion

ActinicKeratosis(AK)� Definition:rough,scaly,erythematous patches,papules,orplaquesthatdeveloponsundamagedskinresultinginatypia ofthekeratinocytes

� Onlydeveloponsunexposedareas� MostAKswillnotprogresstoinvasiveSquamous CellCarcinoma(SCC)oftheskin;however,about60%ofallSCCprobablydevelopedfromanAK

� Incidenceincreaseswithage

ActinicKeratosis

Erythematoushyperkeratoticplaque

(UpToDate2011CourtesyofJamesCShaw,MD.)

ActinicKeratosis(AK)� TREATMENT

� Dependsonthesize,numberandlocationofthelesions� Liquidnitrogencryotherapy goodforsmallersuperficiallesions

� Surgicaltherapy(shave,curettageorexcision)usinglocalanesthesiaforlarger,thickerlesions;providespathspecimenfortissuediagnosis

� PreventiveStratagies� avoidsunexposure� sunblock� UVprotectiveclothing

ActinicKeratosis(AK)� TREATMENTCONTINUED

� Pharmacotherapy� Effudex (5-fluorouracil/5-FU)isatopicalchemotherapuetic agent

appliedtoareasofsundamagedskinwithmultipleAKsonceortwiceadayfor2-4weeks(1-2%face;5%body)followedbyalowpotencycortizone creamtwiceadayonceinflammationandulcerationoccuruntilskinishealed� inhibitsthymidylate synthetase,acriticalenzymeinthesynthesisofDNA;attacksfast-growingdysplasticcells,preventingcellproliferationresultingincelldeath

� theskinprogressesthrougherythema,blistering,necrosiswitherosion,andreepithelialization inapprox.4-6weeks

� UsuallyprescribedbyDermatology� Othertreatmentsinclude:diclofenac,imiquimod cream(Aldara),&

retinoids

ActinicKeratosis(AK)

InflammationresultingfromtreatmentwithEffudex (topical5-FU)(UpToDate2011CourtesyofJamesCShaw,MD.)

Hidradenitis Suppurativa (HS)� Definition:achronic,suppurative processaffectingthesweatglands;mostlikelyd/tocclusionoffolliclesresultinginsecondaryinflammationandsometimesinfection(“acneinversa”)

� Occurswheretwoskinareastouchorrubtogether,including:axilla,groin,perianal,perineal,genitalandinframammary regions

� Morecommoninwomenthanmen(3:1)� Onsetisusuallybetweenpubertyandage40� Initiallypresentsassmallpainfulsubcutaneousnodulesthatmayprogresstoabscessesthatruptureanddrainpurulentand/orserosanguineous material

Hidradenitis Suppurativa (HS)� Spontaneousorsurgicaldrainageofabscessesusuallyrelievespain

� Overtimethisconditionresultsinformationofdeepfluctuantcysts,sinustracts/fistulas,hyperpigmentation,scarringandpittingoftheskin

� Differsfromacneinthatthereislittleinvolvementofthesebaceousglands

� Unlike“boils”or“furuncles”thenodulesareusuallydeep,roundandlackcentralnecrosis

� Diagnosisisbasedonclinicalmanifestations.Biopsyisnotrequiredandgenerallynon-diagnostic.

HidradenitisSuppurativaComedones andbridgedscarsintheaxilla

(UpToDate2011:Ridley,CM,Neill,SM(Eds),TheVulva2nded,BlackwellScience,Oxford,1999,p.141.)

Hidradenitis Suppurativa (HS)� ENVIRONMENTAL/BEHAVIORAL/DIETARYCHANGES

� Avoidtraumatoinvolvedareas� Avoidheat,humidity,frictionandsweatingtoinvolvedareas� Encourageweightloss� Encourageloosefittingbreathableclothing(cottonvs.synthetic)� Encouragesmokingcessation� UsegentlesoapswithneutralpH� Useofantiperspirantsisacceptableunlessitcausesirritation;avoiddeodorants

� Avoidmilk,milkproducts,caseinandwhey

Hidradenitis Suppurativa (HS)� TREATMENT (treatmentisbasedontheseverity/Stageofthedisease)

� HurleyStageI-single ormultipleabscessformationwithoutsinustractsandscarring(MILDDISEASE)� Topicalantibioticsandintralesional steroidsforinflammation

� clinamycin 1%solutionBIDtoaffectedareas� triamcinolone acetonide (5-10mg/mL,0.1to0.5mLinjectedintothecenterofindividual,

painful,smallnodulesoncemonthlyfor1-3times)� Oralsystemicantibioticsforresistantcases

