Dermatology/Skin lesions Flashcards
(102 cards)
1
Q
What is this
A
Nodular Basal Cell Carcinoma
2
Q
What are treatments for a BCC?
Superficial BCC versus non superficial BCC types
(3)
A
- Excisional biopsy for all types with a 3-4 mm border sent away for histopathology
(referral for excision is appropriate if in an awkward area) - If superficial BCC you can try liquid nitrogen (2 x 20 second applications) on NEW lesions only
- If superficial consider Imiquod 5% cream topically, at night 5 times weekly for 6 weeks. In the morning, wash the treated area with mild soap and water
3
Q
What are these? (1)
A
Actinic / Solar keratosis
4
Q
When are solar keratosis a problem?
(2)
And what problem is that.
(1)
A
They can turn into SCCs.
A person with > 10 solar keratosis has a 10-15% risk that some will turn into SCCs
A tender, thickened, ulcerated or enlarging solar/actinic keratosis is more suspicious of turning into an SCC
5
Q
Treatments for this ?
If medication- dosing not required
(3)
A
(this is a solar keratosis)
- first line: Liquid nitrogen
- Cutterage or shaving in specific cases
- Topical/Field treatments
6
Q
Topical treatments for Actinic Keratosis (solar damage)?
Give dosing instructions
(2)
A
- fluorouracil 5% cream topically, once or twice daily for 2 to 4 weeks on the face or 3 to 6 weeks on arms and legs
- imiquimod 5% cream topically, at night 3 times weekly for 3 to 4 weeks. In the morning, wash the treated area with mild soap and water. Review patient 4 weeks after treatment ends. If any lesions persist, repeat treatment once only
7
Q
Side effects of Field treatment? Especially 5-fluorouracil
A
Soreness/pain/discomfort
Itching
Burning sensation
Stinging sensation
Sores/ulcers
Crusting of the skin
Weeping
Skin cracking (?dryness)
Hyperpigmentation or erythema/redness
Scarring
Blistering
Skin peeling
Photosensitivity (increased sensitivity to the sun)
Contact dermatitis
8
Q
Other than to expect pain/burning and tenderness, what other advice can you give to someone using field treatment for solar keratosis?
(6)
A
The complete healing process can take 1-2 months
Men- avoid cutting self when shaving
Advise proper sun protection: hat outside, broad-spectrum sunscreen everywhere OTHER THAN his face
If one reaches the ulceration stage, they can stop the treatment
Advise the reaction that follows is not an infection and antibiotics are not needed
The patient may need to take time off work.
9
Q
In pregnancy or in women trying to conceive what is an appropriate oral medication to treat acne ?
Give full dosing
A
erythromycin 250 to 500 mg orally, twice daily until inflammation resolves (usually takes weeks)
10
Q
Treatment for moderate to severe acne (in non-pregnant females or in males) for primarily comedomal acne
A
- Early referral to Dermatologist for oral isotetrenoin
Can consider anti-androgen in female patients (spironolactone or COPC) before referral.
11
Q
How to treat inflammatory acne of moderate- severe in nature? (or even a mixed acne)
Male v. Female
A
- First line: (more in the mild cases)
benzoyl peroxide+clindamycin 5%+1% gel topically, once daily for 6 weeks then review - Second line
in Males: Doxycycline 50-100mg daily
in females: COPC or spironolactone or oral antibiotic as for males
3rd line: refer to dermatology for isotetrenoin
12
Q
List some of the myths about Acne
A
MYTHS:
Acne is caused by a poor diet. high GI foods can exacerbate Acne, but does not cause it
Acne is due to a hormonal imbalance
Caused by poor hygiene
People grow out of acne
13
Q
Non medical management of acne
A
Avoid hot steamy environments
Make sure cosmetics and sunscreen is non-comedomal
Oily skin care products can make acne worse
Do not pick or squeeze at the spots
Consell/assess for anxiety and depression caused by acne
14
Q
Advice regarding treatment of Acne.
A
Use your prescribed treatment every day, unless directed otherwise.
