Skin 2 Flashcards
what is the most common skin cancer
basal cell carcinoma - common, locally invasive, kertionycte cancer
aetiology of BCC
DNA mutation in the patched tumor suppressor gene (PTCH) gene
RF for BCC
elderly males previous BCC sun damage actinic keratoses repeated prior episodes of sunburn fair skin, blue eyes and blonde or red hair thermal burn inherited BCC
clinical features of BCC
- raised rolled edge pearly lesion
- telangiectasia - may be one the surface and the center may break open to form a scab
- sore can bleed and form a scab and heal
- slowly growing plaque or nodule
- skin-colored, pink, or pigmented
- spontaneous bleeding or ulceration
investigation of BCC
- Diagnosis of clinical suspicion
- Dermatoscope
- Excision biopsy – gold standard diagnosis.
which subtype of BCC is the most common on the face
nodular BCC
which subtype of BCC is the most common on the younger adults
superficial BCC
which subtype of BCC is the most common to spread through perinerual means
morphoeic BCC
mx of BCC
Routine referral (3 months) unless delay may have significant impact e.g. size and site of lesion.
Types of treatment
• Excision.
• Mohs micrographically controlled excision: involves examining carefully marked excised tissue under the microscope, layer by layer, to ensure to complete excision - tissue sparing or head and neck
• Superficial skin surgery
• Cryotherapy
• Photodynamic therapy:
• Imiquimod cream: immune response modifier
• Fluorouracil cream: topical cytotoxic agent
• Radiotherapy
what is a squamous cell carcinoma
A proliferation of atypical transformed keratinocytes in the skin with malignant behaviour which ranges from in-situ tumours to invasive metastatic disease.
what are the different types of SCC
- actinic keratoses - precursor
- SCC in situ (bown disease) - confined to outer layer of skin
- invasive SCC - spread into deeper layers of the skin
- metastatic SCC - spread to other parts of the body
what are the different variants of SCC
keratoacanthoma - rapidly growing dome shaped nodule with a central kertin filled crater –> known as a well differentiated SCC
Verrucous carcinoma: Lesions appear as exophytic, fungating, verrucous nodules, or plaques on skin or mucosa.
Marjolin ulcer - aggressive, ulcerating SCC that arises in chronic wounds, burns, scars, or ulcers
aetiology of SCC
• DNA mutation in protooncogenes and tumour suppressor genes.
• Actinic keratoses- most common precursor.
Sun exposed sites- face, hands, ears.
risk factors of SCC
- Male
- UV light exposure
- Ionising radiation
- Burns
- Inherited skin conditions.
- Immunosuppression
- Fairs kin
- HPV
- Previous SCC
clinical features of SCC
• Squamous cell carcinoma insitu– BOWEN’S DISEASE.
One or more slowly enlarging erythematous of skin coloured plaques.
• Invasive Squamous cell carcinoma
Fast growing lesion.
Occur in a actinic keratosis on within SCC in-situ
Irregular keratinous nodule or a firm erythematous plaque and frequently ulcerates and bleeds
• Metastatic
Bone pain.
Hepatomegaly.
investigation of SCC
diagnosisc of clinical featuers
dermatoscope
biopsy - full thickness keratinocyte atypia
management of SCC
Urgent 2-week suspected cancer pathway.
Squamous cell carcinoma in situ 1st line- cryotherapy, electrodessication/curettage, photodynamic therapy 2nd line- fluorouracil, imiquimod Surgical excision or Mohs surgery radiotherapy
Invasive squamous carcinoma
1st line: surgical excision or Moh’s surgery.
Metastatic SCC
Surgery + radiotherapy + chemotherapy.
what is melanoma
cancer of uncontrolled growth of melanocytes (pigment cells)
aetiology of melanoma
- DNA mutation of oncogene/ tumour suppressor genes resulting in uncontrolled melanocyte growth
- melanocytes present in the skin, eye and CNS
- the gene associated with familial melanoma is CDKN2A which encodes the P16 and p14ARF gene
what are the different types of melanoma
- Superficial spreading Melanoma most common, any sight but preference for torso in men or legs in woman, average diagnosing age between 30 and 50
- nodular Melanoma second most common , any side to, diagnosis in 60s, rapid vertical growth and later stage and diagnosis
- Lentigo Maligna Melanoma Most commonly diagnosed > 60 yrs old on sun damaged
- Acral lentiginous melanoma most common in people with darker skin types, palms, soles and nail apparatus
clinical features of melanoma
- Most common on back or leg.