� tetracycline250-500mgPOQIDfor7-10days� doxycycline 100mgPOBIDfor7-10days� clinidamycin 300mgPOBIDfor7-10days� Augmentin 500-1000mgQ8HPOfor7-10days

� Concurrenttherapywithanti-androgens� Women:ethinyl estradiol/drospirenone oralcontraceptive� Men:finasteride ordutaseride (5alphareductase inhibitors)� Spironolactone 25mgPOdaily(mayincreaseupto100mg/day)

� Retinoids-isotretinoin (Accutane)1mg/kgPOx4months� Zincgluconate 50to90mgPOdaily (anti-inflammatory/anti-androgenproperties)

Hidradenitis Suppurativa (HS)� TREATMENTCONTINUED

� HurleyStageII-recurrentabscesseswithtractsandscarring;singleormultiplewidelyseparatedlesions(MODERATEDISEASE)� GOAL:toreduceactivitytostageIdisease� ContinuestageIbaselinetreatments� Antibioticsformoderatetoseverediseasemayinclude:

� rifampin 300mgPOBIDandclindamycin 300mgPOBIDx3months� dapsone 50-100mgPOdaily

� Glucocorticoids� prednisoneforacuteinflammatoryflares(initial3to4daycourseof40to60mgtaperedover7to10days)

� Surgery� IncisionandDrainage(I&D)ofindividualnodules/abscessesunderlocalanesthesiafollowedbypackingtoallowhealingbysecondaryintention;relievespainofacuteabscesses

� Localorextensiveunroofing� Maintenanceantibiotictherapypostoperatively:doxycycline 100-200mgPOdailyordapsone 100mgdaily

Hidradenitis Suppurativa (HS)� TREATMENTCONTINUED

� HurleyStageIII-widespreadinvolvementormultipleinterconnectedtractsandabscesses/chronicdrainingfistulas(SEVEREDISEASE)� GOAL:toreduceactivitytostageIIandeventuallystageIdisease� ContinuestageIandstageIIbaselinetreatments� Preoperativeuseofanti-inflammatoryagents

� prednisone(1mg/kg/dayPO)� cyclosporine(4to5mg/kg/dayPO)� TNF-alphainhibitor(Infliximab 5mg/kgIVevery6weeks)

� Concurrentuseofpreoperativeantibiotics� clindamycin 300mgPOBIDandrifampin 300mgPOBIDconcurrently

� Widesurgicalunroofing,debridementandexcisionofallcysts,sinusesandscartissue� generallyperformedintheOR� healingisbysecondaryintentionorwithmeshgrafting

� Postoperativemaintenanceantibiotictherapy� doxycycline100-200mgPOdaily� dapsone 100mgPOdaily

� Biologicmedications� adalimumab/Humira istheonlyFDAapprovedBiologicagentfortreatmentofmoderatetosevereHS� Initialdose(Day1):160mg(givenasfour40mginjectionsonDay1orastwo40mginjectionsperdayonDays

1and2)� Seconddosetwoweekslater(Day15):80mg(two40mginjectionsinoneday)� Thirddose(Day29)andsubsequentdoses:40mgeveryweek.

HidradenitisSuppurativaSinustract;surgicalunroofing wouldinvolveopeningtheskinbetweenthetractsusinglocalanesthesia

(UpToDate2011:FWDanby,MDandLJMargesson,MD.)

OverviewofCancerousSkinLesions

�BasalCellCarcinoma(BCC)� Squamous CellCarcinomaoftheskin(SCC)

� Keratoacanthoma

�Melanoma

BasalCellCarcinoma(BCC)� Definition:acommonskincancerarisingfromthebasallayeroftheepidermis

� Commonlycalled“epitheliomas”� Lowmetastaticpotential(<0.5%)butcanbelocallyinvasive,aggressiveandcausedestructionoftheskinandsurroundingstructures

� Morecommoninlight/fairskinnedpopulations� Uncommonindarkskinnedpopulations� Incidenceincreaseswithage� PresenceofoneBCCincreasesriskforsubsequentBCC� 30%higherincidenceinmen� Excellentprognosis

BasalCellCarcinoma(BCC)� RISKFACTORS

� UVlightexposure� Chronicarsenicexposure� Ionizingradiation� Immunosuppression� Geneticfactors/inheriteddisorders� Actinickeratosis� Lifestylefactors

� smoking

BasalCellCarcinoma(BCC)� PREVENTION

� protectionfromsunexposure� smokingcessation

� CLINICALPRESENTATION� 70%occuronface;15%ontrunk;15%misc.� 60%arenodular (pinkorfleshcoloredpearlypapulestypicallyonface;telangiectasias maybepresent;ulcerationsmaybepresent)

� 30%aresuperficial (typicallyoccurontrunk;scalypinkpapulesorplaques)

� 5-10%aremorpheaform (smooth,fleshcoloredormildlyerythematous papulesorplaques;firmorindurated;ill-defined)

BasalCellCarcinoma(BCC)NodularBCC

Apearlypapulewithtelangiectasias

(UpToDate2011:www.visualdx.com.CopyrightLogicalImages,Inc.)