Apply creams to the whole affected area, not just to the spots.
Use water-based or oil-free cosmetics and sunscreens.
Use a light moisturiser.
Try not to pick and squeeze the spots, because this causes scabs that make the skin look worse and may increase likelihood of scarring.
Be patient—most treatments take at least 6 to 12 weeks to work.
15
Q
General measures to treat rosacea?
(8)
A
Avoid triggers of rosacea
Minimise factors that cause flushing
Use an emollient soap-free cleanser to reduce irritation
Regularly use an emollient to improve the skin condition
Avoid essential oils
Minimise sun exposure and use low irritate sunscreen
Avoid topical corticosteroids
Green tinted foundation can help mask redness
16
Q
List a few rosacea triggers
A
Emotional stress
Hot/Cold weather
Sun exposure
Wind
Exercise
Hot drinks
alcohol consumption
Spicy foods
Diary products
Hot baths or showers
17
Q
What is this, and what sub-classification is this condition?
How can you treat it?
A
Mild Rosacea- pustolopapular
first line:
ivermectin 1% cream topically, once daily
Second line
metronidazole 0.75% gel or cream topically, once or twice daily
18
Q
How would you treat this?
A
This is SEVERE papulopustular rosacea.
Doxycycline 50 to 100 mg orally, once daily for up to 8 weeks, and repeat as required. If response is inadequate after 4 weeks, consider minocycline
19
Q
What can be offered to treat background erythema and telengectasia in rosacea
A
Refer patients with permanent background erythema and telangiectasia to a specialist for consideration of vascular laser therapy. Vascular laser therapy does not relieve transient erythema, flushing, or inflammatory papules and pustules in rosacea
20
Q
How do you treat ocular rosacea
A
First line: ocular lubricant
Daily eyelid hygiene
Firm eyelid massage towards margins
If these don’t work then use oral antibiotics
If oral Abx don’t work then refer to ophthalmologist
21
Q
medications to trial for flushing?
(2)
A
propranolol 10 mg orally, twice daily or as required.
if that doesn’t work then
clonidine 25 to 50 micrograms orally, twice daily.
Can take 4-6 weeks to assess response to therapy as flushing is usually intermittent anyway.
22
Q
How do you treat this
A
This is granuloma annulare
Tends to be more common in diabetes
Treat with
betamethasone dipropionate 0.05% ointment topically, twice daily for a minimum of 4 to 6 weeks
23
Q
what are these lesions? and what are some non-pharmacological treatments?
A
Pityriasis Rosea
Apply moisturising creams/emollients to area
Use soap substitutes
Gradual exposure to sun (without burning)
Takes about 6-10 weeks to resolve
24
Q
This started with a herald patch and is completely itchy. How can you treat this? Conservative measures have failed
A
Triamcinolone acetonide 0.02% cream or ointment topically, once or twice daily.
Mainly for the itch
Can use an oral antihistamine too
25
What organism is responsible for pityriasis versicolour?
And what would you use to treat it?
Malassezia yeasts
ketoconazole 2% shampoo topically, once daily (leave for 3 to 5 minutes and wash off), for 5 days
26
Which of these is this?
And why?
How to prevent it?
Pityriasis rosea
Pityriasis versicolor
Pityriasis alba
Pityriasis Alba
Usually seen in children
Low grade dermaitis
Use sunscreen to prevent
no treatment necessary
can use emollient
can use mild steroid for face
can take months to years to clear
27
What can predispose to Melasma?
Sun exposure
Tends to occur in pregnancy
Also tends to occur in those takin HRT
28
Give three steps to treatment of this
This is Melesma
1. Switch or stop contraception, or change from COCP to POP
2. Topical depigmenting- hydroquinone 2% cream topically, once or twice daily for 2 to 4 months
3. Referral to dermatology for consideration of other treatment such as topical tretinoin or laser therapy
29
What general advice would you give for management of this?