- First sign- freckle or mole.
- Variation in colour from tan, dark brown, blue, red and light grey.
- May be areas of regression that are the colour of normal skin, white and scarred.
- Can be itchy and tender
- Can be amelanotic
- Hutchinson’s sign (nail sign= blackness in the nail)
- Bluish white veil of melanoma.
- fixed lymphadenopathy
- A-E tool asymmetry of lesion, border irregularity, colour variability, diameter > 6mm, evolution
investigation of melanoma
Diagnosis of clinical features Dermatoscopic features Biopsy – diagnostic. Sentinel lymph node biopsy Serum lactate dehydrogenase used to classify metastatic disease can be elevated CXR may show pulmonary mets CDKN2A genetic test
management of melanoma
Non-Metastatic
In-situ (melanoma confined to epidermis)
• 1st line: surgical excision
• 2nd line: topical therapy (imiquimod)
Breslow < 1mm to > 4mm
• Surgical excision +/- lymph node biopsy.
Metastatic
• Surgical excision
• Chemotherapy and radiotherapy and immunotherapy.
what is a leg ulcer
a break in the skin below the knee which has not healed within 2 weeks
which is the most common leg ulcer
venous ulcer - 80%
what is the aetiology of venous leg ulcer
due to pooling of blood and waste products in the skin secondary to venous deficiency (varicose veins, DVT, phlebitis etc)
RF for venous leg ulcers
inc age obesity immobility limited range of ankle function previous ucler personal/Fhx of varicose veins female multiple pregnancies AV fistula Hx of leg fractures or trauma prolonged standing
clinical features of venous leg ulcers
- Large, shallow ulcers with a granulated base and irregular borders
- Pain, heaviness, aching swelling and itching of the affected leg.
- More likely to bleed
- Pain relieved by elevation and worse on hanging
• Features of venous insufficiency:
Oedematous flushed skin
Hyperpigmented skin
Varicose eczema
Lipodermatosclerosis (champagne bottle leg)
Atrophe blanches - ivory-colored stellate scars on the legs
investigation of venous leg ulcers
diagnosis is usually clinical
- assess the ulcer, take photographs if possible and appropriate
- signs of infection - eg cellulitis signs, fever, inc pain, rapid extension of the area of ulceration, inc exusdate
- examine both legs for venous insufficiency
- examine lying and standing to assess for varicose veins
- Doppler USS - will demonstrate venous insufficiency
- ABPI > 1 = no arterial disease
management of venous leg uclers
• Treating underlying cause (arterial or venous disease)
• Assess need for immediate referral: alternative diagnosis, ulcer is recurrent,
• Conservative: leg elevation + lifestyle (weight reduction)
• Compression therapy
• Pentoxifylline to aid ulcer healing
treat associated symptoms
- oedema - compression, leg elevated, regular exercise
- itchy skin (varicose veins) - emollient and topical corticosteroid
good wound care
- debridement
- cleaning
- dressing
- antibiotics where infected
- skin craft in severe and appropriate cases
what is the cause of an arterial ulcer
ulceration as a manifestation of peripheral vascular disease
RF for arterial ulcer
smoking diabetes hypertension hyperlipaemia inc age FHX obesity physical activity
clinical features of an arterial ulcer
• Hx: intermittent claudication (pain on walking) or critical limb ischemia (pain at night)
• Smaller, shallow ulcer with regular borders, no granulation tissue and less bleeding (no healing due to no blood supply). • Painful (more than venous ulcers) • Pain at night when legs elevated • Pain wore on elevating the leg and improved by hanging. • Signs of PVD Absent pulses Pallor Hair loss Necrotic toes
investigation of arterial ulcer
examine the ulcer - size, location, depth
examine for signs of arterial insufficiency - pale, hairless, necrotic toes
ABPI (diagnostic) - > 0.9 = normal, 0.8-0.5 = moderate, < 0.5 = severe)
• Anatomical location of any arterial disease; duplex ultrasound, CT Angiography, and / or Magnetic Resonance Angiogram (MRA).
mx of an arterial ulcer
- URGENT VASCULAR REVIEW (as ulcers develop in critical limb ischemia)
- Conservative: lifestyle changes: smoking, increased exercise
- Medical: CVD risk modification: statin + antihypertensive therapy.
