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Derm Lecture 4

Derm Lecture 4. Skin issues associated with systemic disease Skin Cancers Systems IV 2013. Things I’ve seen which are related to systemic disease. Erythema nodusum with inflammatory bowel issues Porphyria with “coin” lesions of the hands associated with Hep C

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Derm Lecture 4

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  1. Derm Lecture 4 Skin issues associated with systemic disease Skin Cancers Systems IV 2013

  2. Things I’ve seen which are related to systemic disease • Erythemanodusum with inflammatory bowel issues • Porphyria with “coin” lesions of the hands associated with Hep C • “Splinter” hemorrhages of the nails and tips of fingers and toes associated with systemic lupus endocarditis (Libman-Sachs syndrome). Splinter hemorrhages are also a sign of subacute bacterial endocarditis-REFER

  3. Erythemanodosum Commonly on lower leg Splinter hemmorrhages-fingernail, toenail, fingertip or on toes-indicate subacuteendo- Carditis. REFER “Coin” lesions on hands with porphyria associated with Hep C Can be on palms as well. Get worse With stress or toxin exposure

  4. Actinic Keratosis (AK) • “Actinic keratosis (AK) is a UV light–induced lesion of the skin that may progress to invasive squamous cell carcinoma. It is by far the most common lesion with malignant potential to arise on the skin.” Medscape • Commonly known as “sun damaged skin” • It is considered “premalignant” although studies show that only 0.1%-10% of AK develop into cancers • However, “nearly 65% of primary squamous cell carcinomas and 36% of primary basal cell carcinomas arise from clinically diagnosed actinic keratoses.” Medscape

  5. Actinic Keratosis (AK) • Can either heal on its own, remain unchanged or progress to a cancerous lesion, espsquamous cell carcinoma • Some uncertainty about the contribution of AK to the development of basal cell carcinoma, some studies say yes, others no. • “Actinic keratosis frequency correlates with cumulative UV exposure.[7]Therefore, the frequency of actinic keratosis increases with each decade of life, is greater in residents of sunny countries closer to the equator, and is greater in persons with outdoor occupations.” Medscape

  6. Actinic Keratosis (AK) • Usually, the skin appears as rough, dry, scaly or flaking erythematous patches • Conventional treatment includes topical anti-cancer, immunosuppressive, or anti-inflam-matory drugs which vary in efficacy, depending on studies from 15-65% • Cryosurgery, skin resurfacing treatments, other types of excisions and photodynamic therapies are also used • Low fat diets, elimination diets, and diets high in essential fatty acids are also useful.

  7. Review Question that is important to understand • In what layer of the skin do the melanocytes arise? • Epidermis? • Dermis? • Subcutaneous? • How about the keratinocytes? • Where are the blood and lymph vessels? • Epidermis? • Dermis? • Subcutaneous?

  8. Melanoma • A cancer of the melanocytes, or of cells produced by the melanocytes • 2 stages of growth • Radially (Outward from a central starting point) • Vertically (Deeply into the dermis, allowing for metastasis) • They may arise from a precursor lesion or as a new lesion (de novo) • Not all lesions are due to direct sun exposure and may arise on typically unexposed skin

  9. 5 Histological Types of Melanoma • Superficial Spreading Melanoma (SSM):70% • Usually arise from a previous nevus-the classic “mole that changes” • Can be anywhere on body • Nodular Melanoma (NM) 10-15% • More common in males, usually found on the trunk • Have quick vertical growth-get evaluated ASAP • Lentigomaligna melanoma (LMM) 10-15% • Typically found on face and neck, and sun exposed areas • Typically arise from previous lesions and have hypopigmented areas • AcralLentiginous melanoma (ALM) • Occur on palms, soles, and under the nails • Extremely aggressive-refer ASAP • Mucosal Lentiginous melanomas (MLM) 3% • Can occur on any mucosal surface, usually in advanced age, aggressive, refer ASAP, risk factors unknown.

  10. Risk Factors For malignant melanoma • Changing mole (s) • Family or personal history of melanoma or dysplastic moles • 50 or more moles 2 cm or greater in diameter or freckling • Sun sensitivity • Congenital nevi (“birthmarks”) • History of acute, intense, blistering sunburn • Potentially, tanning bed use. • Immunosuppression • More common in white collar workers than those that work in the sun

  11. Stats for Malignant Melanoma •  ”The incidence of malignant melanoma is increasing rapidly worldwide, and this increase is occurring at a faster rate than that of any other cancer except lung cancer in women.” Medscape • 5% of skin cancers but 3x the deaths of all other skin cancers. Third highest death rate of all cancers • More common in light skin than dark skin • Slightly more common in males than females • Can occur at any age, but unusual under 10 • Most common cancer diagnosed in women 25-29 years of age.