1. Cautious Sun exposure is beneficial
2. Avoid irritants
3. Use soap substitutes to wash self
4. No specific diet works. If patient has coeliac then avoidance of gluten should prevent worsening.
30
What might trigger this rash?
A streptococcal infection either in the pharynx or perianal
Treat the infection if it is still active
Otherwise treat the rash with milder steroids for the trunk/limbs
(this is guttate psoriasis)
31
What three classes of topical treatment are available to treat this?
It is only mildly itchy.
This is psoriasis
Tar preparations
Steroid Creams
Vitamin D derivatives (Calcipotriol) - not for use on the face
32
What is the first line treatment for this chronic condition?
Knee- (limb psoriasis)
LPC 4 to 8%+salicylic acid 3% cream or ointment topically, twice daily for 1 month
LPC stands for liquor picis carbonis- which is basically a tar solution
33
For an acute flare of psoriasis on the trunk or limbs, what can you use as a topical agent?
methylprednisolone aceponate 0.1% cream, ointment or fatty ointment topically, once daily until skin is clear (usually 2 to 6 weeks)
also to be used for long term management if LPC is not enough
34
what is the main caution with using long term calcipitriol?
Be cautious when treating widespread psoriasis; limit use of calcipotriol ointment or foam to less than 15 g per day or 100 g per week to reduce the risk of hypercalcaemia resulting from systemic absorption
35
what is this? what are the first, second and third line treatments?
Pustular Psoriasis
1. betamethasone dipropionate 0.05% ointment topically, once daily until skin is clear (usually 2 to 6 weeks)
2. Use optimised vehicle
3. If still not resolved after 2 months then calcipotriol+betamethasone dipropionate 50+500 micrograms/g ointment or foam topically, once daily until skin is clear (usually about 6 weeks).
Then refer
36
What should you do with this rash?
urgent referral to hospital for assessment and management by a dermatologist for generalised pustular psoriasis
37
What is this?
Patient complains of recurrent lesions and multiple lesions at once with discharge at times.
How do you treat this pharmacologically?
3 points to note
Hidradenitis Suppurativa
1. Use a antiseptic wash like benzyl peroxide 5% when bathing
2. Clindamycin 1% solution to be applied twice daily to BOTH axillae for 3 months
Or
3. Doxycycline 50-100mg orally once daily for 6-12 weeks OR minocycline 50-100mg orally once daily for 6-12 weeks (1)
(additionally if on a COPC or progesterone only option, switch to an anti-androgenic COPC like ethinylestradiol + cyproterone)
38
What is this?
List 4 non pharmacological management options.
(hidradenitis suppurativa)
1. Encourage smoking cessation, if smoker
2. Encourage weight loss to achieve a body mass index within the normal range / Encourage to lose 5 - 10% of body weight if appropriate
3. Advise to avoid tight-fitting clothing
4. Screen for depression/anxiety/mental health concerns
39
A young aboriginal girl (8years old) presents with multiple lesions on her body, they are intensely itchy especially at night.
The lesions are widespread (hands, soles, arms, legs, torso but not face) with some lesions crusted or oozing.
What is this specifically?
How would this be treated?
Infected Scabies
Management
1. permethrin 5% cream to be applied topically to the whole body (dry skin) from the neck down for 8 hours
- repeat topical permethrin in 7 days time
2. Prescribe oral Cephalexin 12.5mg/kg six hourly for five days to treat the secondary infection
3. For itchy you can provide a steroid ointment of moderate strength, e.g betamethasone valerate, 0.05% ointment), to be applied 2 - 3 times daily
40
What do you do with
a melanoma that has this reported after you've performed the initial excisional biopsy?
The initial biopsy for a suspected skin cancer should be 2mm.
With a breslow thickness of 1.9mm you NEED to refer to a specialist for a wide excisional biopsy and consideration of a sentinel node biopsy.
If you do the Wide Local excision in General practice the patient cannot receive the SNB
"Sentinel lymph node biopsy should be considered for all patients with melanoma greater than 1 mm in thickness and for patients with melanoma greater than 0.75 mm with other high risk pathological features to provide optimal staging and prognostic information and to maximise management options for patients who are node positive."
