objectives - cdn.ymaws.com · treatment continued pharmacotherapy effudex(5-fluorouracil/5-fu) is a...
TRANSCRIPT
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.