Dermatology

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BCC

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1. Basal cell carcinoma is the most common but least dangerous type of skin cancer. Almost 70% of skin cancers in Australia are basal cell carcinomas.

2. These tumours grow slowly over months or years and only very rarely metastasise to distant sites.

3. BCCs are easily treated if detected early. Left untreated, they may ulcerate and invade more deeply causing damage to underlying structures, particularly the eyelids and nose.

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BCC Risk Factors

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- Male

- Sun exposure

- >40

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BCC Distribution

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BCC arises on parts of the body that are chronically exposed to the sun - over half are found on the head and neck, a quarter to a third is found on the trunk and smaller proportions are found on the limbs. The anatomical distribution of BCC is similar for men and women.

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Types of BCC

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1. Nodular

2. Superficial

3. Morphoiec or infiltrating

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nodular BCC face

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Nodular BCC: ulcerated red pre-auricular nodule.

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Morphoeic BCC

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Superficial BCC

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Trunk and limbs are common sites.

Quite well defined erythematous, scaling or slightly shiny macule.

Mostly asymptomatic.

May be itchy.

Rarely ulcerate/bleed.

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Nodular BCC

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Head and neck are the commonest sites.

Shiny, pearly, papule or nodule with telangiectatic vessels.

Stretching the skin enhances pearly features. May see central umbilication with a raised, rolled edge.

Commonly asymptomatic.

Frequently ulcerate and bleed.

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Morphoeic BCC

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Similar to nodular BCC (head and neck).

Resemble a pale scar.

Firm induration usually palpable.

Frequently asymptomatic.

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BCC Dx

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Biopsy is recommended to confirm the diagnosis of a suspected BCC prior to definitive therapy.

Margin-controlled complete excision is the preferred approach as this enables examination of the architecture of the tumour and assessment of the adequacy of excision. In some circumstances complete excision may not be appropriate, in which case partial biopsies, for example punch or shave biopsies may be useful.

Important features on the pathology report that may influence further treatment and prognosis are:

• Subtype (nodular, superficial, morphoeic or other (e.g. micronodular, infiltrating).
  
• Adequacy of excision.
  
• Perineural invasion.
  

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BCC Tx

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Most clinically favourable BCC (i.e. small, nodular or superficial subtypes, not located on the central face) can be excised under local anaesthesia with 2-3 mm margins with a high chance of achieving long-term local control. A

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SCC

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Squamous cell carcinomas (SCC) are less common but potentially more dangerous than basal cell carcinomas. They typically grow more rapidly, over weeks or months, and have greater potential to metastasise to regional lymph nodes and distant sites if not treated promptly.

Most SCC develop from solar keratoses, therefore these two pathologies are found in a similar anatomical distribution. They occur most commonly on chronically sun-exposed sites, such as the hands, forearms, head and neck. A minority of SCC may arise from chronic ulcers or other sites of chronic inflammation.

It is thought that there is a continuum of keratinocyte dysplasia from solar keratosis to Bowenoid keratosis, Bowen’s disease (SCC in situ) and invasive SCC. It can be difficult to clinically distinguish between the various lesions representative of this continuum. Generally, SCC present as a thickened scaly red patch or nodule, which may bleed easily or ulcerate and may be tender.

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SCC Continuum

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1, Solar keratosis

2. Bowenoid keratosis

3. Bowen's disease (SCC in situ)

4. Invasive SCC

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Solar keratosis

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Bowenoid solar keratosis

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SCC DISTRIBUTION

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SCC arise on parts of the body that are chronically exposed to the sun. In contrast to BCC, the anatomical distribution of SCC is different for men and women. In men, head and neck are the commonest sites, whereas in females, the arms are the commonest site.

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Most SCCs present as a papule or nodule, with a variable amount of overlying hyperkeratosis. Progressive enlargement over weeks to months is typical, with increasing tenderness. There may be a history of bleeding or ulceration, becoming more common as the lesion enlarges. Some SCCs may present as an ulcer, without a nodule. A minority of SCCs may become locally aggressive and larger lesions may metastasise to regional lymph nodes.

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Most SCCs present as a papule or nodule, with a variable amount of overlying hyperkeratosis. Progressive enlargement over weeks to months is typical, with increasing tenderness. There may be a history of bleeding or ulceration, becoming more common as the lesion enlarges. Some SCCs may present as an ulcer, without a nodule. A minority of SCCs may become locally aggressive and larger lesions may metastasise to regional lymph nodes.

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SCC: hyperkeratotic, ulcerated nodule on the ear, growing over 1-2 months.

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SCC Bx

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Punch biopsy

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SCC Tx

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Margin-controlled surgical excision is the treatment of choice for SCC.

1. Most well-differentiated SCC smaller than 2 cm in diameter can be treated with margin-controlled excision, with a good chance of achieving complete eradication and long-term control. The majority of favourable (well-differentiated) SCC less than 2 cm in diameter can be excised with a margin of at least 4 mm

SCC larger than 2 cm require larger margins up to 10 mm to achieve similar local control rates (Luce 1995). The depth of excision should be through normal underlying fat.