41
General management for peri-oral dermatitis?
1. Always wash off/clean off toothpaste after brushing
2. Wash face and mouth after using ICS
3. Use an emollient soap to wash the face
4. Always stop topical steroids (counts as pharmacological)
5. Use a wet face cloth on the area to relieve symptoms
6. avoid cosmetics and moisturisers
42
What is first and second line treatment for this?
Perioral Dermatitis
1. Doxycycline 100mg daily for 6 weeks
or
2nd line. metronidazole 0.75% cream or gel topically, twice daily for 4 to 6 weeks until skin returns to normal
or also second line
clindamycin 1% lotion topically, twice daily for 4 to 6 weeks until skin returns to normal
43
Lifestyle advice for psoriasis?
1. Gentle Sun exposure can be useful
2. Special diets don't have a role. (though if clearly coeliac, then avoidance of gluten may help)
3. Use soap substitutes
4. Swab for infection if present
44
In long term treatment of psoriasis for different areas of the body, what general strength (mild, mod, strong, potent or ultrapotent or last ditch SUPER EXTRA MEGA POTENT) of topical steroid/agent should you use in the first instance:
Scalp
Trunk/Limbs
Palms and soles
Pustular
Nails
Face
Flexural
Scalp - Moderate e.g. methylprednisolone aceponate 0.1% LOTION (not practical to use ointment in hair)
Trunk/Lumbs- ultrapotent Coal Tar solution e.g. LPC 6% + salicylic acid 3% cream or ointment topically, twice daily for 1 month
Palms and soles - similar to trunk and limbs also coal tar
Pustuluar - Ultrapotent, Coal tar or betamethasone diproprionate in an OINTMENT.
Nails - SUPER EXTRA MEGA Potent. calcipotriol+betamethasone dipropionate 50+500 micrograms/g ointment topically, in proximal nail fold and under nail, once daily at night for up to 3 months
Face - Moderate e.g methylprednisolone aceponate 0.1% in ointment
Flexural - Also moderate strength, same as face
Note: as you can see there is no role for weak steroids in psoriasis. the thicker the dermal layer, the stronger the steroid. The face, scalp and flexures are the thinnest layers but still require a moderate strength, unlike in eczema. The nails are extremely thick and even with SUPER EXTRA MEGA potent they may still not get better.
45
This is a rare condition. Called Phemigus. It has two forms. There are two types, one effecting more superficial layer of the epidermis, the other more mucosal layers.
Which of the two would you try to treat first, and which would you refer to a dermatologist?
The picture here is of the superficial type
Initial treatment for pemphigus foliaceus (superficial epidermis type) is a potent topical corticosteroid. If that doesn't work send to a dermatologist.
Refer to a dermatologist or oral medicine specialist for treatment of pemphigus vulgaris (mucosal/deeper epidermis type) because management is complex and protracted. It's essentially an autoimmune disease.
This picture here is of the second type.
46
What is venous eczema and what is some general management?
The venous congestion tends to cause irritation of the skin
General measures
cleanse with a pH-appropriate skin cleanser (avoid soap)
use products without fragrance or preservatives
avoid frequently changing skin products
to protect skin in the shower, apply an emollient (see here ...) to skin before showering (it will wash off)
shower in potable water or wash the leg using a dedicated bowl of potable water
wipe the leg with a moist cloth
gently pat the leg dry (avoid rubbing) with a clean towel
apply moisturiser (in the direction of hair growth) after showering to maintain healthy skin
47
Lines of treatment for facial/body seborrhoeic dermatitis?
First line: low irritant skin cleanser
Second: Antifungal and Mild Steroid combo
hydrocortisone+clotrimazole 1%+1% cream topically, once or twice daily until skin is clear or for up to 2 weeks
Third line: seperate anti-fungal and mild-moderate steroid formulations
E.g. methylpred aceponate 0.1% CREAM and ketoconazole 2% CREAM, daily for 2 weeks
48
Risk factors for developing seborrhoeic dermatitis?
