Derm wk 3 Flashcards
Red, crusted bump
dry and rough, lotion does not help
sometimes itchy, friable
Good description example:
Well circumscribed, 2 cm, erythematous NODULE w central ulceration and crust. The lesion is firm with palpation.
Squamous Cell Carcinoma
Cell or origin: Keratinocyte
Squamous cell carcinoma
Erythematous nodule, rolled borders, CENTRAL ulceration, crust, growth looking thing
Squamous Cell Carcinoma has all sorts of appearances
Papule, plaque, nodule
Pink, scaly, or red
Exophytic- with outward growth
i.e.: Cutaneous horn
Friable
Are Squamous Cell Carcinoma lesions symptomatic?
Often not at first, may be ITCHY and TENDER
“SCC in situ”
Bowen’s Dz
“SCC in situ” aka Bowen’s dz
Circumscribed pink/red patch or thin plaque w scaly or rough surface
confined to Epidermis, does not invade past dermal-epidermal junction
“SCC in situ” aka Bowen’s dz almost looks like
Cellulitis or Erysipelas
Can have SCC of the Nail
males 50-70s
Nails appear warty, subunqual hyperkeratosis, oncholysis oozing, destruction of nail plate
Tx for SCC
Surgical excision- make sure borders got all CA
What does invasive mean?
that the carcinoma cells are in the DERMIS
if not, it will be called “in situ”
Surgical tx options for SCC
Surgical excision
- excision w margins
- Mohs
Curettage and Electrodesiccation or Cryosurgery
-for in situ SCC
If pt can’t have surgery and has SCC, what are options?
Radiation
Photodynamic therapy
5-Fluorouracil
Imiquimod
5-Flour
Antimetabolite, meaning it interferes w DNA synthesis
Approved for AK, Basal Cell, and SCC who can’t have surgery
Imiquimod
Immune response modifier
Induces pro-inflammatory cytokines
Imiquimod
for AK of Scalp and FACE
for Superficial Basal cell CA
Non surgical SCC
What indicates a better response rate when using Imiquimod?
a greater inflammatory response
Higher rates of METs if:
- on Ears, lip without hair, scalp, mask of face
- in Scars, chronic ulcers, burns, sinus tracts, anogenital region
- Immunosuppressed
- Tumor was caused by arsenic ingestion
Pts w NON-metastatic SCC need f/u how often?
every 6-12 mo for 3 years
then yearly
AK- Actinic Keratosis
have the potential of turning into —> SCC Squam Cell CA
Do all AK turn into SCC?
No, risk within one year is 8%
The order of skin progression is:
Photo damaged skin –> AK–> SCC in situ (bowens) –> Invasive SCC
SANDPAPER lesion
red, flat papule or thin plaque with a rough and gritty scale
Actinic Keratosis
AK
Red, scaly patches
Actinic Keratosis
Cutis Rhomboidalis nuchae
Reddish neck w rhomboidal furrows (wrinkes)
-example of sun damage
Solar Elastosis
fine nodularity, pebbly surface
-example of sun damage
When you think of “old people arms” w easy bruising
Actinic (senile) Purpura
Extravasated erythrocytes and increased perivascular inflammation
Actinic Cheilitis represents
AK on the lips, often the lower lip
Option to treat Actinic Keratosis
Cryotherapy
w liquid nitrogen
What is Cryotherapy?
FREEZE it off w liquid nitrogen
Freeze ball should be
1.5x the size of the lesion
AK treatment
MANY options, helpful to include Dermatologist to guide therapy
- Liquid nitrogen
- Curettage and electrocautery
- 5-FU
- Imiquimod
- Ingenol mebutate gel
- Photodynamic therapy
- Diclofenac
How does Diclofenac work?