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Keratoacanthoma

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Keratoacanthoma is likely to be a type of well-differentiated SCC. These lesions are characterized by rapid growth and spontaneous involution. Patients may give a history of a small papule that enlarges over 1-2 months to form a red nodule with a central Keratosis plug. The resulting nodule is often very tender. After a period of stable lesion size, the nodular rim begins to regress and over a period of 2-3 months the lesion may involute completely, sometimes leaving a scar. Differential diagnoses include amelanotic nodular melanoma, atypical fibroxanthoma and Merkel cell tumour. It is currently recommended that these lesions be excised completely. Partial biopsies are usually unhelpful, as the entire architecture of the lesion is needed for the pathologist to be able to diagnose keratoacanthoma.

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Appeared and disappeared

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Keratoacanthoma

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Specialist Referral for MGMT

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invasion

thicker than 4 mm

perineural spread

wider than 2cm

poorly differentiated

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When Surgery is C/I

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1. Cryotherapy

2. Radiotherapy

3. Photodynamic therapy

4. Curettage and diathermy

5. Topical agents

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Eczema Treatment

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General measures

•Avoid soap ( use soapsubstitute, nondetergent)

•Regular emollient (egsorbolene cream)

• Warm, not hot showers

Specific measures

•Topical steroid toinflamed areas eg potentsteroid to body;

•Mild steroid for face, ornon steroid antiinflammatory creams(pimecrolimus)

•Treat infection ifsuspected with systemicantibiotics

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Eczema Tx other than avoidance and coticosteroids

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Wet dressings

Phototherapy with UVB

Systemic immunosuppression:

• Short term with oral prednisolone

• Medium to long term – Azathioprine,Cyclosporin A, Methotrexate, Mycophenolatemofetil

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Scabies Rash

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Intensely itchy rash

Worse at night

Starts hands, feet, interdigital spaces with "burrows" of scabies mite

Spreads to genital areas and body (Non-specific eczematous rash –This is a secondaryhypersensitivity reaction andoccurs later)

Face and hands spared in adults

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Scabies Tx

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5% permethrin cream 1st line treatment forscabies• Apply cream all over from neck down – esphands, genitalia and under nails with naibrush(care with handwashing)• Infants (>6 months) and children need to treatscalp as well• Leave on overnight (8hrs)• Wash off in morning, treat clothing with hot washand tumble dry (>55c)

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Acne Causes

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• Starts in adolescence with increasing sebum production

• Strong genetic component

• Can be flared by hormonal factors (menstruation), picking,emotional stress

• Medications: Lithium, anabolic steroids, topicalcorticosteroids (steroid acne)

• Topical occlusion – “oily” makeup, moisturisers, headwear andhairstyling

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Features

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1. Open comedone (black head) - oxidized sebum

2. Closed comedone (white head)

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Acne Tx: TOPICAL

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1. Topical Salicylic acid or Retinoic acid (dissolves Comedones)

2. Topical antibacterials (Benzoyl peroxide, erythromycin, clindamycin)

3. Combos (clindamycin + Benzoyl)

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Acne Tx: SYSTEMIC

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1. Systemic ABx

2. OCP anti-androgenic (Ethinyl estradiol +cyproterone acetate)

- female only

3. Anti-androgens (Spironolactone)

-female only

4. Systemic Retinoids (Isotretinoin) (Accutane)

- potent

- teratogenic

- depression???

- t

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Psoriasis Tx

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Topical – steroids, tars, calcipotriol, dithranol,keratolytics, emollients

Phototherapy – Narrowband UVB treatment,(PUVA)

Systemic – oral acitretin, methotrexate,cyclosporin A, biologic treatments.

Often used in combination.

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Guttate Psoriasis

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Acute onset of small, scattered uniform lesions

Often post streptococcal infection

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Bullous impetigo

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Staphylococcus aureus

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nodular bCC

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The most common form of BCC is nodular.

These lesions appear as a raised, firm papule or nodule, described as waxy, pearly, shiny, or translucent.

The border appears to be a rolled edge. The lesions may form a central ulceration or scab and commonly have surface telangectasia, dilated red blood vessels.

A common patient complaint is easy bleeding and scabbing.

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pigmented BCC

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A second subtype, pigmented BCC, appears similar to nodular BCC, but its black or blue pigmentation makes it appear like melanoma.

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superficial BCC

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Superficial BCC, appears as a thin, red, irregular, scaly plaque or eczematous-like patch. There may be single or multiple lesions, but they retain the pearly border and may bleed easily. It is more common in middle-aged adults on the torso and extremities

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Morpheaform BCC

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The fourth subtype, morpheaform BCC, although the least common, is the most aggressive, infiltrating deeper into the dermis than other BCC forms. It is difficult to identify because of its smooth, ill-defined, scar-like appearance.

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Squamous cell carcinoma: pink, scaly, fleshy, irregular borders.

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Squamous cell carcinoma: pink, scaly, fleshy, irregular borders.

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Seborrhoeic Keratosis

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Seborrheic Keratosis Seborrheic keratosis is another common benign lesion also resembling melanoma. It is known for having a stuck-on appearance, with a well-defined border and raised, warty surface. Its color ranges from pale brown to black but is mostly uniform. The size can vary from 0.5–3 cm

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solar (actinic) keratoses are premalignant for SCC and are a scaly spot found on sun-damaged skin on FACE OR BACK OF HAND. It is also known as solar keratosis. It is considered precancerous or an early form of cutaneous squamous cell carcinoma.