(8)
Oily skin
Family history of SD or psoriasis
Immunosuppression: cancers, HIV, chemo etc
Neurological or psychiatric diseases (parkinson's, depression)
Use of neuroleptic medications
Treatment of psoriasis with UVA therapy
Lack of sleep
Stressful life events
49
What are the two types of contact dermatitis? and give an example
Irritant Contact Dermatitis
e.g. hair products, soaps, solvents, rubber gloves
Allergic Contact Dermatitis
e.g Nickel (8% of the population)
50
Steps to investigating a Contact dermatitis?
1. Interview- determine potential irritantas
2. Allergic reaction? assess for allergic Contact type or for comorbidity with eczema
3. usage testing if possible. Some creams/etc have multiple components. apply a small amount of the product to skin for 7 nights and assess reaction if possible.
4. Patch testing - dermatology
5. Treat/manage or refer
51
Management of Contact dermatitis of the hands?
Avoid irritants
Avoid strong cleaning agents
Use protection of household tasks (cotton lined rubber gloves)
Seek advice for OHS team for occupation reactions
Apply frequent emollient
Can use a topical steroid - same strengths as eczema
Severe? use oral pred 25mg- 50mg oral daily 5 days and refer. Taper over 2 weeks
52
How do you treat contact dermatitis of the foot?
1. Avoid overheating or excessive sweating
2. Avoid heavy footwear in hot environments
3. Topical steroid same as eczema for feet/lichenified feet
4. Apply emollient to dry skin
5. If severe oral pred 25-50mg oral, daily for 5 - 7 days , taper over 2 weeks and refer
53
What are some first line agents available OTC for mild acne?
benzoyl peroxide
salicylic acid
azelaic acid
niacinamide
54
For mild acne not responding OTC preparations, what can you use for the following scenarios?
Mostly comedomal with minimal inflammation
Mostly comedomal with some pustules/papules
Mixed inflammatory and comedomal
Mostly inflammatory with some comedomes
1. Mostly Comedomal:
Topical retinoid (Adapalene 0.1% cream or gel topically, apply every 2nd night for 2 weeks, then nightly (after washing) for a total of 6 weeks.
2. Comedomal with some pustules/papules:
Benzoyl peroxide + retinoid
benzoyl peroxide+adapalene 2.5%+0.1% gel topically, once daily for 6 weeks then review
3. Relatively equal mix of comedomes and inflammatory pustules/papules
Retinoid + antibioitc.
Adapalene+clindamycin 0.1%+1% gel topically, once daily for 6 weeks then review
4. Mostly inflammatory with some comedomes:
benzoyl peroxide + antibiotic
benzoyl peroxide+clindamycin 5%+1% gel topically, once daily for 6 weeks then review
55
what is this? what causes it? how to treat it?
Asteotatic Dermatitis
"crazy paving"
Due to dry skin- from whatever cause: drugs, zinc deficiency, fatty acid deficiency, older age, hypothyroid
Rx
Frequent emollients
Thick creams
Mod strength steroid
Derm referral after 4-6 weeks
56
Treatment of this?
Who does it affect?
Diagnosis?
Lichen simplex
usually occurs in females 2;1 mostly ages 30-50
Usually clinical, buy may need a punch/skin biopsy
Treatment with potent topical steroids
eg. betamethasone diproprionate 0.05% ointment. up to 4 weeks
then use optimised vehicle
57
Lichen planus (LP) is a chronic inflammatory condition affecting the skin and mucosal surfaces. There are several clinical types.
Epidemiology of it?
What causes it?
About 1% of the population usually aged 30-60
T cell mediated autoimmune issue
Without treatment, skin lesions usually resolve over 6 to 9 months
Usually not seen in primary care, so if you see this or get the result on biopsy, then refer.
58
What are some differences between lichen Planus (LP) and Lichen sclerosus (LS)
The main difference between the two conditions is that LP has a propensity to involve the mucous membranes including the mouth and vagina which are rarely affected in LS.
