Skin lesions The Good and the Bad Dr Virginia Hubbard Ipswich Hospital NHS Trust Barts and the London School of Medicine and Dentistry
Case 1 32 year old woman Australian Lesion on back New hair growing
Benign intradermal naevus
Dermoscopy patterns of benign naevi Reticular or globular pigmentation Regular Lack features of melanoma
Dermoscopy patterns of melanoma Blue-white veil Irregular pigment network Black blotches
Case 2 27 y man with 8/12 history of new mole on back
Melanoma
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
Case 3 30 y mole on arm. Years. Worried re darker centre
Benign naevus reticular pigmentation hyperpigmented type
Case 4 45 y female, mole on leg, now more red around edges
45 y female, mole on leg, now more red around edges Dermoscopy: Irregular pigment network and irregular black pigmentation
Melanoma Changing size Changing colour Irregular on exam Irregular pigment network and irregular black pigmentation
Case 5 82 y male, lesion on abdo, unsure when appeared
Melanoma Irregular pigmentation and blue-white veil
Melanoma If history is doubtful, have low threshold for referral / dermoscopy Irregular pigmentation and blue-white veil
Vascular lesions
Angioma Lacunar pattern
Angiokeratoma
Subcorneal haemorrhage Red / black homogenous colour
Case 6 48 year old woman New lesion scalp Growing
Seborrhoeic keratosis Warty Stuck-on appearance May see cysts
Seborrhoeic keratoses Usually multiple lesions
Seborrhoeic keratoses Usually quite obvious
Seborrhoeic keratoses Sometimes less obvious
Seborrhoeic keratoses - dermoscopy Milia like cysts Comedo-like openings Cerebriform appearance
Dermatosis papulosis nigra (like seb K s)
Case 7 24 year old woman Lesion on lower leg 4 months Was more red, now darker around edge
Dermatofibroma
Dermatofibromas Solitary nodules, few mms, pea-like, dermis
Nodular melanoma
Nodular melanoma with mets
Case 8 28 year old woman Lesion on thumb 3 weeks Bleeding +++
Well circumscribed Often preceded by trauma Pyogenic granulomas
But don t miss the amelanotic melanoma... All new bleeding nodules should be excised
Case 9 68 year old man Lesion on scalp Few weeks Slightly tender
Cutaneous horns AK Viral wart SCC Can treat with cryotherapy If in doubt about underlying cause, then excise
Case 10 48 year old man Lots of sun in past Lesion on forehead 6 months Not symptomatic
Poorly defined erythematous plaque with adherent scale Actinic keratosis
Actinic Keratoses multiple presentations
Actinic Keratoses management options Why bother? Treatment depends on patient factors and type of AK Lesion vs Field
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).
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)
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 60 90 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 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
Q11 60y female Solitary lesion on leg for 5 months What are the clinical features? What is the diagnosis?
Bowen s disease Erythematous plaque Crust Full thickness dysplasia on histology Treatment options: Cryotherapy Topical efudix or aldara Photodynamic therapy Curettage and cautery / excision
Bowen s disease
Q12 56y male Lesion appeared 2/52 ago What is the diagnosis?
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
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 of sun Lesions on forehead Increasing in number
Sebaceous hyperplasia Single / multiple Often yellowish Central umbilication Sebum Risk factors: Age, UV, previous severe acne, immunosuppression
Sebaceous hyperplasia Dermoscopy shows lots of vessels crown shape Treatment: Can try cautery Topical retinoids
Can look similar to BCCs
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?
Superficial BCC Well defined erythematous patch with crust Treatment options: Efudix or Aldara Cryotherapy Excision
Case 15 26 year old woman Lesions around eyes Increasing in number
Milia Milia en plaque
Milia Easily extruded Green needle
Case 16 Lesions under eyes Years
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)
Other harmless skin lesions of the Syringomas face Harmless sweat duct tumours Usually in clusters around the eyes Skin coloured or yellow
Other harmless skin lesions of the Xanthelasma face -2 Firm yellow plaques Check serum lipids