- Surgical: Angioplasty or bypass grafting
what is the aetiology of a neuropathic ulcer
occurs as a result of peripheral neuropathy - result in loss of protective sensation, leading to repetitive damage
clinical features of a neuropathic ulcer
• Varied size, punched out painless ulcers.
• Hx peripheral neuropathy
Glove and stocking pattern.
• Burning and tingling in the legs
• Affects pressure point areas (metatarsal heads or heels, bottom of the feet)
investigation of a neuropathic ulcer
Assess the ulcer
• Assess for peripheral neuropathy
10g monofilament
128Hz tuning fork: vibration sensation.
blood glucose, B12
swab and if bone visible - X-ray to exclude osteomyelitis
ABP - > 0.9
mx of neuropathic ulcer
- Diabetic foot clinical
- Optimize diabetes control: lifestyle and medication
- Regular chiropody
- Appropriate footwear
- If ischaemia consider surgical debridement.
what is a solar keratosis
it is a scaly spot found on sun damaged skin that is a precursor to SCC
clinical features of solar keratosis
- can be solitary or multiple
- sites of sun exposure eg back of hands, face, upper trunk, neck
- a flat or thickened plaque or papule
white or yellow scaly, warty or horny surface
skin coloured red or pigmented
tender or asymptomatic
what is another name foe solar keratosis
acintic keratosis
investigation and management of solar kertaosis?
clinical diagnosis
dematoscope and biopsy used to exclude SCC
removal due to risk of SCC
what is a keloid scar
firm, smooth, hard growth due to spontaneous scar formation. It can arise soon after an injury or develop months later and is typically much larger than the wound itself
clinical features of a keloid scar
scar formation at site of wound (ear piercing, tattoo, burns, insect bites and spots)
shinny hairless raised above surrounding skin hard and rubbery red or purple uncomfortable itchy
investigation and management of a keloid scar
- Diagnosis of clinical features
* Treatment can be nothing or reduction or removal.
what is a ganglion
sac-like swelling or cyst formed from the tissue that lines a joint or tendon (synovium/synovial fluid)
causes of ganglion
mostly unknown
arthritis
clinical features of a ganglion
most commonly found in wrist and ankles
painless localised jelly-like swelling
examples = a baker’s cyst in the knee
differentials for a ganglion
lipoma
malignancy
investigation and management of a ganglion
clinical diagnosis
X-ray used to determine joint involvment
Tx - self-limiting, massage, aspiration and surgery
what is a vascular lesion of the skin?
common abnor of the vasculature in and underlying the skin
what is a telangiectasis
small, dilated blood vessles near surface of the skin
what is a angiokeratoma
small red or blue lesions caused by caillaries
what is cherry angioma
red lesions of collected blood vessels that look like a red mole
what is spider angioma
a cluster of a blood vessel with a central red spot and vessels that radiate outwards
what is a granuloma faciale
lesion of the face ranging from skin coloured to purple that is caused by inflamed blood vessels
what is a hemangioma
a rubbery, bright red mark of blood vessels often presented at birth
what is keratosis pilaris
small, light-colored bumps that result from a build up of certain
what is a pyogenic granulma
an eruptive hemangioma ranging from pink to purple caused by irritation, hormones or trauma
what is a venous lake
a drak blue to purple lesion found on sun exposed areas, often in the elderly
what is a kaposi sarcoma
a disease of the endothelial cells of blood vessels and lymphatic system. no longer classified as sarcoma as it is due to multicentric vascular hyperplasia
what is the cause of kaposi sarcoma
Kaposi sacroma herpesvirus (KSHV)
what are the different types of kaposi sarcoma
classic - associated with DM
HIV associated Kaposi sarcoma
African kaposi Sarcoma
Iatrogenic Kaposi sarcoma (immunosuppression mediation)
what is the most common type of kaposi sarcoma
HIV associated Kaposi sarcoma
what are the clinical features of Kaposi sarcoma
red/purple macules, papules and nodules anywhere on the mucous membranes lining the mouth, throat, lymph nodes and other organs
lesions are small and painless but can ulcerate and become painful
internal
- discomfort and welling
- bleeding
- haematemsis
- haematochezia
- melaena
- bowel obstruction
- SOB
- swollen legs
investigation and management of Kaposi sarcoma
- Skin biopsy: diagnostic
* Treatment: treat the causes (HIV), localized therapy, systemic therapy (anti-cancer drugs)
