Dermatology in Primary Care Identifying Benign and Malignant Skin Lesions Christy Quire Baker, APRN, FNP-BC, DCNP Dermatology Certified Nurse Practitioner No Disclosures Common Benign Lesions Seborrheic Keratoses Can be located anywhere there are sebaceous glands Stuck on waxy appearance There may be keratin plugs visible Color varies: tan, light/dark brown, black well demarcated borders Stucco Keratoses Believed to be a variant of seborrheic keratoses Usually located on the lower leg, ankle, dorsa of feet, forearms and dorsal hands 1-5mm in size, loosely attached, rough texture Benign Lesions usually white, grey, or flesh colored Treated with emollients and Ammonium Lactate lotion 12% Keratin Plugs 1
Benign Lesions Benign Hyperplasia of a Sebaceous Gland Most commonly found on males over 40 y.o. with sebaceous (oily) complexions Predilection for forehead, temples, infraorbital regions Small, cream colored or yellowish, umbilicate papules, 2-6mm Frequently confused with Basal Cell Carcinoma Benign Melanocytic Nevi Commonly referred to as moles Follow the A, B, C, D, E rules when evaluating Sun exposure increases the number of nevi in the exposed skin Increase in number during the first 3 decades of life Benign Lesions Halo Nevus Characterized by a pigmented nevus with a surrounding depigmented zone Occur most frequently on the trunk, usually on teenagers The central nevus gradually loses its pigmentation and disappears leaving a round to oval area of depigmentation that overtime repigments in the majority of cases The width of the halo is variable but is generally of uniform radial distance from the central nevus. The cause is unknown, but halo nevus is believed to be due to an immune response against melanocytes. Benign Lesions 2
Benign Lesions Photo Damage Cherry Angiomas A.K.A. senile angiomas & de Morgan spots dilated capillary on skin surface very common starting from 3rd decade of life round, flat or elevated, often dome shaped,.5 to 6mm in diameter and ruby red in color A.K.A. Dermatoheliosis Poikiloderma of Civatte Cutis Rhomboidalis Nuchae Nodular Elastoidosis with Cysts and Comedones (Favre-Racouchot Syndrome) Actinic Purpura Stellate Pseudoscars Photo Damage Photo Damage Why does damage occur? The immune system is responsible for recognizing and killing abnormal cells before they become cancerous. The body has systems to repair DNA and control some mutations, but not all. The risk of cancer increases as we age because sometimes cancer is caused by many mutations accumulating over time. A person's risk of skin cancer is related to lifetime exposure to UV radiation. As we get older, our immune systems are less able to fight infection and control cell growth. Most skin cancer appears after age 50, but the sun damages the skin from an early age. DNA. 3
Don t forget to protect your lips Always wear a minimum of a 3 inch brim Yes, dear Actinic Keratoses Pre-Cancer In-situ dysplasia resulting from sun exposure found chiefly on chronically sun exposed surfaces, known as the photo distribution rough or hyperkeratotic texture with adherent scale, often with a pink or red base Patient may complain of lesional tenderness A percentage of these will progress to NMSC (Non Melanoma Skin Cancer) Eye Sunscreen 4
AK Treatments Lesional vs. Field Cryotherapy Imiquimod 5 Fluorouracil (5-FU) Photo Dynamic Therapy (PDT) Topical Diclofenac 3% Ingenol Mebutate Chemical Peels/Dermabrasion Retinoids A.K.A. atypical mole Dysplastic Nevi Dysplastic nevi may grow larger than ordinary moles They may have irregular or indistinct borders. They may demonstrate asymmetry Their color may not be uniform atypical moles are more likely than ordinary moles to develop into a type of skin cancer called melanoma. It is worth noting that the vast majority of atypical moles will never become malignant. Individuals with multiple dysplastic nevi are at much higher risk for developing melanomas Suspicious nevi should be biopsied On histological exam an atypical mole is read as having architectural disorder and/or cytologic atypia. Cytologic atypia is categorized as being mild, moderate or severe Cytologic atypia is of more important clinical concern than architectural disorder Moderate to severe cytologic atypia will usually require further excision to make sure that the surgical margin is completely clear of the lesion Punch Biopsy Shave Biopsy 5
