Richard Turner Consultant Dermatologist
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- Peregrine Payne
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1 Old Problems & New Treatments Photo Album by Administrator Richard Turner Consultant Dermatologist
2 Plan for tonight? Refresher on SCC and solar keratosis How to distinguish the two Classic therapy than can be done in 1 0 care Newer therapies Quiz if we have time!
3 Solar keratoses Very common in fair skin types Sun exposed sites, scalp and ears in men Diagnosis of palpation and inspection Keratin layer may be pronounced Sometimes painful, pricking sensation Always feel base, if thick or indurated SCC
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11 Bowens disease Lower legs of elderly ladies a Well defined non itchy erythematous plaques and patches, scaly Slow history of growth Don t forget eczema, psoriasis Unresponsive to topical steroids Treat as for solar keratoses
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15 Squamous cell carcinoma Probably overdiagnosed on 2WW Palpation is essential, if thick pain is a worrying sign Keratotic tumours by definition Short history, if really quick and middle aged think keratoacanthoma Don t attempt treatment refer anyway
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23 Quick comparator quiz
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33 Treatment options Cryotherapy 5 fluorouracil (Efudix & Actikerall) Imiquimod (Aldara) Ingenol Mebutate (Picato) Curettage and cautery Excision
34 Cryotherapy Really useful for benign and premalignant lesions Only appropriate to treat malignancy in secondary care (sbcc and very early SCC) Dosage a bit of an art rather than science Assess the thickness of the lesion and freeze slowly to ensure only the lesion is treated with a narrow margin Keratin an insulator so needs longer freezes
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45 5 Fluorouracil Solar keratoses, Bowens disease & sbcc Differing protocols Our practice bd 2 to 4 weeks on the face Needs to be longer on more distant sites Secondary eczematisation common Impetigo too Counselling essential, don t forget to stop Selfie service
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51 Day 3 Day 5 Day 7 Day 9 Day 10 Day 11 Day 12 Day 14
52 Day 3 Day 5 Day 7 Day 9 Day 10 Day 12 Day 14 Day 21
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54 Imiquimod Solar keratoses, Bowens disease sbcc, mucosal HPV, lentigo maligna Effective treatment 3X per week for SK, Bowens, LM 5X per week for sbcc Very irritant and can have systemic effects Make a box last!
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64 Ingenol Mebutate Extract of Euphorbia Peplus Petty spurge, radium weed, cancer weed Widespread annual weed Crops up in disturbed ground Used in traditional medicine for years for the treatment of skin cancer
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66 Ingenol Mebutate (Picato) Effective treatment for solar keratoses Faster onset of action cf 5FU Head & neck 3 consecutive days (150mcg/g) Body 2 consecutive days (500 mcg/g) Skin reactions peak within a week or so Red, weeping, crusting and scaling Usually settles within a couple of weeks
67 Ingenol Mebutate Gel for Actinic Keratosis Mark Lebwohl et al N Engl J Med 2012; 366:
68 Ingenol Mebutate (Picato) Benefits are fewer applications Much more rapid onset Good for patients in work Downsides are inflammation can be profound Pain and occasionally systemic effects Persistent erythema
69 Mild skin reaction Day 1 Composite LSR Score = 3 Day 57 Composite LSR Score = 1 Day 4 Composite LSR Score = 6 Day 8 Composite LSR Score = 4 Day 15 Composite LSR Score = 2 Day 29 Composite LSR Score = 2 Patient Demographics: 68 years old, Male, Fitzpatrick Type II, Baseline AK Count: 7
70 Moderate skin reaction Day 1 Composite LSR Score = 0 Day 57 Composite LSR Score = 0 Day 4 Composite LSR Score = 10 Day 8 Composite LSR Score = 8 Day 15 Composite LSR Score = 2 Day 29 Composite LSR Score = 0 Patient Demographics: 53 years old, Male, Fitzpatrick Type II, Baseline AK Count: 7
71 Moderate skin reactions Day 1 Composite LSR Score = 0 Day 57 Composite LSR Score = 0 Day 3 Composite LSR Score = 12 Day 8 Composite LSR Score = 5 Day 15 Composite LSR Score = 2 Day 29 Composite LSR Score = 1 Patient Demographics: 53 years old, Female, Fitzpatrick Type II, Baseline AK Count: 6
72 Moderate skin reactions Day 1 Composite LSR Score = 2 Day 57 Composite LSR Score = 1 Day 4 Composite LSR Score = 14 Day 8 Composite LSR Score = 6 Day 15 Composite LSR Score = 1 Day 29 Composite LSR Score = 0 Patient Demographics: 82 years old, Male, Fitzpatrick Type II, Baseline AK Count: 6
73 Severe skin reactions Day 1 Composite LSR Score = 1 Day 57 Composite LSR Score = 0 Day 4 Composite LSR Score = 21 Day 8 Composite LSR Score = 10 Day 15 Composite LSR Score = 3 Day 29 Composite LSR Score = 0 Patient Demographics: 73 years old, Female, Fitzpatrick Type III, Baseline AK Count: 5
74 Severe skin reactions Day 1 Composite LSR Score = 1 Day 57 Composite LSR Score = 0 Day 4 Composite LSR Score = 21 Day 8 Composite LSR Score = 10 Day 15 Composite LSR Score = 3 Day 29 Composite LSR Score = 0 Patient Demographics: 73 years old, Female, Fitzpatrick Type III, Baseline AK Count: 5
75 Shave and cautery
76 Shave and cautery
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