Carrie McMahon, PA-C, MPASFROSTBURG STATE UNIVERSITY PA PROGRAM

ACADEMIC COORDINATOR, ADMISSIONS CHAIR

Actinic Keratosis (Solar Keratosis)

❖ Precancerous lesions that result result from the proliferation of atypical epidermal

keratinocytes

❖ Accounts for approximately 14% of all dermatology visits

❖ #1 risk factor: SUN EXPOSURE

❖ Males> Females; fair skin; age > 40; red/ blond hair

❖ Risk of progression to Basal Cell Carcinoma is 1.6% within 4 years

❖ Risk of progression to Squamous Cell Carcinoma is 0.03- 20% within 4 years

Actinic Keratosis- History

❖ Rough feeling patch or patches that may not be visible

❖ May come and go

❖ Generally asymptomatic but can be associated with itching or burning

(especially when exposed to sunlight)

❖ Most common on scalp, face, ears, neck, forearms and hands

❖ Lips (actinic cheilitis)- feel constantly dry

Actinic Keratosis- Exam

Classic: erythematous, scaly macule,

papule or plaque; typically few mm-2cm in size.

Hypertrophic: thick, adherent scale on

an erythematous base.

Actinic Keratosis- Exam

Atrophic: scale is absent; smooth, red

macules.

Cutaneous horn: mound of compact

keratin resembles a cone.

Actinic Keratosis- Exam

Pigmented: hyperpigmented macules or

patches; may be large and resemble

lentigo maligna.

Actinic cheilitis: scaly patch(es) typically

on lower lip.

Actinic Keratosis- Treatment Options

Cryotherapy (liquid nitrogen):

❖ most common treatment

❖ cure rate directly related to freeze time (time lapse from formation of ice ball to

beginning of thawing)

❖ 39% cure for 5 second freeze; 83% cure for 20 seconds of freeze

Photodynamic Therapy (PDT):

❖ 5- aminolevulinic acid (ALA) or methyl aminolevulinate (MAL) are applied followed by

an incubation time of 1-3 hrs. Patient then sits under red or blue light for 17 minutes.

❖ Advantage: treats multiple lesions with single application. Disadvantage: burning/

stinging. Photosensitive for 2 days after tx.

❖ 70% clearance after 2 treatments

Actinic Keratosis- Treatment

Topical 5- fluorouracil: (Efudex, Carac, Fluoroplex, Tolak)

❖ Rx Cream applied by patient twice daily for 2-4 weeks

❖ Causes erythema, scabbing, soreness

❖ Result highly variable depending on compliance

Imiquimod: (Aldara)

❖ Rx cream applied by patient 2-3 times weekly for 12- 16 weeks

❖ Causes erythema, pruritis, , erosion, crusting, and possibly flu-like symptoms (fever, myalgias, malaise)

❖ Approximately 50% complete resolution

Topical Diclofenac:

❖ Rx cream applied by patient twice daily for 60-90 days

❖ Prostaglandins thought to play a role in UV-B induced skin cancers

Actinic Keratosis- Treatment

Retinoids:

❖ Adapalene 0.1% or 0.3% applied daily x 4 weeks then BID thereafter as field therapy lowered number

of AKs as well as improved the appearance of photodamaged skin

❖ Tretinoin was ineffective

Chemical Peels:

❖ Topically applied wounding agent (TCA with or without Jessner’s solution) creates smooth, rejuvenated

skin by way of wound repair process, collagen remodeling, and exfoliation

Surgical therapies:

❖ Surgical excision, shave excision, or curettage & electrodessication (C&E)

Basal Cell Carcinoma

❖ Most commonly diagnosed cancer in the United States- 3.3 million cases annually

❖ Lifetime risk 30% in US

❖ Arises from the basal layer of epidermis

❖ Approximately 40% will develop another lesion within 5 years = ROUTINE SKIN EXAMS

❖ #1 Risk Factor- SUN EXPOSURE

❖ Other risk factors: PUVA treatment (psoriasis patients), age >55, men 30% > women,

geographic variation (closer to equator), photosensitizing drugs (TCN and diuretics), chronic arsenic exposure (contaminated drinking water, seafood, medication), ionizing radiation, chronic immunosuppression (organ transplant, HIV), inherited disorders (basal

cell nevus syndrome, epidermolysis bullosa), actinic keratosis

BCC- History

❖ Location: 70% of BCCs occur on the face; 15% on trunk; rare on genital skin

❖ Slow growing lesion

❖Most often asymptomatic

❖ Tend to bleed easily

❖Oozes or crusts over

❖ Rarely painful or itchy

BCC- ExamNodular

❖ Most common subtype (60% of cases)