  12. Malignant Melanoma Prognosis and Treatment • Great if caught early 95-100% survival • Bad if caught late <20% 5 year survival rate • Depth of lesion, degree of ulceration, lymph node involvement, degree of metastasis, age at diagnosis, previous chemotherapies, all play a part in outcome (Know 3) • Surgical excision with biopsy, radiation and chemotherapy (many different regimens) are standard, depending on biopsy results.

  13. Diagnosing suspicious lesions • A Asymmetry • B Borders irregular • C Color black or dark blue with other coloration • D Diameter > 6 mm • E Erythematous base

  14. Classic presentation:Erythematous base irregular borders, ulceration with bleeding and crusting, black color with some other color- ations.

  15. This is an invasive nodular type of melanoma. It is seen at an earlier age and more often in men. Again, you see an erythematous base with asymmetric borders, often with a tendency to crack and bleed.

  16. This is a typically missed or questionable lesion that is in fact, an invasive melanoma. Look closely if you’re not sure and refer…

  17. Lentigomaligna melanoma

  18. Mucosal melanoma

  19. Acral Melanoma

  20. Basal Cell Carcinoma (BCC) • 80% of nonmelanoma skin cancers are BCC • Rarely metastasize (<1%), but can be disfiguring or require disfiguring surgical intervention. • Seems to be related to longterm exposure to UV radiation, rather than the bad sunburn • Arise from the pluripotent cells of the basal layer of the epidermis, may be related to the sebaceous glands, hair follicles or sweat glands. • Usually on the face, head, neck and hands

  21. Basal Cell Carcinoma (BCC) • Usually described as pearly white nodules, but can have black-blue or brown pigments • Very slow growing • Most common in light skin folks. Twice as common in men than women • Rates of occurrence in Caucasians in the US is25-35% • Treatment is usually surgical removal, occasional radiation therapy and very occasional anti-cancer topical agents • Lesions recur 7-12% with first removal. With subsequent recurrences and removals, recurrence rates can rise as high as 60%.

  22. Basal Cell Carcinoma

  23. Basal Cell Carcinoma

  24. Squamous Cell Carcinoma (SCC) • The second most common non-melanoma skin cancer (20%) and the most common cancer of the head and neck (90%) • Unlike BCC, SCC can be aggressive, metastasize and cause death due to metastasis • SCC is a cancer of epithelial cells which line all of the body, so you can have primary SCC in many parts of the body, for instance the bladder as well as the skin. • When it is cutaneous, it can be a de novo lesion of the keratinocytes, or arise from a previous lesionassociated with chronic damage to the keratinocytes

  25. Squamous Cell Carcinoma (SCC) • Appear on sun exposed skin, and may arise from actinic keratosis lesions • Biggest risk factor is longterm UV exposure-this is important, not only for sunworshippers and tanning bed fanatics, but also for psoriasis patients receiving UV treatment • Other risk factors are fair skin (mc cancer in albino pop.), immunosuppression, older than 50, hx of other nonmelanoma skin CA, tobacco and ETOH use, male gender, exposure to ionizing radiation, chronic inflamed lesion. (Know 2 in addition to longterm UV exposure and actinic keratosis)

  26. Squamous Cell Carcinoma

  27. Squamous Cell Carcinoma • “The classic presentation of an SCC is that of a shallow ulcer with heaped-up edges, often covered by a plaque.” Medscape • Invasive SCCs are usually slowly-growing, and tender, scaly or crusted. The lesions may develop sores or ulcers that, classically, don’t heal. Occasionally, a keratin “horn” is produced. • SCC is considered a “field defect cancer”, which means there can be many small separate lesions in an area, the cheek for example.

  28. Squamous Cell Carcinoma (SCC) • Treatment options are varied according to staging and location of lesion. • Surgery or “destructive removal” including freezing, burning, and electrodessication are most often used for noninvasive or minimally invasive SCCs • Topical chemo, topical immune modulators, radiation therapies, and systemic chemotherapy are all used. • Recurrence is not uncommon, and the recurrent disease is typically more aggressive • People who have an SCC removed have a 40% chance of developing additional SCCs within 2 years. Monitoring is important!!

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