IT S FUNDAMENTAL MY DEAR WATSON! A SHERLOCKIAN APPROACH TO DERMATOLOGY

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1 IT S FUNDAMENTAL MY DEAR WATSON! A SHERLOCKIAN APPROACH TO DERMATOLOGY Skin, Bones, and other Private Parts Symposium Dermatology Lectures by Debra Shelby, PhD, DNP, FNP-BC, FADNP, FAANP

2 Debra Shelby, PhD, DNP, FNP-BC, FADNP, FAANP President, National Academy of Dermatology Nurse Practitioners President, American College of Dermatology Nurse Practitioners Owner, Florida Specialty Medical Services, LLC Owner, New Mexico Specialty Medical Services, LLC Owner, National Institute for Dermatology Owner, Dermstaffing No conflicts of interest to report

3 PART THREE THE SUSPECTS: COMMON CRIMINALS AND DEATH ROW

4 OBJECTIVES Discuss two risk factors that contribute to skin cancer. Demonstrate understanding of three basic characteristics of describing a lesion. Identify three benign lesions. Identify three skin cancer lesions.

5 Seborrheic keratoses Sebaceous hyperplasia Xanthelasmas Skin tags Fibrous Papules Dermatofibromas Angioma Solar Lentigenes Venous lake BENIGN LESIONS

6 MOLE OR NEVUS Most people have a number of small colored spots on their bodies- moles, freckles, birthmarks. The average young adult has at least 25 brown moles. May be present since birth most others develop throughout life. Almost all moles are normal and remain so. a change in a mole or other spot on the skin may be the first sign of an early skin cancer.

7 ACTINIC KERATOSES (AK) The skin is severely sun damaged and the cells in the outer epidermis layer are now quite abnormal. AKs are scaly or crusty papules or Macules. Aks can also be hypertrophic. If left untreated, they can progress into SCC. Considered precancerous, but some dermatopathologists and dermatologists consider them squamous cell insitu Actinic Cheilitis: More aggressive, solar damage around the lips (vermillion border). Subclinical Aks cannot be seen or felt.

8 SKIN CANCERS BCC SCC Melanoma

9 SKIN CANCER FACTS CONT. An estimated 87,110 cases of invasive melanoma in 2017 Estimated 9,730 deaths from melanoma in 2017 (Skin Cancer Foundation, 2017) (American Cancer Society, 2017)

10 SKIN CANCER FACTS Skin cancer is the most common form of cancer in the United States. More than 5.4 million skin cancers in over 3.3 million people are diagnosed annually Basal cell carcinoma (BCC) is the most common form of skin cancer; an estimated 4 million are diagnosed annually in the US. BCCs are rarely fatal, but can be highly disfiguring if allowed to grow Squamous cell carcinoma (SCC) is the second most common form of skin cancer. An estimated 1 million cases are diagnosed each year in the US. (Skin Cancer Foundation, 2017)

11 BASAL CELL CARCINOMA Malignant skin tumor Origin basal cell layers cutaneous appendages: skin follicle sebaceous gland eccrine gland apocrine gland Displaying varying clinical appearances or morphology histopathology

12 BASAL CELL CARCINOMA CONT. Most common malignant tumor Rarely metastasize most are treated effectively Locally destructive leading to disfigurement functional impairment

13 RISK FACTORS UV Radiation Tanning beds: Studies show that teens are still using tanning beds despite proof of carcinogenic risk Trauma Chemicals Biologic treatment Cancer treatments Genetics

14 TYPES OF BCC Superficial BCC. These BCCs are the least dangerous. They grow only on the outer layers of the skin. Nodular BCC. These BCCs grow into the deeper layers of the skin. Most of these look like pink round lumps on the skin. Some have an ulcer or crater feature to them. Tough BCC. Infiltrating, micronodular, morphoeic, desmoplastic, sclerosing and morpheaform. Notorious for growing into nearby organs or later recurring nearby. By the time a recurrence is apparent, they may have burrowed into and destroyed other structures. (Australasian College of Skin Cancer Medicine, 2007)

15 SQUAMOUS CELL CARCINOMA Malignant skin tumor of keratinizing cells of epidermis or its appendages: Hair follicles Sebaceous glands Apocrine glands Eccrine glands

16 RISK FACTORS Radiation: UV light: sun (tanning); PUVA ionizing radiation Chemical agents: arsenic; hydrocarbons Develop in chronic inflammatory or degenerative conditions: scars; ulcers; sinus tracts Preexisting dermatologic conditions: lichen planus, burns Decreased immunologic competence: HIV Associated with human papillomavirus