It’s a POTENT NSAIDs
approved for AK
Ingenol Mebutate
cause cell death then inflammatory response
approved for AK
Pts w AK should have regular skin exams how often?
every 6-12 months
How often to re-apply sun screen?
every 2 hours
Extra caution in sun when you are around:
Water, Snow, or Sand
All intensify the damage rays of sun
Altered tumor suppressor gene in SCC and also AK
p53
What’s the big difference b/w SCC and AK, because they both can be rough and scaly
SCC protrude more, can be crazy looking and stick out
AK are papules or thin plaque
Good description of Basal Cell CA
Solitary, 5 mm pearly pink papule with telangiectasias, on R zygomatic cheek
SubQ injection can be provided prior to intradermal
bc subQ is much less painful
Results on biopsy indicating Basal Cell CA
Rounded nests of basaloid cells, peripheral palasaiding, fibromyxoid stroma and clefts
What do you need to do before excising what you think to be a Basal Cell CA?
Biopsy the lesion first!
What gene mutation is usually involved with Basal Cell CA?
PTCH1
Although Basal cell CA are often Nodular, they can also present like:
Infiltrative Sclerotic Ulcerated Pigmented Superficial
Difference b/w Basal Cell CA scale and SCC in situ scale
Basal: fine scale
SCC in situ: Keratotic scale crust
Tool used to help evaluate skin lesions
Dermoscope
good for pigmented lesions
Benign angiofibroma
fibrous papule
Small, homogenous skin colored/pink papule on the nose
No telangiectasias or pearly texture
Morpheaform/Infiltrative Basal cell CA requires what treatment?
Excision with Mohs micrographic surgery
Surgery options for BCC
Curette and Desiccation
Cryosurgery
Excisional surgery
Mohs microscopic
Is Mohs good?
YES
offers complete histologic analysis of 100% tumor margins while permitting max conservation of tissue
Recurrence rates are lower s/p Mohs
Indication for Mohs surgery
Nose, ears, eyes, lips, scalp, hands
Basically HEAD, or hands
Agressive type
Large tumors or tumors w indistinct borders
Recurrent tumors
Non surgical tx for Basal Cell CA is considered when:
Superficial
Nodular
Imiquimod
5-FU
Photodynamic
Radiation
Basal cell CA prognosis
Locally invasive
METs are rare
BUT at greater risk for developing other types of skin CA in the future, should f/u regularly
BCC f/u
every 6-12 mo for 2 years, then can do self exams
Warning signs of BCC
Open sore Reddish patch or irritated area Shiny bump or nodule Pink growth Scar like area
ABCDEs of Melanoma
Asymmetry Borders Color Diameter Evolving
Most common skin CA
Basal cell
head or neck
Good way to describe Melanoma
___(size) dark blue to black plaque w asymmetry, irregularly notched borders and a pink erythematous rim
To decrease discomfort with injection
what can be added to lidocaine?
Bicarb
Where do Melanocytes typically live?
Basal layer
Where do Melanocytes hang out in cancerous Melanoma??
In the upper portions of epidermis
BAD NEWS BEARS
When nuclei are large and of different shapes, this is abnormal and known as
Cytologic atypia
Clinical sx of Melanoma
often A-sx
Most common type of Melanoma
Superficial spreading
on the back, and legs in women. growth is mostly horizontal
Other types of Melanoma
Nodular Lentigo maligna Acral Lentiginous (gnarly looking) Subungual (nailbed) Amelanotic (presenting like something else, the key here is that it is evolving)
Breslow depth
how to measure depth of Melanoma
A good thing to think about before sending someone for biopsy about a lesion concerning for Melanoma
Take a picture of the lesion
What is the single most important prognostic factor for survival and clinical mgmt of Melanoma?
Thickness or depth of the tumor
What other things hint at a bad prognosis with Melanoma?
Ulceration
Involvement of lymph nodes or distant mets
3 prog factors review
Breslow
Ulcer
Lymph involvement
How often to f/u for Melanoma if pt has stage 1-2?
every 6-12 mo for 5 years,
then annually
How often to f/u for Melanoma if pt has stage 2b-4?
every 3-6 mo for 2 years,
then every 3-12 mo for 3 years,
then annually
Who is at the greatest risk for Lethal Melanoma?
White males over 50 who live alone
How many moles are concerning?
> 25 or
5 Atypical moles
or 1st deg relative with biopsy proven Melanoma