❖ Pink or flesh colored papule with telangiectasias

❖ Rolled boarder with central umbilication

❖ Ulceration is frequent

BCC- Exam

Superficial

❖ Approximately 30% of BCCs❖ Slightly scaly, non-firm macules, patches or thin plaques

❖ Light red- pink in color

BCC- Exam

Morpheaform (Sclerosing)

❖ 5-10% of BCCs

❖ Smooth or flesh colored plaques or papules

❖ Frequently atrophic (look like a scar)

❖ Ill- defined boarders

BCC- Low Risk vs High Risk

Low Risk Lesion High Risk Lesion

Size/ location <6mm in high risk areas of

face*

>6mm in high risk areas of

face*

<10mm diameter in other

areas of head & neck

>10mm diameter in other

areas of head & neck

<20mm diameter in other

areas

>20mm diameter in other

areas

Pathology Nodular or superficial Morpheaform/ sclerosing

(-) perineural invasion (+) perineural invasion

Other Primary lesion Recurrent lesion

(-) hx radiation at site (+) hx radiation at site

Immunocompetent Immunocompromised

* High risk regions of the face

BCC- Treatment

BCC- Low Risk Lesion Treatment

BCC- High Risk Lesion Treatment

BCC- Patient Follow-up

Latest Advancements

Cell Surface receptor

smoothened homolog (SMO)

Signals Hedgehog Pathway

Hedgehog pathway

• The hedgehog signaling pathway can cause basal cell proliferation and tumor growth Signaling in this

pathway is initiated by the cell surface receptor smoothened homolog (SMO).

• This pathway normally is inhibited by another cell surface receptor, the patched homolog 1 (PTCH1).

• Binding of the hedgehog ligand to PTCH1 prevents this inhibition.

Two mechanisms have been identified by which the hedgehog pathway

may be involved in the pathogenesis of basal cell carcinoma

Mutations of PTCH1

may prevent inhibition

of SMO activation of

the hedgehog

pathway

Mutations of SMO

may result in

constitutive activation

of the pathway

OR

Medications

Vismodegib (Erivedge)— 150 mg as a single oral daily dose is an oral

small-molecule inhibitor of SMO, which thus blocks activation of the

hedgehog pathway

Sonidegib (Odomzo)— 200 mg as a single daily oral dose is a second

SMO inhibitor

Squamous Cell Carcinoma❖ Second most common type of skin cancer: about 700,000 new cases each year

in United States

❖ Arises from malignant proliferation of epidermal keratinocytes

❖ Most commonly on sun exposed areas (head, neck, dorsal hands)

❖ Can occur on any part of the body- oral mucosa, lips, genitals

❖ #1 risk factor: SUN EXPOSURE

❖ Other risk factors: closer to equator, age >45, fair skin, red/ blond hair, PUVA

treatments or tanning beds, ionizing radiation, immunosuppression (organ

transplant and HIV) , arsenic exposure, chronic inflammation (scars, burns,

lichen sclerosis), inherited disorders (xeroderma pigmentosum, epidermolysis

bullosa, albinism), smoking, HPV, actinic keratosis

SCC- History

❖ A bump or lump that can feel rough

❖ Often becomes dome shaped as it grows

❖ “sore that doesn’t heal”

❖ Recurrent bleeding

❖ Typically faster growth than BCC

SCC- Exam

SCC in situ (Bowen’s disease):

well demarcated, erythematous,

scaly patch or plaque; slow

growing.

Invasive SCC: firm, hyperkeratotic

papules, plaques or nodules; +/-

ulceration.

SCC- Exam

Keratoacanthoma: dome shaped

nodules with central keratotic

core; fast growing

Oral SCC: presents as an ulcer,

nodule or plaque; floor of mouth

and lateral tongue most common

sites

5% of SCC cases are metastatic

Feature of SCC 5 year metastatic rate (percent)

Size > 2cm in diameter 30.3

Ear 11.0

Lip 13.7

Genitals 20-60

Arising within a scar or burn 37.9

Immunosuppressed patient 12.9

Histologic features

Depth > 4mm/ Clark’s level 45.7

Poorly differentiated 32.8

Perineural involvement 47.3

Perivascular invasion 87.5

SCC- Exam

❖ Always palpate for locoregional lymphadenopathy:

Nose and cheek lesions- submandibular nodes

Lip and anterior mouth lesions- submental nodes

Auricular lesions- posterior auricular nodes

Posterior scalp lesions- occipital nodes

Anterior scalp, forehead, temple lesions- parotid nodes

❖ If lesion is high risk and/ or lymphadenopathy is noted-

get CT or MRI

SCC- Low Risk vs High risk

H&P Low Risk High Risk

Location/ size Area L <2cm Area L >2cm

Area M <1cm Area M >1cm

Area H

Borders Well- defined Poorly defined

Primary vs recurrent Primary Recurrent

Immunosuppression (-) (+)