LP is t-cell mediated
LS is also autoimmune, but unknown
LS commonly affects the genital regions but not the mucous membranes.
LS and LP of anogenital sites is associated with an increased risk of vulval, penile or anal cancer (squamous cell carcinoma, SCC)
59
What are the features of bullous phemigoid?
What is the management?
1. Autoimmune disease
2. Blistering skin
3. Erythematous base on the blister
4. Usually affects older persons
Rx
1. Dermatology referral is appropriate for local and widespread blisters
2. Can use a potent steroid while waiting for dermatologist
(betamethasone diproprionate 0.05%, applied daily until clear)
60
In a gluten sensitive enteropathy is always present with this rash.
Though that doesn't mean everyone with coeliac disease develops it.
What is the rash?
What are the steps to treatment?
1. Dermatitis herpetiformis
Rx
1. Gluten free diet
2. dapsone 25 mg orally, once daily, increasing cautiously to a maximum of 100 mg orally, daily, if required. Use the minimum effective dose to reduce the risk of adverse effects
3. Once the gluten-free diet takes effect, gradually reduce the dose of dapsone (doses as low as 25 mg daily may be sufficient), with the goal of stopping the drug if possible
4. Dermatologist if concerned or not responding
61
This is a common benign and asymptomatic skin condition that begins from 6-12 months of age, but is most visible in adolescents.
What is it?
Treatment?
Keratosis Piliaris
Can be difficult to treat
Avoid picking
Dermnet advises exfoliant scrub/brushes in the shower
Moisturiser creams with urea
eTG suggests adding salicylic acid or lactic acid or topical tretinoin to the urea cream
laser assisted hair removal might work for ingrown hairs
pulse dye laser treatment
62
This is?
Treatment?
Vitiligo
hard to treat, usually poor response
Can use potent topical steroid daily for 3 months and review (but not on face)
Pimecrolemus on the face 1% cream BD for 3 months
For rapidly progressing AND extensive vitiligo refer to dermatology
Seems to occur more with autoimmune diseases: thyroid, pernicious anaemia, type 1 diabetes.
63
This is Poikiloderma of Civatte
Consists of hypopigmentation, hyperpigmentation, atrophy and telengectasia. Occurs in the V line of the neck usually in fair skin persons exposed to sun.
See answer slide for management
Sun protection advice
Depigmenting cream as for melasma
Referral
64
Name it
Can these be a problem?
Cafe Au Lait macule
Larger or multiple café au lait macules can be associated with other conditions (eg neurofibromatosis type 1).
Consider referring infants who have large or multiple café au lait macules to a paediatric dermatologist for assessment
65
What is this and what are the associated issues (2)?
Congenital melanocytic naevi
1. Large- and giant-sized congenital melanocytic naevi have been associated with an increased risk of melanoma development (10 to 15% lifetime risk), especially if they are accompanied by multiple smaller satellite naevi at birth.
2. The presence of multiple congenital melanocytic naevi (of any size) is also an independent risk factor for neurological complications (eg neuromelanosis, central nervous system tumours and malformations, hydrocephalus, seizures, abnormal neurodevelopment)- refer to paediatric dermatologist.
66
What is this? Is it something to worry about?
Naevus of Ota
No, only cosmetic.
67
Info
The porphyrin pathway is involved in haem synthesis. Haem is the red pigment in haemoglobin in blood cells and carries oxygen in the blood. A deficiency or block of one of the enzymes in the porphyrin pathway results in a build-up of the corresponding precursor protein or intermediate molecule.
What does this manifest as on the skin?
Porphyria cutanea tarda (PCT) is the most common type of porphyria.
Characteristically, the urine is darker than usual, with a reddish or tea-coloured hue.
It is diagnosed by measuring the plasma porphyrin concentration. About 75% of cases are sporadic (PCT-S), resulting from liver damage caused by iron overload, excessive alcohol consumption, hepatitis C infection, HIV infection, estrogen-containing preparations, and occupational or environmental hepatotoxins (eg dioxins). The remaining 25% of cases are familial (PCT-F); PCT-F has autosomal dominant inheritance and a younger age of onset
68
What is angioedema
What can cause it?
