Acne, Rosacea, Skin Cancers Precursors and mimics

Question 1

Acne vulgaris
-epidemiology
-pathophysiology
-presentation
-diagnosis
-management
-referral

Answer 1

10-20s in both genders

Proliferation of propioninibacterium acnes within follicles => inflammation
Increased sebum production from androgens creates a favourable environment for Pacnes

Comedones, inflammation and pustules
Scarring - icepick, hypertrophic (raised)

Clinical diagnosis

Initial - 12wk TOP
-adapalene + benzoyl peroxide
-clindamycin + tretinoin
-clindamycin + benzoyl peroxide

If severe add
-PO lymecycline or doxycycline
or TOP azelaic acid + 1 PO ABx

COCP can be alternative to PO ABx + TOP

Refer to specialist for PO isotretinoin if
-scarring, persistent pigment changes
-no change to 2 treatment courses
-no change with PO ABx
-persistent psychological distress

Change POP => COCP
-can be pro-acne

Question 2

Acne vulgaris
-prescribing cautions

Answer 2

Avoid tetracyclines if
-pregnant or breastfeeding => use erythromycin or
-children U12

Reducing risk of resistance
-Don’t use PO and TOP ABx together
-Give ABx with TOP retinoid or benzoyl peroxide
-Give COCP with TOP agent

Avoid retinoids if pregnant
-unless using 2 forms of contraception

Question 3

Basal cell carcinoma
-risk factors
-presentation
-investigations
-management

Answer 3

Sun exposed sites - H+N

Rolled edges with crater
Telangiectasia around edges

Very slow progression, so routine referral is sufficient

Surgical removal
Cryotherapy
RT
TOP fluorouracil

Question 4

Bowen’s disease
-risk factors
-presentation
-diagnosis
-management

Answer 4

Precancerous precursor to squamous cell carcinoma
Elderly
Sun exposed areas

Red scaly patch
Slow growing

Diagnosed and managed in primary care if diagnosis
-TOP 5 fluorouracil with TOP steroids to manage inflammation and redness
-cryotherapy
-exicision

Question 5

Rosacea
-epidemiology
-presentation
-diagnosis
-management

Answer 5

40-50s females

Nose, cheek and forehead
Flushing => persistent redness, papules, pustules
Telangiectasia
Blepharitis
Worsened by sunlight

Clinical diagnosis

Suncream, camouflage cream
1st line - TOP ivermectin
Metronidazole/azelaic acid

Severe, papules, pustules
-TOP ivermectin + PO doxy

Question 6

Malignant melanoma
-risk factors
-presentation
-management
-prognosis

Answer 6

Sunexposure

Asymmetry
Borders poorly defined
Colours - many
Diameter 7mm+
Exudate - oozing, bleeding

Excision biopsy - margin of excision related to Breslow thickness of lesion

Breslow thickness => lower 5 year survival

Question 7

Cautions with TOP CS

Answer 7

TOP CS - skin atrophy, striae, rebound symptoms

4wk break before starting another round of TOP CS

Systemic SE seen when used on 10%+ BSA

Potent CS - max 8wks
V potent CS - max 4wks

Question 8

Squamous cell carcinoma
-risk factors
-presentation
-management

Answer 8

Sunexposure, UVA therapy
Actinic keratoses, Bowen’s disease
Immunosuppression post renal transplant, HIV
Smoking
Chronic leg ulcers

Sunexposed sites
Rapidly expanding, painless, ULCERATING nodules
Cauliflower
BLEEDING
Telangiectasia around periphery

Surgical excision

Question 9

Actinic keratoses
-what is it
-presentation
-mamagement

Answer 9

Common premalignant skin lesion from chronic sun exposure

Small, crusty, scaly lesions
Pink/red/brown/skin coloured
Sunexposed areas

Avoid the sun, suncream
Fluorouracil cream - 2-3wks, can cause skin inflammation
-TOP hydrocortisone used afterwards
TOP diclofenac
TOP imiquimod
Cryotherapy
Curettage and cautery

Question 10

Keratoacanthoma
-what is it
-presentation
-management

Answer 10

Benign epithelial tumour - more common with increasing age

Volcano, crater
-smooth dome papule => crater centrally filled with keratin

Spontaneous regression within 3 months => scarring
URGENTLY EXCISED - clinically difficult to exclude SCC

Question 11

Seborrhaic keratoses
-what is it
-presentation
-management

Answer 11

Benign epidermal skin lesions

Variation in colour - flesh to light-brown, black
Stuck on appearance
Keratotic plugs

Reassurance about benign nature of lesion
Surgical management
-cryosurgery
-shave biopsy
-curettage

Question 12

Types of melanoma
-frequency
-typically affects
-appearance

Answer 12

MOST COMMON - superficial spreading
-arms, legs, back, chest
-young people
-growing mole with ABCDE features

2nd most common - nodular
-sun-exposed skin
-middle age
-red, black lump, bleeds/oozes

3rd most common - lentigo maligna
-chronic sun-exposed skin
-older people
-growing mole with ABCDE features

Rare - acral lentiguous
-nail, palm, soles - areas not associated with sun exposure
-darker skin pigmentation
-subungual pigmentation (Hutchinson’s sign), palms and feet