Excisional Biopsy Take A Break Malignant Lesions Non Melanoma Skin Cancer (NMSC) Basal Cell Carcinoma BCC 6
BCC The most common skin cancer in the U.S. Natural History: slowly enlarge, tend to ulcerate, often bleed without pain or other symptoms Metastasis is extremely rare, 0.0028% to.55% There are MANY clinical morphologies: Nodular (50-80%), Cystic, Morpheaform, Infiltrative, Superficial, Pigmented, Rodent Ulcer. Majority are found on the head or neck Squamous Cell Carcinoma Squamous Cell Carcinoma 2nd most common form of skin cancer Most are induced by UVR, chronic, long term sun exposure is the major risk factor Immunosuppression greatly enhances the risk for developing SCC s metastasis is uncommon, 0.5% to 5.2% Keratoacanthoma NMSC Treatments Reactive condition/lesion vs. pseudomalignancy vs. low-grade squamous cell carcinoma (SCC) Fast growing with unpredictable course dome shaped nodule with central crater filled with a keratin plug In most cases regress spontaneously Lesion Size, location & type, patients age, PMHx, overall health and personal preferences all are important factors when deciding upon a treatment modality Aim of treatment is for a permanent cure with the best cosmetic results Treatment options include: 1. Surgical excision 2. Electrosurgery/ED&C 3. Pharmacological 4. Radiation therapy 5. Photodynamic therapy 6. Combination of any of above 7
Shave Excision/Biopsy with ED&C Fusiform Excision, Ellipse Following appropriate regional anesthesia, a surgical blade is used to excise the bulk of the lesion Curettage is alternated with electrodessication for further destruction at the base and margins Technique is guided by feel-skin cancer yields easily to curette and blade whereas healthy dermis is quite tough and leathery when you reach firm dermis with regular pinpoint bleeding you are done Excellent cure rate, about 93%, when used on appropriate NMSC s Technique is often used for removal of benign lesions Moh s Micrographic Surgery Recurrent tumors NMSC Indications for Moh s Tumors >0.5cm on the face or >2.0cm on the body High risk anatomic locations: eyelids, nose, ears, lips, genitalia, fingers Tumors with indistinct margins or incompletely excised margins (positive margins after surgical excision) Tumors occurring in sites of previous radiation therapy or in chronic scars Tumors with aggressive patterns (micronodular, infiltrative and morpheaform BCC, basosquamous carcinoma, and poorly differentiated or deeply invasive Squamous Cell Carcinomas) Tumors in immunosuppressed patients Malignant Melanoma Acral Lentiginous Without a Primary Ocular In the U.S. it is the 5th most common cancer in men and the 7th most common in women In contrast to other skin cancers (like SCC & BCC), melanomas are aggressive and can spread to virtually any organ of the body Early diagnosis and treatment is the key to minimizing morbidity and mortality. There are 4 histologic patterns: 1. superficial spreading melanoma 2. nodular melanoma 3. lentigo maligna melanoma 4. acral lentiginous melanoma Lentigo Maligna Nodular Superficial Spreading 8
Malignant Melanoma Risk Factors Sun exposure, particularly during childhood Fair skin which burns easily Blistering sunburn, especially during childhood Large numbers of moles/dysplastic moles Family Hx of MM Previous NMSC Previous Melanoma Superficial Spreading MM Most common subtype of MM comprise about 75% of all MM 1/4th of SSMM s are found in a pre-existing nevus, the majority arise de novo Most common on back in men and lower extremities in women Can occur in any anatomic location, at any age Nodular MM nodular melanomas are vertical growth phase MM s 15-30% of all MM s usually appear as a darkly pigmented, rapidly growing nodule Ulceration/bleeding are common poor prognosis Lentigo Maligna Melanoma Acral Lentiginous MM most common in sundamaged areas of older individuals begins as a freckle-like tanbrown macule, gradually enlarges, gets darker and asymmetric transformation is slow, lesion may be present for 10-50 years before vertical growth phase least common variant of radial growth phase melanomas, comprising fewer than 5% of all MM s arise most commonly on subungual & plantar surfaces; occasionally on palmar and mucosal surfaces ALMM subtype is the most common type of MM among Asians and dark-skinned individuals poor prognosis due to delayed dx in many cases 9
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