39b. Benign and malignant skin lesions Flashcards
Assessment of pigmented lesions for red flags for melanoma
ABCDE for pigmented lesions - red flags for melanoma:
For superficial melanomas — ABCDE signs
A: Asymmetry of shape and colour
B: Border irregularity, including smudgy or ill-defined margin
C: Colour variation and change
D: Different (formerly diameter)
E: Evolving (enlarging, changing)
Melanomas may not conform to the ‘ABCD’ rule alone. For nodular melanomas, also consider the EFG signs
E: Elevated
F: Firm to touch
G: Growing
what scoring system for pigmented skin lesions is used by GPs to know when to warrant referrals
Glasgow 7 point weighted checklist (3 or more indicates referral)
what is Glasgow 7 point weighted checklist?
Major features (2 points)
Change in size of lesion (G)
Irregular pigmentation ©
Irregular border (B)
Minor features (1 point)
Inflammation
Itch or altered sensation
Larger than other lesions (diameter >7mm) (D)
Oozing/crusting of lesion
4 Ss for non-pigmented lesions
Site
Size
Shape
Surrounding skin
what % of melanoma aarise from moles
20-30% of melanomas are found in existing moles
70-80% arise on normal looking skin
Most common type of melanoma
Superficial spreading
most aggressive form of melanoma? presentation
Nodular melanoma
Red or black lump or lump which bleeds or oozes
plan ?melanoma
- excision biopsy
- re-excision of margins if required / Sentinel node biopsy
Immunotherapy and BRAF stuff used in some cases
what is the single most important factor in determining prognosis of patients with malignant melanoma
The invasion depth of a tumour (Breslow depth)
features of basal cell carcinoma
Slowly growing plaque or nodule
Skin coloured, pink or pigmented, often shiny or pearly
Rolled edges
Telangiectasia
Ulceration and spontaneous bleeding
rf for BCC
routine rf: lesion that raises the suspicion of a BCC
2ww: lesion that raises the suspicion of a BCC with a particular concern that a delay may have a significant impact due to site or size
high risk factors BCC
High risk site : near eyes etc
Large size >2cm
Morpheic
Poorly defined
management bcc
Surgery
Radiotherapy sensitive if surgery not an option
most important RF SCC
Chronic UVR exposure
presentation SCC
indurated nodular keratinising or crusted tumour that may ulcerate, or it may present as an ulcer without evidence of keratinisation
red flags for SCC
Rapid growth
Raised base
May ulcerate and/or bleed
May be painful
plan ?SCC
2ww rf
Surgical excision with 4mm margins if lesion <20mm in diameter. If tumour >20mm then margins should be 6mm.
Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites.
presentation actinic keratosis
Erythema, scaling, on sun exposed areas
DO NOT HAVE ANY
Red flags:
Rapid growth
Raised base
May ulcerate and/or bleed
May be painful
presentation bowens disease
slowly enlarging erythematous scaly plaques,
DO NOT HAVE ANY
Red flags:
Rapid growth
Raised base
May ulcerate and/or bleed
May be painful
management of pre-squamous disorders (actinic keratosis and bowens)
5-fluorouracil cream (Efudix)
cryotherapy
what are warts caused by?
HPV
Types 1, 2, 3, 4, 10, 27 and 57 are most often implicated in the aetiology of cutaneous warts
Management of cutaneous warts
- no treatment (they will resolve without)
- Topical salicylic acid
Daily treatment for at least 12 weeks is required. - Cryotherapy with liquid nitrogen every two weeks until the wart has gone (up to four months)
presentation seborrhoeic keratosis
Flat or raised papule or plaque
1 mm to several cm in diameter
Skin coloured, yellow, grey, light brown, dark brown, black or mixed colours
Smooth, waxy or warty surface
Solitary or grouped in certain areas, such as within the scalp, under the breasts, over the spine or in the groin
They appear to stick on to the skin surface like barnacles.
what is solar lentigo
harmless patch of darkened skin. It results from exposure to ultraviolet (UV) radiation, which causes local proliferation of melanocytes and accumulation of melanin within the skin cells (keratinocytes).
presentation solar lentigo
flat, well-circumscribed patch. It can be round, oval or irregular in shape. Colour varies from skin-coloured, tan to dark brown or black, and size varies from a few millimetres to several centimetres in diameter. They can be slightly scaly.
on sun-exposed sites
presentation lichen keratosis
Small, inflamed macule or thin pigmented plaque, usually solitary, with a lichenoid tissue reaction on histology.
what is lichenoid keratosis
Lichenoid keratosis is an inflammatory reaction arising in a regressing existing solar lentigo or seborrhoeic keratosis. It is not known what causes the reaction, but triggers can include minor trauma such as friction, drugs, dermatitis, and sun exposure.
