detection and treatment of non- melanoma skin cancers toby maurer, md university of california, san...
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Detection and Treatment of Non-Detection and Treatment of Non-Melanoma Skin CancersMelanoma Skin Cancers
Toby Maurer, MDUniversity of California, San Francisco
Basics of Skin CancerBasics of Skin Cancer
• Large majority caused by sun exposure
• Often sun exposure before age 20
• Persons who burn easily and tan poorly are at greatest risk
SunscreenSunscreen
• Don’t forget sun-protective clothing• Physical sunscreen
– zinc oxide and titanium dioxide– thick and more waterproof– fewer allergic reactions
• Chemical sunscreens– burns if gets into eyes– more comedonegenic
SunscreenSunscreen
• Apply 1/2 hr. before going out
• May need to reapply every 2-3 hours– especially if going in water
• Be liberal with amount
• UVA protection probably added benefit
Non-Melanoma Skin CancersNon-Melanoma Skin Cancers
• Basal cell carcinoma (BCC)
• Actinic keratosis (AK)
• Squamous cell carcinoma (SCC)
Basal Cell Carcinoma (BCC)Basal Cell Carcinoma (BCC)
• Who is at Risk?– Age 20+– Fair-skinned persons– Sun-exposed sites
• over 50% on face
Clinical Features of BCCClinical Features of BCC
• Pearly papule with telangiectasia (face, ears forehead, neck)
• Scaly red patch (back, chest, legs of women)
• Sclerotic (scarlike) lesion
• Pigmented in pigmented races (blacks, etc.)
• May erode or ulcerate
Diagnosis of BCC: Shave or Punch Biopsy
Differential Diagnosis of BCC
• Intradermal Nevus
• Sebaceous hypersplasia
• Fibrous Papule (angiofibroma)
• Eczema
• Melanoma
Recommended Treatment of BCCRecommended Treatment of BCC
• Surgical excision (head and neck)
• Curettage and desiccation (trunk)
• Radiation therapy (debilitated pt)
• Microscopically controlled surgery (Mohs)– Recurrent/sclerotic BCC’s– BCC’s on eyelid and nasal tip
Aldara (Imiquimod)
• Topical therapy designed for wart treatment
• Upregulates interferon and down regulates tumor necrosis factor
• Seems to have efficacy in superficial BCC’s
• Do Not use in BCC’s that are nodular or invasive
Topical Treatment of Skin Cancer
• Imiquimod 5% cream can effectively treat superficial BCC’s and SCC in situ
• Treatment regimen is 5X per week for 6-10 weeks depending on the host reaction
• Efficacy is relatively high (75%-85%)• Scarring may be reduced compared to surgery• Other possible uses: Extramammary Paget’s, lentigo
maligna (trials needed)
Topical Treatment of Skin Cancer
• Patient selection is the key
• Biopsy to confirm diagnosis before TX
Treatments Treatments NOTNOT Recommended Recommended
• Cryotherapy
• Topical chemotherapy
- 5 Fleurourical (Efudex)
• Radiation therapy (age < 65)
When to ReferWhen to Refer
• It depends on your surgical skills
• > 1 cm
• Sclerotic BCC
• Recurrent BCC
• Eyelid BCC
Actinic Keratosis (AK)Actinic Keratosis (AK)
• Who is at risk?– Over age 35-40– Fair-skinned persons– Sun-exposed sites
• Face, forearms, hands, upper trunk
– History of chronic sun exposure
Clinical Features of AKClinical Features of AK
• Red, adherent, scaly lesions, usually < 5mm
• Sandpapery, rough texture
• Tender when touched or shaved
• Thick, warty character (cutaneous horn)
Diagnosis of AKDiagnosis of AK
• Diagnosis– Clinical features– Shave or punch biopsy
• Differential Diagnosis– BCC/SCC– Seborrheic keratosis– Wart
Treatment of AKTreatment of AK
• Cryotherapy• Topical chemotherapy/chemical peel
– Efudex (5FU crème) 2x’s/day x 6 wks or Imiquimod-3X’s /wk and 3 mos.
• When to refer?– Too extensive for local treatment– Consider biopsy or referral with any lesion that doesn’t
resolve with cryotherapy
• Make sure you know what you are treating
• Be very careful with pigmented lesions
• Rule of thumb for cryotherapy:– make sure lesion resolves after one month– if not, refer or biopsy to rule out malignancy
Squamous Cell Carcinoma (SCC)Squamous Cell Carcinoma (SCC)
• Who is at risk?– Age 50+– Chronic sun exposure
• Head, neck, lower lip, ears, dorsal hands, trunk
– Special circumstances• Immunosuppression (organ transplant)
• Radiation therapy
Clinical Features of SCCClinical Features of SCC
• Papule, nodule or tumor
• Non-healing erosion or ulcer
• Cutaneous horn (wart-like lesion)
• Fixed, red, scaling patch/plaque (Bowen’s-SCC-in-situ)
Differential Diagnosis of SCCDifferential Diagnosis of SCC
• Actinic keratosis
• Wart
• Seborrheic keratosis
• BCC
• Eczema or psoriasis
How to DiagnoseHow to Diagnose
• Punch or excisional/incisional biopsy
• Shave biopsy for flat, non-elevated lesion
Treatment of SCCTreatment of SCC
• Recommended treatment– Excision– Radiation therapy ( debilitated pt)
• Treatments NOT recommended– Curettage and desiccation– Topical chemotherapy
When to ReferWhen to Refer
• SCC’s may metastasize
• Low threshold for biopsy and referral
• Regularly check draining lymph nodes
• High risk SCC’s
High-risk SCC’sHigh-risk SCC’s
• Lip
• Temple
• Immunocompromised host (i.e. organ transplant)
• Area of previous radiation therapy