It is abrupt, temporary, localised swelling of the deep dermal layer, subcutaneous tissue, and mucous membranes.
Can be due to allergic, drug-induced, idiopathic, and hereditary angioedema (HAE).
69
Treatment for angioedema/urticaria
Less sedating antihistamines
e.g. cetirizine 10 mg orally, once daily
or loratadine 10mg, orally, daily
If that doesn't control it then add montelukast at asthma doses for age
If severe (lip and eye swelling) then use prednisolone 25 to 50 mg orally (child: 1 mg/kg up to 50 mg), once daily for 2 to 3 days
70
Risk factors for Skin Cancer?
(7)
Solarium use
Lifetime exposure to sun
Severe sunburn during childhood/adolescence
Fair skin/red hair
Previous history of non-melanoma skin cancer
Previous history of melanoma
Family history of melanoma
71
Additional risk factors for melanoma?
Apart from the usual risk factors for skin cancer there are some additional risks for melanoma specifically.
(3)
1. > 50 melanocytic naevi on the body AND >10 on the arms
-RACGP red book states >5 dysplastic naevi increases the relative risk to 6.
2. Marked solar damage (actinic keratosis)
3. Immunodeficiency
Immunodeficiency includes HIV, cancers like lymphoma or leukemia, organ transplantation.
nb. autoimmune disorders are not an immunodeficiency.
72
What is the ABCDE approach to melanoma analysis?
Asymmetry
Borders- irregular
Colour- various within the lesion
Diameter- enlarging diameter is more important than actual size, thought mostly > 6mm
Evolution: changing or evolving
73
What should you do if you suspect a melonoma in the first instance.
Walk through the steps.
Need an excisional biopsy with a 2mm border and containing subcutaneous fat.
Use a marker to draw a 2mm border ellipse
Use hand hygiene practices
Put on surgical gloves using an aseptic technique
Infiltrate skin with 3-5 mls of 1% lidocaine with 1: 100,000 adrenalin
Using a scalpel excise along the ellipse containing the lesion
Place a suture at the 12 oclock position on the specimen
Place specimen in a biopsy container to send for histopathology
Ensure haemostasis is achieved by pressure
Achieve primary closure with interrupted sutures using 4.0 nylon suture material
Apply a sterile dressing to the lesion
Make sure pathology container is labelled and placed in correct destination to be sent
Instruct about aftercare (remove sutures in 10days) and follow up
74
What is the maximum dose of lidocaine that can be used for a person?
For a 65kg person?
answer: The max dose is 4.5mg/kg
Extra: The liquid usually states 1% or 2%
For 1% solutions:
1% means 10mg lidocaine in 1ml of solution
So divide the max dose by 10
65 x 4.5 = 292.5 mg (max)
In the solution the max mls will be...
292.5mg/10mg/ml so approx 30mls
This is important incase you plan to remove multiple skin lesions at once. You don't want to use more that the max dose of the local anaesthetic.
If the solution says 2% lidocaine:
Same max dose for 65kg of 292.5
But there is 20mg of lidocaine in 1 ml
so 292.5/20 = 14.6mls.
So significantly less
You may be using lidocaine 2% when you cannot use adrenaline (extremities, allergies).
75
Which is the most common skin cancer?
Basal cell carcinoma
76
What is an appropriate initial margin for an excisional biopsy, irrespective of the cancer?
What would you do next?
1. 2mm border in an ellipse preferably.
Do not use a punch biopsy if suspicious of melanoma in particular, because of the risk of under-diagnosis.
2. Depending on the lesion
Likely to refer to someone trained in skin cancer removal:
SCC/BCC do a wide local excision with a 3-4 mm margin.
For Melanomas greater than 1mm thickness, refer to specialist, do not re-excise. (or 0.75mm thick and immunosuppressed)
77
7 point checklist for Melanoma. as an alternative to ABCDE.
