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

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

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).

Surgical removal Photodynamic therapy (PDT)

5% 5-fluorouracil (5-FU) (Zyclara) + 10%

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

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

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

immunosuppression, chronic inflammation (e.g.

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

Case 13 38 year old woman South African Lots

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

Benign versus Cancerous Lesions How to tell the difference FMF 2014 Christie Freeman MD, CCFP, DipPDerm, MSc

1 Benign versus Cancerous Lesions How to tell the difference FMF 2014 Christie Freeman MD, CCFP, DipPDerm, MSc Benign lesions Seborrheic Keratoses: Warty, stuck-on Genetics and birthdays Can start in late