BasalCellCarcinoma(BCC)SuperficialBCC

erythematous,slightlyscalypatch/plaque

(UpToDate2011:www.visualdx.com.CopyrightLogicalImages,Inc.)

BasalCellCarcinoma(BCC)Morpheaform BCC

Maypresentasanindented/induratedscarasseenhereorasafirmwhitishplaque

(UpToDate2011:www.visualdx.com.CopyrightLogicalImages,Inc.)

BasalCellCarcinoma(BCC)� DIAGNOSIS

� Diagnosiscanbemadebyshaveorpunchbiopsyorcompleteexcisionoflesionunderlocalanesthesia(1-2%lidocaine withorw/oepi dependingonlocation)

� TREATMENT� Topical:

� 5-fluorouracil(5-FU/Effudex)5%creamorsolutionBIDtoaffectedareasfor3-6weeks

� Imiquimod 5%creamdailytoaffectedareasfor6-12weeks� Misc:

� Radiationtherapycanbeusedforpatientswhoarepoorsurgicalcandidates

BasalCellCarcinoma(BCC)� TREATMENTCONTINUED

� Surgery:� Cryosurgery-freezinglesions/tumorswithliquidnitrogen(mayrequire

localanesthesia)� Mohs surgery-aspecializedmicrographicsurgicaltechniquethat

optimizescontroloftumormarginswhileminimizinglossofnormaltissue;generallyreservedforhighrisklesionsincosmeticallysensitiveareas

� Electrodesiccation &curettage(ED&C)-techniqueofshavingorscrappingthelesionfollowedbycauterizationofthewoundbedunderlocalanesthesia;generallyreservedforlowrisklesionsontrunkorextremities

� Excision-canbeusedforlowriskandhighrisklesions;generallyunderlocalanesthesiaintheoutpatientsetting

Squamous CellCarcinoma(SCC)� Definition:acutaneous cancerthatmaypresentaspapules,plaquesornodulesaswellassmooth,hyperkeratotic orulceratedlesions

� Candeveloponanycutaneous surface(head,neck,trunk,extremities,oralmucosa,periungual skinandanogenital regions)

� SecondmostcommonskincancerbehindBCC(approx.20%ofnon-melanomaskincancers)

� Morecommoninfairskinnedpopulations� Morecommoninsunexposedareasexceptindarkskinnedpopulations

� Incidenceincreaseswithage� Genitalandperiungual SCCisrareandusuallyrelatedtoHPVinfection� SCClesionsontheear,preauricular regionsoratmucocutaneousinterfaces(lips/genitalia/perianal)tendtobemoreaggressiveandhavehigherratesofmetastasis(10-30%)

Squamous CellCarcinoma(SCC)� RISKFACTORS

� UVlightexposure(UVB/UVAradiation)� Ionizingradiation(usedtotreatcancer,acne,psorias)� Immunosuppression� Chronicinflammation(scars,burns,chroniculcers,sinustractsorinflammatoryskinconditions)

� Chronicarsenicexposure� Geneticfactors/inheriteddisorders/familyhx ofSCC� HPVinfection� Lifestylefactors(smokinganddiet)

Squamous CellCarcinoma(SCC)� PREVENTION

� Protectionfromsunexposure� Chemoprevention

� Oral/topicalretinoids (rolestillbeinginvestigated)� CLINICALMANIFESTATIONS

� Actinickeratosis:rough,scaly,erythematous macules thatdeveloponsundamagedskin(~60%ofSCCsarisefromAKs)

� Keratoacanthoma:rapidlygrowingepithelialtumorsthatresembleSCConphysicalandhistologicalexam;foundinareasofactinicchange;maybebenignorinvolveSCC

� Wounds&Scars:Marjolin’s ulcerreferstotumors/SCCthatdevelopsatsitesofchronicnon-healingwounds/ulcers/scars

� SCCinsitu (Bowen’sdisease): welldefinedscalypatchorplaque(erythematous,skincoloredorpigmented);asymptomaticandslowgrowing

� InvasiveSCC:� well-differentiatedlesionsareusuallyfirm/indurated,hyperkeratotic papules,plaquesor

nodules;withorw/oulceration;0.5-1.5cminsizebutocc.Larger� poorlydifferentiatedlesionsareusuallyfleshy,softgranulomatous papulesornodules

lackinghyperkeratosis;mayhaveulceration,hemorrhageornecrosis

ActinicKeratosis(AK)

Erythematoushyperkeratoticplaque

(UpToDate2011CourtesyofJamesCShaw,MD.)

