psoriasis & skin cancer
Post on 02-Jan-2016
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Dermatology HistoryPC
What’s the problem? Where is it? How long has it been there?
Hx Of PCWhat did it look like to begin with? Has it changed? If so, how?Itchy? Painful? Bleeding?Aggravating/ relieving factorsPrevious & current treatments (effective or not)Recent contact with diseases? Stressful events? Illness? Travel?History of sunburn, use of tanning machinesSkin type? (1-4)
Past medical history History of atopy i.e. asthma, allergic rhinitis, eczemaHistory of skin cancer & any suspicious skin lesions
Medication & allergies
Family history
Social history Occupation- alcohol gel, over washing of hands, gloves Improvement of lesions when on annual leaveSmoke/Drink?
ICE
INSPECT
– Where are the lesions & how many are there?
– Is there a pattern i.e extensors affected only
DESCRIBE SCAM
– Size (at the widest diameter) & Shape– Colour– Associated secondary change– Margin (border)
If lesion is pigmented ABCDE
–Asymmetry–Irregular Border–Two or more Colours within the
lesion–Diameter > 6mm–Evolution- change in size, shape
over time? Started to bleed?
• PALPATE & comment on:– Consistency– Mobility– Tenderness– Temperature
• SYSTEMATIC CHECK Examine:
– Nails– Scalp– Hair– mucous membranes– Regional lymph nodes
• General examination
PsoriasisChronic inflammatory skin disease
“Hyperproliferation of keratinocytes & inflammatory cell infiltration”
Chronic plaque psoriasis most common typeOther types include:• Guttate (raindrop lesions), • Seborrhoeic (naso-labial and retro-auricular),• Flexural (body folds), • Pustular (palmar-plantar)• Erythrodermic (total body redness)
Which type?
Seborrhoeic Pustular
Flexural Guttate
Erythrodermic
2% of population in UK
Complex interaction of genetic, immunological & environmental factors
Precipitating factors inc:-Trauma-Infection (e.g. Strep throat)-Drugs-Stress-Alcohol
Well-demarcated, erythematous, scaly PLAQUES
Extensor surfaces of the body & over scalp
Auspitz sign (Gentle removal of scales = capillary bleeding)
50% have nail changes (e.g. pitting, onycholysis)
5-8% assc. psoriatic arthropathy:• Symmetrical polyarthritis• Asymmetrical oligomonoarthritis• Lone distal interphalangeal disease• Psoriatic spondylosis• Arthritis mutilansLesions itchy, burning, painful
Management Avoid precipitating factors, emollients to reduce
scales
• Topical therapies (localised & mild psoriasis):-Vitamin D analogues i.e calcitrol-Topical corticosteroids-Coal tar preparations inc. scalp treatments-Dithranol-Topical retinoids i.e Tarazotene-Keratolytics (Urea based creams)
• Phototherapy (extensive disease) - Mainly UVA-UVB can be used when UVA fails- can cause sunburn
•Oral therapies (extensive, severe psoriasis & psoriasis with systemic involvement)
-Methotrexate-Retinoids-Ciclosporin-Mycophenolate mofetil-Biological agents (e.g. infliximab, etanercept,
efalizumab)
Skin cancer can be divided into:
• Non-melanoma (basal cell carcinoma & squamous cell carcinoma)
• Melanoma (malignant melanoma).
Slow-growing, locally invasive tumour epidermal keratinocytes- affect basal layers of skin
Malignant but rarely metastasises
Most common malignant skin tumour
Risk factors include:-UV exposure-History of frequent/ severe sunburn in childhood-Skin type 1-Increasing age-Being male -Immunosuppression-Previous history of skin cancer-Genetic predisposition
Basal Cell Carcinoma
Nodular most commonSmall, skin-coloured papule or noduleSurface telangiectasia,Pearly rolled edgeMay have necrotic/ ulcerated centre rodent ulcerHead & neck involvement
Management• Surgical excision• Radiotherapy - when surgery is not appropriate• Cryotherapy• Topical photodynamic therapy• Topical treatment (imiquimod cream) -small, low-
risk lesions
Locally invasive malignant tumour of epidermal keratinocytes - affect squamous layer of skin.
Potential to metastasise
Causes Risk factors include: • Excessive UV exposure• Actinic/ Solar keratoses• chronic inflammation (leg ulcers, wound scars)• Immunosuppression• Genetic predisposition
Squamous Cell Carcinoma
Keratotic (scaly, crusty), ill-defined noduleMay ulcerate
Management• Surgical excision - treatment of choice• Radiotherapy - for large, non-resectable
tumours
Malignant MelanomaInvasive malignant tumour of epidermal melanocytesPotential to metastasise
Causes Risk factors include: • Excessive UV exposure• Skin type 1 • History of multiple moles/ atypical moles• Family history or previous history of melanoma
The ‘ABCDE Symptoms’ rule → What are they? Legs in women & trunk in men
Name the types of melanoma
Superficial Spreading Melanoma
Nodular melanoma
Lentigo Maligna Melanoma
Acral Lentiginous Melanoma
Types:•Superficial spreading melanoma – lower limbs, young & middle-aged, intermittent high intensity UV exposure
•Nodular melanoma - trunk, in young & middle-aged adults, intermittent high-intensity UV exposure
• Lentigo maligna melanoma - face, elderly pop, long-term cumulative UV exposure
•Acral lentiginous melanoma - palms, soles & nail beds, elderly pop, no clear relation with UV exposure
Prognosis
Recurrence based on Breslow thickness <0.76mm thick – low risk0.76mm-1.5mm thick – medium risk>1.5mm thick – high risk
5-year survival rates based on TNM classification Stage 1 (T <2mm thick, N0, M0) – 90%Stage 2 (T>2mm thick, N0, M0) – 80%Stage 3 (N≥1, M0) – 40- 50%Stage 4 (M ≥ 1) – 20-30%
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