Lichenoid keratoses gradually disappear.
what is a Melanocytic naevi
a mole
presentation epidermoid cyst
They have a central punctum, they may contain small quantities of sebum
presentation dermatofibroma
solitary firm papule or nodule, typically on a limb
typically around 5-10mm in size
overlying skin dimples on pinching the lesion
Pathophysiology acne
Obstruction of the pilosebaceous follicle with keratin plugs which results in comedones, inflammation and pustules.
Activity of sebaceous glands may be controlled by androgen
colonisation by the anaerobic bacterium Propionibacterium acnes
inflammation
whata re inflammatory lesions in acne
Inflammatory lesions form when the follicle bursts releasing irritants
papules
pustules
comedones acne
Comedones are due to a dilated sebaceous follicle
if the top is closed a whitehead is seen
if the top opens a blackhead forms
monomorphic acne
drug-induced acne is often monomorphic (e.g. pustules are characteristically seen in steroid use)
what is acne fulminans
very severe acne associated with systemic upset (e.g. fever). Hospital admission is often required and the condition usually responds to oral steroids
Management of mild to moderate acne
12 week course of topical combination therapy
topical adapalene with topical benzoyl peroxide
topical tretinoin with topical clindamycin
topical benzoyl peroxide with topical clindamycin
topical benzoyl peroxide may be used as monotherapy if these options are contraindicated or the person wishes to avoid using a topical retinoid or an antibiotic
Management of moderate to severe acne
12 week course of
topical adapalene with topical benzoyl peroxide
topical tretinoin with topical clindamycin
topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline
a topical azelaic acid + either oral lymecycline or oral doxycycline
how long should antibiotics be used for acne
only continue a treatment option that includes an antibiotic (topical or oral) for more than 6 months in exceptional circumstances
why is it important that a topical retinoid (if not contraindicated) or benzoyl peroxide should always be co-prescribed with oral antibiotics in acne
to reduce the risk of antibiotic resistance developing
cautions tetracyclines acne treatment
tetracyclines should be avoided in pregnant or breastfeeding women and in children younger than 12 years of age. Erythromycin may be used in pregnancy.
what is an alternative to oral antibiotics for women with acne
combined oral contraceptives (COCP)
who should be referred to a dermatologist for acne
severe acne:
- conglobate acne
- nodulo-cystic acne
acne that hasn’t responded:
- mild to moderate acne has not responded to two completed courses of treatment
- moderate to severe acne has not responded to previous treatment that includes an oral antibiotic
complications:
- acne with scarring
- acne with persistent pigmentary changes
- acne is causing or contributing to persistent psychological distress or a mental health disorder
presentation salmon patches
Pink and blotchy, and commonly found on the forehead, eyelids and nape of the neck.
what are salmon patches? how do they change over time?
vascular birthmark
They usually fade over a few months, though marks on the neck may persist.
what are port wine stains? how do they change over time?
Port wine stains are vascular birthmarks that tend to be unilateral.
They do not spontaneously resolve, and in fact often darken and become raised over time.
Presentation port wine stains
Unilateral
Deep red or purple in colour
management port wine stains
cosmetic camouflage or laser therapy (multiple sessions are required).
bacteria impetigo
Staphylcoccus aureus or Streptococcus pyogenes
features impetigo
‘golden’, crusted skin lesions typically found around the mouth
Management impetigo limted local disease ‘people who are not systemically unwell or at a high risk of complications’
- hydrogen peroxide 1% cream
- topical antibiotic creams:
topical fusidic acid
topical mupirocin should be used if fusidic acid resistance is suspected
MRSA is not susceptible to either fusidic acid or retapamulin. Topical mupirocin should, therefore, be used in this situation
management impetigo extensive disease
oral flucloxacillin
oral erythromycin if penicillin-allergic
school exclusion impetigo
children should be excluded from school until the lesions are crusted and healed or 48 hours after commencing antibiotic treatment
what type of melanoma can cause brown lesion on palms, soles, and nails?
acral lentingious melanoma
what is different about acral lentingious melanoma vs other types of skin cancer?
not as related to sun exposure, most common type in darker skin
what sign to look for in acral lengingious melanoma
Hutchinson’s sign
periungual extension of brown-black pigmentation from longitudinal melanonychia onto the proximal and lateral nailfolds
plan ?acral lentingious melanoma
incision biopsy
Amputation, margins depending on biopsy results.
red dots on skin - like small freckles
cherry angiomas
small, raised, and red bumps on the skin. The bumps have a smooth surface and may be moist. They bleed easily because of the high number of blood vessels at the site
pyogenic granuloma