Keratoacanthoma

Domeshapedorcrateriform nodulewithcentralkeratotic core/plug

(CourtesyofTaraL.Roberts,NP2011)

Marjolin’sUlcerSCCcanformatsitesofchronicinflammationincludingwounds,ulcersandscars

(courtesyofWikipedia2006)

SquamousCellCarcinomaInsitu

AlsoknownasBowen’sDisease

(UpToDate2011:www.visualdx.com.CopyrightLogicalImages,Inc.)

InvasiveSquamousCellCarcinoma

Anerythematous,hyperkeratoticpapuleontheskin

(UpToDate2011:www.visualdx.com.CopyrightLogicalImages,Inc.)

Squamous CellCarcinoma(SCC)� DIAGNOSIS

� Diagnosiscanbemadebyshaveorpunchbiopsyorcompleteexcisionoflesionunderlocalanesthesia(1-2%lidocaine withorw/oepi dependingonlocation)

� TREATMENT� Topical:

� 5-fluorouracil(5-FU/Effudex)5%creamorsolutionBIDtoaffectedareasfor3-6weeks

� Imiquimod 5%creamdailytoaffectedareasfor6-12weeks� Misc:

� Radiationtherapycanbeusedforpatientswhoarepoorsurgicalcandidates

Squamous CellCarcinoma(SCC)� TREATMENTCONTINUED

� Surgery:� Cryosurgery-freezinglesions/tumorswithliquidnitrogen(mayrequire

localanesthesia;forsmall,superficiallowrisklesionsandSCCinsitu)� Mohs surgery-aspecializedmicrographicsurgicaltechniquethat

optimizescontroloftumormarginswhileminimizinglossofnormaltissue;generallyreservedforhighrisklesionsincosmeticallysensitiveareas

� Electrodesiccation &curettage(ED&C)-techniqueofshavingorscrappingthelesionfollowedbycauterizationofthewoundbedunderlocalanesthesia;generallyreservedforsmall,superficiallowrisklesionsontrunkorextremities

� Excision-canbeusedforlowriskandhighrisklesions;generallyunderlocalanesthesiaintheoutpatientsetting

MalignantMelanoma� Definition:askincancerinvolvingthemelanocytes whicharethecellsthatproducethepigment(melanin)oftheskin

� Themostseriousformofskincancer� The6th mostcommoncancerinNorthAmerica� Incidenceincreaseswithage� Higherincidenceinmen� Tendstobeaggressiveandcanmetastasizethroughoutthebody

� Survivaldependsonthestageofthediseaseatdiagnosis

MalignantMelanoma� RISKFACTORS

� Personalorfamilyhx ofmelanoma� Sun/UVexposure� Presenceofmultipleand/oratypicalnevi� Phenotypictraits:lightskin,hairandeyecolor;freckling

� PREVENTION/EVALUATION� Protectionfromsunexposure� ABCDErule

� Asymmetry� Borderirregularities� Colorvariegation(3ormore:brown,red,blackorblue/gray,andwhite)� Diameter>=6mm� Evolving:alesionthatischanginginsize,shape,colororanewlesion

� The“uglyduckling”sign(whenapatientwithmultiplenevihasapigmentedlesionthatlooksdifferentfromthesurroundinglesions)

� Patientself-examinationofskin� Clinicalexaminationofskin

MalignantMelanoma� SUBTYPES

� Superficialspreadingmelanoma:mostcommon(70%);canoccuranywhereonthebody;amacule orplaquewithirregularborderandvariablepigmentation

� Nodularmelanoma:2nd mostcommon(15-30%);darklypigmented,pedunculated orpolypoid nodules

� Lentigo maligna melanoma:10-15%;occursmostofteninsundamagedareasofolderadults;beginsasatan-brownmaculethatgraduallyincreasesinsizedevelopingasymmetryandvariationincolor

� Acral lentiginous melanoma:<5%;mostcommonindark-skinnedpopulations;usuallydevelopsonpalmer,plantarandsubungual surfaces

MalignantMelanomaSuperficialspreadingmelanoma,(asymmetry,irregularborder,colorvariegation)

(UpToDate2011:www.visualdx.com.CopyrightLogicalImages,Inc.)