17 TYPES OF SCC In situ SCC. This is the mildest type. The tumor is confined to the outer layer of the skin (epidermis). This type of cancer is also sometimes called Bowen s Disease Well differentiated SCC. This is the commonest type. The SCC has grown into the deeper layers of the skin (dermis). Well differentiated SCCs often appear as very thick crusty lesions on the skin. Often the top falls off. Sometimes patients think they may have gone away. Keratoacanthoma. This is a particular type of SCC that grows very quickly yet is not very dangerous. Often they appear and grow large in 6 to 10 weeks. They can look like a mini volcano. The center of the crater is often full of loose tissue

18 TYPES OF SCC CONT. Aggressive SCCs. There are several types of SCC in this category. They include poorly differentiated and spindle cell types. These SCCs have a variable appearance of the skin. Some are soft and others are hard. Some bleed on and off. They usually grow quickly and may double in size over months (Australasian College of Skin Cancer Medicine, 2007)

19 MELANOMA Most serious skin cancer Cancer of the Melanocytes Treatment determined by pathology: -Ulceration, Breslow depth, tumor thickness, mitotic rate -Lymph node involvement -Metastasis

20 MELANOMA STATISTICS The incidence of melanoma has been steadily increasing for the past 30 years Melanoma is the most common form of cancer for young adults years old and the second most common form of cancer for adolescents and young adults years old Melanoma is increasing faster in females years old than males in the same age group 10,130 deaths annually will be attributed to melanoma

21 MELANOMA STATISTICS CONT. People with more than 50 moles, atypical moles, or a family history of melanoma are at an increased risk of developing melanoma Less than 1% of skin cancers are melanoma, but causes the vast amount of deaths. The five-year survival rate for people whose melanoma is detected and treated before it spreads to the lymph nodes is 99 percent Five-year survival rates for regional and distant stage melanomas are 62 percent and 18 percent, respectively (Skin Cancer Foundation, 2017)

22 RISK FACTORS CONT. Fair skin Light Hair and Eye Color Moles - People who have many moles (more than 50) have an increased chance of developing melanoma Dysplastic nevi Personal and family history of melanoma - A previous diagnosis of melanoma increases the risk of getting melanoma again. About 5-10 percent of people with a melanoma will develop it again during their lifetime

23 RISK FACTORS Non-melanoma skin cancer Weakened immune system Severe sunburns, especially while young Exposure to ultraviolet (UV) radiation, such as sunlight or indoor tanning booths - Exposure to UV radiation is one of the major risk factors for most melanomas. Using tanning beds before age 30 increases your risk of developing melanoma by 75 percent and occasionally using tanning beds can triple your chances. Age - Although melanoma is most common in men over the age of 50 (more common than colon, prostate, and lung cancer), it is also one of the most common cancers in people under the age of 30. Melanoma is the most common form of cancer for young adults 25- to 29-years-old and the second most common cancer in adolescents and young adults 15- to 29-years-old.

24 TYPES OF MELANOMA Congenital Nevus May be giant or small, and may be present at birth or shortly after birth. May occur anywhere on body -Giant congenital nevus is rare occurring in about 1 of 20,000 births with a lifetime risk of malignant transformation of 2-40%. -Small congenital nevus occurs in 1 of 100 births and lifetime risk of malignant transformation is not known. Lentigo Maligna (Hutchinsons Freckle) Flat pigmented lesion which gradually enlarges, light tan to dark brown or black with irregular notched borders. -Begins as MM in-situ and may take 5 to 50 years to become invasive

25 TYPES OF MELANOMA CONT. Superficial Spreading Malignant Melanoma Slightly raised lesion with an irregular border and variable, unevenly distributed pigmentation with shades of red, blue, brown, purple, and black Acral Lentiginous Malignant Melanoma Initially the lesion is flat with irregular margins and pigmentation, the lesion rapidly becomes raised and nodular

26 TYPES OF MELANOMA CONT. Nodular Malignant Melanoma Lesion is raised, nodular and sometimes ulcerated. Borders are irregular and color variegated. Occasionally the tumor has no apparent visible pigmentation (amelanotic MM) (Australasian College of Skin Cancer Medicine, 2007)

27 QUESTIONS?

Clinical characteristics

Skin Cancer Fernando Vega, MD Seattle Healing Arts Clinical characteristics Precancerous lesions Common skin cancers ACTINIC KERATOSIS Precancerous skin lesions Actinic keratoses Dysplastic melanocytic