11. Dermatology Flashcards
A 64 year old man presents with a lesion on his upper ear that has been present for months but has now begun to ulcerate. On examination: non-pigmented, hyperkeratotic, crusty lesion with raised everted edges on the pinna.
What is the most likely diagnosis? A. Basal call carcinoma B. Malignant melanoma – superficial spreading type C. Malignant melanoma – nodular type D. Non-healing scab E. Squamous cell carcinoma
E. Squamous cell carcinoma
Hints: Age Classic site Non-pigmented Hyperkeratotic, crusty Everted edges
A 64 year old man presents with a lesion on his upper ear that has been present for months but has now begun to ulcerate. On examination: non-pigmented, hyperkeratotic, crusty lesion with raised everted edges on the pinna.
How should the GP proceed? A. Provide sun exposure advice B. Monitor for changes with serial follow up C. Treat in primary care D. Dermatology referral - routine E. Dermatology referral – 2 week wait
E. Dermatology referral – 2 week wait
Hints:
Diagnosis = SCC
Potentially malignant spread
Must refer urgently as for melanoma
A 32-year old professional surfer had a seizure three days ago. He has no history of epilepsy and reports headaches for the past 5 months. The headaches are worse when he goes to bed. On examination, a dark irregular skin lesion is found on the back of his neck. An MRI scan shows multiple lesions across both cerebral hemispheres.
What is the most likely diagnosis? A. Acoustic neuroma B. Glioblastoma multiforme C. Meningioma D. Metastases E. Neurofibromatosis type I
D. Metastases
Hints:
- Signs of raised ICP (brain mets)
- Lesion suspicious of melanoma
- Significant sun exposure
A 76-year-old woman has recently attended her GP because of a ‘spot that won’t go away’. The lesion is on her nose and has pearly, rolled edges with telangiectasias.
What is the most likely diagnosis? A. Squamous cell carcinoma B. Molluscum contagiosum C. Basal cell carcinoma D. Acne rosacea E. Acne vulgaris
C. Basal cell carcinoma
Hints:
Classic site
Features of BCC
Malignant melanoma Definition and Epidemiology
Definition: invasive, malignant tumour of the epidermal melanocytes which has the potential to metastasize
Epidemiology:
Least common skin cancer
Average age is 63 years (but can affect much younger people ~30 years)
Malignant melanoma RF
Modifiable - Excessive UV exposure
Non-modifiable
- Skin type I* (always burns, never tans)
- History multiple moles, atypical moles
- Family Hx/PMHx melanoma
*Fitzpatrick skin types: 1-6 (1 is fairest skin, 6 has darkest skin)
Malignant Melanoma Presentation - Signs and Symptoms
Where is it most commonly found?
What is the 7 point check list and when do you refer to 2-week-wait
Asymmetry (2) Borders irregular Colour irregular (2) Diameter >7mm (1) Expanding size (evolution of lesion) (2)
Symptoms:
- Inflammation (1)
- Oozing (1)
- Change in sensation (1)
Legs in women, trunk in men
If >3 = 2 week referral
Types of Melanoma (4)
LANS
- Lentigo Maligna (Elderly, face, Chronic UV)
- Acral Lentiginous (Darker skin types, palm/soles/nails)
- Nodular* (raised, black, poor prog as vertical spread at Dx)
- Superficial Spreading (Most common)
*May not fit 7 pt criteria – NICE say refer if you suspect
Differential: melanocytic lesions
Slightly Commoner In Just Countries
Seborrheic wart
- (Elderly)
- Often multiple, Wart-like, greasy, Stuck on appearance
Congenital naevi
- Can be large, pigmented, hairy
Intradermal naevi
- Dome-shaped papule/nodule
Junctional naevi
- Small, flat, dark
Compound naevi
- Raised, warty, hairy
Cancer: malignant melanoma Investigation(s)
GP: 2 week dermatology referral
Dermatology:
- Examination with dermatoscope
Definitive: full thickness excisional biopsy
Atypical melanocytic lesion - take photographs and r/v at 3 months
If there is a suggestion of metastases:
- CXR (lung mets)
- Liver ultrasound (liver mets)
- CT chest, abdomen, pelvis
- Brain MRI
Basal cell carcinoma Definition and Epidemiology
Slow growing locally invasive tumour of basal cells of the epidermis, rarely metastasizes
Epidemiology: older individuals, most common (skin) cancer
Basal cell carcinoma
Modifiable
- Excessive UV exposure
- Frequent/severe sunburn in childhood
Non-modifiable
- Skin type I
- Older age
- Males
- Immunosuppression
- PMHx/FHx skin cancer
Presentation & subtypes:
Most common over head and neck (nose)
Nodular (most common) - Small - Skin coloured nodule - Surface telangiectasia - Pearly rolled edge ± Ulcerated centre (rodent ulcer)
Superficial (Flat)
Sclerosing/morphea (Scar like)
Pigmented (May appear like melanoma)
Investigation BCC
Routine referral to dermatology – NOT 2 week wait, or if low risk Mx/follow up in primary
Examine with a dermatoscope
The lesion is then usually removed
Squamous cell carcinoma Definition and Epidemiology
Definition: locally invasive malignant tumour of the epidermal keratinocytes or its appendages, with potential to metastasize
Epidemiology: middle aged and elderly
SqCC Risk factors
- Excessive UV exposure
- Pre-malignant skin conditions e.g. actinic keratoses (crumbly yellow-white crusting, premalignant)
- Chronic inflammation e.g. leg ulcer, wound scar (Marjolin’s ulcer - chronic defect causes proliferation of epithelium which becomes unchecked)
- Immunosuppression
- Family history
SqCC Presentation
Keratotic (scaly, crusty) Ill-defined nodule May ulcerate Non-healing lesion Everted edges
SqCC Investigation
Refer to dermatology (2 week wait)
Dermatoscope
(Biopsy) & excision
A 4-year old girl presents to the GP with multiple lesions on her face. The lesions are raised and shiny, non-tender, non-erythematous, and 3 mm in diameter. They have an umbilicated centre. The patient is known to be HIV positive.
What is the most likely diagnosis? A. Chicken pox B. Molluscum contagiosum C. Atopic eczema D. Eczema herpeticum E. Herpes simplex virus
B. Molluscum contagiosum
Hints
Classic appearance
HIV
A 52-year-old woman presents to the GP with redness and swelling of her right cheek. On examination the area of erythema is well-demarcated and warm to touch. Her temperature is 37.9C and she feels unwell.
What is the most appropriate management plan for this patient?
A. Cold compress, reassure, home
B. Admit to intensive care unit
C. Take skin swabs, blood cultures, and give paracetamol
D. Draw around the lesion, give pain relief, oral fluids and antibiotics
E. Emergency dentist referral
D. Draw around the lesion, give pain relief, oral fluids and antibiotics
Hints
Well-demarcated & systemic upset – probably erysipelas
Molluscum contagiosum definition and epidemiology and RF
Definition: viral skin infection (molluscum contagiosum virus, pox virus)
Epidemiology: preschool children aged 1-4
RF:
- Transmission: close contact, swimming pools, sexual contact
- HIV infection
- Atopic eczema
Presentation of Molluscum contagiosum and Invx
- Dome shaped, flesh coloured, pearly white papules
- Central umbilication
- May be >100 if immunocompromised/HIV
- Systemically well
No investigations needed: clinical diagnosis