MalignantMelanomaNodularmelanoma(adiscretenodule,usuallywithdarkpigmentation,however,theymaybeamelanotic (lackingpigment)asinthispicture

(UpToDate2011:CourtesyofJamesCShaw,MD.)

MalignantMelanomaLentigo malignamelanomadevelopsinareasofsun-damagedskin,especiallytheheadandneck;beginsasafreckle-liketan-brownmaculeandgraduallyenlargesanddevelopsdarker,asymmetricfoci,raisedareas,andcolorvariegation

(UpToDate2011:www.visualdx.com.CopyrightLogicalImages,Inc.)

MalignantMelanomaAcral lentiginousmelanomaLocatedonthepalms,solesornailstheselesionshavetheasymmetryandcolorvariegationoftypicalmelanomas

(UpToDate2011:CourtesyofJamesCShaw,MD.)

MalignantMelanoma� STAGING

� Prognosisdependsonstageofdiseaseattimeofdiagnosis(thickness,mitoticrateandulceration)

� Earlydetectionisvitaltoimprovepatientoutcomesandsurvival

� Thereare5stages:� Stage0isinsitumelanoma� StageIislocalizedcutaneous disease(T1:<=1mm;10yrsurvival92%)� StageIIislocalizedcutaneous disease(T2:1.01-2.00mm;10yrsurvival80%)

� StageIIIisregionalnodaldisease(T3:2.01-4.00mm;10yrsurvival63%)� StageIVisdistantmetastaticdisease(T4:>4mm;10yrsurvival50%)

MalignantMelanoma� DIAGNOSIS

� Punchorincisional biopsyoflargerlesionsusinglocalanesthesia� Excisional biopsyofsmallerlesionswith1-3mmmarginusinglocalanesthesia

� TREATMENT� ReferraltoDermatologyforclinicalskinexamandbiopsy� ReferraltoSurgeryforbiopsyandexcision� ReferraltoHematologyOncologyforadvanced/metastaticdisease(InterferonandImmunotherapy)

� ReferraltoRadiationOncologyforpalliativetreatmentofunresectable locallyrecurrentdiseaseormetastaticdiseasecausingbonepain,spinalcordcompression,CNSdysfunctionortumorhemorrhage

References� asp.mednet.ucla.edu.SkinandSoftTissueInfections.Accessed5/9/2017.� Buzaid,AC,Gershenwald,JE&Ross,MI.Tumornodemetastasis(TNM)

stagingsystemandotherprognosticfactorsincutaneous melanoma.UpToDateMay2011.

� Chartier,TK&Aasi SZ.Treatmentandprognosisofbasalcellcarcinoma.UpToDateMay2011.

� GellerAC&Swetter S.Screeningandearlydetectionofmelanoma.UpToDateMay2011.

� Goldstein,BG&Goldstein,AO.Overviewofbenignlesionsoftheskin.UpToDateMay2011.

� Lee,RA&Eisen,DB.Treatmentofhidradenitissuppurativa withbiologicmedications.https://www.ncbi.nlm.nih.gov/pubmed/26470624 ;https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0-S0190962215020010.pdf?locale=en_US .March2017

� LimJL&Asgari M.Clinicalfeaturesanddiagnosisofcutaneous squamouscellcarcinoma(SCC).UpToDateMay2011.

References� LimJL&Asgari M.Epidemiologyandriskfactorsforcutaneoussquamouscellcarcinoma(SCC).UpToDateMay2011.

� Schaffer,JV&Bolognia,JL.Acquiredmelanocyticnevi(moles).UpToDateMay2011.

� Stewart,EG,Margesson,LJ&DanbyFW.Pathogenesis,clinicalfeatures,anddiagnosisofhidradenitissuppurativa.UpToDateMay2011.

� Stewart,EG,Margesson LJ&DanbyFW.Treatmentofhidradenitissuppurativa.UpToDateMay2011.

� Swetter,S&Geller,AC.Skinexaminationandclinicfeaturesofmelanoma.UpToDateMay2011.

� Wrone,DA&SternRS.Epidemiologyandclinicalfeaturesofbasalcellcarcinoma.UpToDateMay2011.

� http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/125057s397lbl.pdf.AccessedMarch2017.