Skin lesions The Good and the Bad. Dr Virginia Hubbard Ipswich Hospital NHS Trust Barts and the London School of Medicine and Dentistry
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1 Skin lesions The Good and the Bad Dr Virginia Hubbard Ipswich Hospital NHS Trust Barts and the London School of Medicine and Dentistry
2 Case 1 32 year old woman Australian Lesion on back New hair growing
3 Benign intradermal naevus
4 Dermoscopy patterns of benign naevi Reticular or globular pigmentation Regular Lack features of melanoma
5 Dermoscopy patterns of melanoma Blue-white veil Irregular pigment network Black blotches
6 Case 2 27 y man with 8/12 history of new mole on back
7
8 Melanoma
9 Malignant melanoma Irregularly shaped Variably pigmented Asymmetrical Risk factors: UV exposure / sunbeds Skin type I Blistering sunburn Family history Atypical naevi A asymmetry B border C colour D - diameter
10
11 Case 3 30 y mole on arm. Years. Worried re darker centre
12 Benign naevus reticular pigmentation hyperpigmented type
13 Case 4 45 y female, mole on leg, now more red around edges
14 45 y female, mole on leg, now more red around edges Dermoscopy: Irregular pigment network and irregular black pigmentation
15 Melanoma Changing size Changing colour Irregular on exam Irregular pigment network and irregular black pigmentation
16 Case 5 82 y male, lesion on abdo, unsure when appeared
17 Melanoma Irregular pigmentation and blue-white veil
18 Melanoma If history is doubtful, have low threshold for referral / dermoscopy Irregular pigmentation and blue-white veil
19 Vascular lesions
20 Angioma Lacunar pattern
21 Angiokeratoma
22 Subcorneal haemorrhage Red / black homogenous colour
23 Case 6 48 year old woman New lesion scalp Growing
24 Seborrhoeic keratosis Warty Stuck-on appearance May see cysts
25 Seborrhoeic keratoses Usually multiple lesions
26 Seborrhoeic keratoses Usually quite obvious
27 Seborrhoeic keratoses Sometimes less obvious
28 Seborrhoeic keratoses - dermoscopy Milia like cysts Comedo-like openings Cerebriform appearance
29 Dermatosis papulosis nigra (like seb K s)
30 Case 7 24 year old woman Lesion on lower leg 4 months Was more red, now darker around edge
31 Dermatofibroma
32 Dermatofibromas Solitary nodules, few mms, pea-like, dermis
33 Nodular melanoma
34 Nodular melanoma with mets
35 Case 8 28 year old woman Lesion on thumb 3 weeks Bleeding +++
36 Well circumscribed Often preceded by trauma Pyogenic granulomas
37 But don t miss the amelanotic melanoma... All new bleeding nodules should be excised
38 Case 9 68 year old man Lesion on scalp Few weeks Slightly tender
39 Cutaneous horns AK Viral wart SCC Can treat with cryotherapy If in doubt about underlying cause, then excise
40 Case year old man Lots of sun in past Lesion on forehead 6 months Not symptomatic
41 Poorly defined erythematous plaque with adherent scale Actinic keratosis
42 Actinic Keratoses multiple presentations
43 Actinic Keratoses management options Why bother? Treatment depends on patient factors and type of AK Lesion vs Field
44 The Field Skin around the AK lesion, which may have been damaged by UV Often red, with telangiectasias Sometimes no visible changes but cells may be genetically damaged Image is published with the permission from the New Zealand Dermatological Society Incorporated (or dermnetnz.org).
45 AK Treatment Options Lesion-directed treatments Field-directed treatments Surgical removal Photodynamic therapy (PDT) Cryotherapy Solareze gel Efudix cream Laser treatment Imiquimod 5% cream (Aldara) Topical treatments Imiquimod 3.75% cream 0.5% 5-fluorouracil (5-FU) (Zyclara) + 10% salicylic acid solution (Actikerall) Ingenol mebutate (Picato)
46 Length of Treatment Courses for Topical AK Treatments Length of treatment course Picato 150 mcg/g gel (on face and scalp) Picato 500 mcg/g gel (on trunk and extremities) Fluorouracil 5% cream 3 days 2 days 3 4 weeks Imiquimod 5.0% cream 4 weeks Imiquimod 3.75% cream Fluorouracil 5mg/g + Salicylic acid 100mg/g solution 3% Diclofenac Gel in 2.5% hyaluronic acid 6 weeks (two 2-week cycles with 2-week break) 6 12 weeks days
47 Treatment of AKs in primary care Patients should be given advice on appropriate levels of UV protection and encouraged to check their skin regularly for any change Pre-malignant and benign lesions may be managed in primary care Lesion-directed treatment does not address the problem of actinic changes in the surrounding sun-damaged skin
48 Q11 60y female Solitary lesion on leg for 5 months What are the clinical features? What is the diagnosis?
49 Bowen s disease Erythematous plaque Crust Full thickness dysplasia on histology Treatment options: Cryotherapy Topical efudix or aldara Photodynamic therapy Curettage and cautery / excision
50 Bowen s disease
51 Q12 56y male Lesion appeared 2/52 ago What is the diagnosis?
52 Keratoacanthoma Solitary nodule with central keratin filled crater Enlarges rapidly over several weeks then involutes spontaneously Clinically and histologically similar to an SCC so should be excised
53 Squamous cell carcinoma Solitary keratotic nodule Risk factors: UV exposure, Human papilloma virus-16 and 18, immunosuppression, chronic inflammation (e.g. erosive lichen planus) and chronic ulcers (Marjolin s ulcer) Treatment: excision
54 Case year old woman South African Lots of sun Lesions on forehead Increasing in number
55 Sebaceous hyperplasia Single / multiple Often yellowish Central umbilication Sebum Risk factors: Age, UV, previous severe acne, immunosuppression
56 Sebaceous hyperplasia Dermoscopy shows lots of vessels crown shape Treatment: Can try cautery Topical retinoids
57 Can look similar to BCCs
58 Case 14 60y female with 8/12 history of this lesion on her back Describe the clinical features What is the diagnosis? What are the treatment options?
59 Superficial BCC Well defined erythematous patch with crust Treatment options: Efudix or Aldara Cryotherapy Excision
60 Case year old woman Lesions around eyes Increasing in number
61 Milia Milia en plaque
62 Milia Easily extruded Green needle
63 Case 16 Lesions under eyes Years
64 Trichoepitheliomas Harmless hair follicle tumours Small, firm, round and shiny Yellow, pink, brown or blue May look like BCCs Rare inherited form of multiple lesions (Brooke-Spiegler)
65 Other harmless skin lesions of the Syringomas face Harmless sweat duct tumours Usually in clusters around the eyes Skin coloured or yellow
66 Other harmless skin lesions of the Xanthelasma face -2 Firm yellow plaques Check serum lipids
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