Site of prior radiation (-) (+)

Rapidly growing (-) (+)

Neurologic symptoms (-) (+)

Pathology

Degree of differentiation Well or moderate Poorly

Thickness/ Clark level <2mm or I, II, III >2mm or IV, V

Perineural, lymph, or

vascular involvement

(-) (+)

Location:

Area H: All High Risk

“mask areas” of face- central face, eyelids, eyebrows, periorbital nose, lips, chin, mandible, ears, genitalia, hands & feet

Area M: Check size

cheeks, forehead, scalp, neck, pretibial

Area L: Check size

trunk and extremities (excluding pretibial, hands & feet)

Melanoma

❖ 6th most common cancer in the US

❖#1 risk factor: SUN EXPOSURE

❖Other risk factors: fair skin, red/blond hair, light eye color, males>

females, age >50, more than 50 moles, family history of melanoma,

personal history of melanoma, history of breast or thyroid cancer

❖Most commonly appear on upper back, torso, lower legs, head, and

neck

❖ People with skin of color are prone to develop melanoma in areas

that are not exposed to sun- palms, soles, groin, mouth, nails

Melanoma- History

❖ Duration of lesion?

❖ Change in lesion- size or color?

❖ Symptoms- bleed, itch, pain?

❖ Personal or FHx skin cancers?

❖ History of excessive sun exposure including tanning bed?

❖ History of severe sunburns in childhood/ teen years?

❖ History of cancer- prone syndrome- familial atypical mole-

melanoma syndrome or xeroderma?

❖ Is patient immunosuppressed?

❖ History of prolonged psoralen plus ultraviolet A (PUVA)

therapy?

Melanoma- Exam

Superficial spreading: 70% of

melanomas; arises from existing nevus; multicolored; irregular

boarders

Nodular melanoma: 15% of

melanomas; darkly pigmented,

pedunculated papule or nodule;

small; symmetrical boarders

Melanoma- Exam

Lentigo Maligna: 10% of melanomas;

begins as a tan or brown macule,

enlarges and darkens over time;

older patients

Acral lentiginous: 5% of melanomas;

most common type of dark-skinned patients; palms, soles and

subungual surfaces; dark brown-

black irregularly pigmented

macules or patches

Melanoma- Exam

ABCDEs

Asymmetry- if the lesion is bisected, one half is not identical to the other

Border- irregular boarders

Color variations- multiple shades of red, blue, black, gray or white

Diameter- >6mm

Evolution- lesion is changing in size, shape, color, or a new lesion

The treatment is dependent upon the

depth of the lesion…

ALWAYS PUNCH A POSSIBLE MELANOMA!

Melanoma- Staging/ Treatment

Melanoma- Staging/ Treatment

Melanoma Staging/ Treatment

Melanoma- Staging/ Treatment

Melanoma- Staging/ Treatment

Melanoma Follow-Up

When In Doubt…Cut It Out

Shave Biopsy

❖ Fast and easy to perform with minimal materials❖Quick healing time for patient

❖ Ideal for raised lesions (suspected AK, BCC or SCC)

❖ DO NOT perform on any lesion suspicious for melanoma

Punch Biopsy

Biopsies are not only a diagnostic tool

but also lucrative…

Biopsy Type Amount Billed Work RVUs (EncoderPro)

Punch $262 .81

Shave trunk/arm <6mm $173 .6

Shave trunk/arm 6mm-1cm $235 .9

Shave scalp/neck <6mm $172 .8

Shave scalp/neck 6mm-1cm $240 .96

Shave face/ear <6mm $214 .8

Shave face/ear 6mm-1cm $269 1.1

Cryotherapy $203 .61

Counseling Patients About Sun Exposure

❖ Start young- Educate parents at WCC

❖ Ask adolescence about tanning bed use

❖ Share perspective:

1 in 5 people will develop skin cancer; 1 person dies from melanoma every hour

❖ Encourage them to enjoy the outdoors- there are many physical and psychological

benefits of being outside

❖ Appropriate clothing- wide brim hats, long sleeves, sunglasses

❖ Avoid most intense mid day sun

❖ Avoid tanning beds

❖Consider Vitamin D supplements for deficient patients: 800-1000 IU daily

SUNSCREEN SUNSCREEN SUNSCREEN

• Physical sunscreen (deflects UV)

zinc oxide and titanium dioxide

great for patients with sensitive skin

• Chemical sunscreen (absorbs UV):

oxybenzone, avobenzone, octisalate, octocrylene, homosalate, octinoxate

rubs in without white residue

• SPF 30 or higher

• Broad spectrum and water resistant

• Apply generously

• Reapply every 2 hours or after swimming/ exercise

THANK YOU!!