A score of > 3 correlates more highly with likelihood of melanoma.
This is the only validated tool
What factors give you points?
2 points for any of
irregular shape
change in size
irregular colour
1 point for any of
largest diameter 7mm or more
inflammation
oozing
change in sensation
78
What is a dysplastic naevus vs. melanoncytic naevus vs. lentigine ?
A melanocytic naevus is a mole, a raised lesion. It starts of flat usually and is seen from childhood. It then becomes raised and loses some pigment
A dysplastic naevus is a subset of a melanocytic naevus. 'funny looking mole'
Usually has raised and flat parts and differences in colour within the lesion, hence why only few of these present would raise suspicion of melanoma.
A lentigine is a macule that is non malignant. is flat therefore. usually <5mm. They are due to sun exposure but do not increase the risk of melanoma. they can be varied in colour too, so might be hard vs a melanoma, to make out clinically hence use the 7 point scoring system
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What are the differentials for this?
What is the next step?
Squamous cell carcinoma or
Keratoacanthoma
Elliptical Excisional Biopsy with a 2mm margin.
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After a primary SCC diagnosis and wider local excision as treatment, what is the recommended follow up?
6 monthly checks for 2 years
Check lymph nodes at every visit
It's not as aggressive as melanoma but up to 5% of SCCs metastasize. The risk increases if it occurs on the ear or lip
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Types of BCC
(4)
SUNS
superficial- can treat with topical field treatments or liquid nitrogen
Ulcerative
Nodular
Scar- "Morphoeic"
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what lesions can you use this for?
imiquimod 5% cream topically, at night 5 times weekly for up to 4-6 weeks. In the morning, wash the treated area with mild soap and water.
OR
fluorouracil 5% cream topically, once or twice daily for 2 to 4 weeks on the face or 3 to 6 weeks on arms and legs
1. Solar keratosis/actinic keratosis for 4 weeks then review
2. Superficial BCC, imiquid only for 6 weeks
3. Bowen disease (SCC in situ) though more likely to either refer or excise these. for 4 weeks then review
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What is this?
Why is it given its name?
What do you tell the patient to do?
Psuedofolliculitis
It is not an infection as folliculitis usually is. But an irritation of the skin caused by an external things trying to remove the hair, the freshly cut hair retracts in and inflames the follicle.
Try to stop shaving or hair removal in the area
Adjust shaving technique:
Use warm water to moisten the skin
Do not pull the skin taught
Use a soap free cleanser on the skin first
Shave with a clean SHARP razor
Can use benzoyl peroxide 5% gel applied topically twice a day. can take 6 weeks for a response. Can add clindamycin 1% (combo medication gel) applied daily
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Name 1 mildly potent steroid?
Hydrocortisone 1%
cream, ointment, lotion
Dapsone 0.05% lotion only
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Name one moderately potent steroid?
triamcinolone acetonide 0.02%, cream or ointment
betamethasone valerate 0.02 or 0.05% cream or cream/ointment respectively
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Name a potent steroid?
Betamethasone dipropionate 0.05%, cream, ointment or lotion
Methylprednisolone aceponate 0.1% cream or ointment
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What can be done to betamethasone dipropionate to turn it into a ULTRA or very potent steroid?
Given in an optimised vehicle such as a wet wrap
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What is equivalent to a very potent steroid but is not a steroid when treating a skin condition?
Coal tar preparations
LPC 4-8% and Salicylic acid 3% in aqueous cream.
This would primarily be used in chronic stable psoriasis. Lower LPC percentage on the face (2%+2%), higher for scalp (4-8% + 3%) and highest for trunk/limbs (4-8% +3%). You would use a steroid for an acute psoriasis flare
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Steroid potencies usually go in 4 steps.
1. mild
2. moderate
3 .potent
4. very potent (ultrapotent)- mainly changed by optimising vehicle.
There is one more last ditch attempt. What can be added to a steroid (which steroid?) to make it super ultra mega potent?
calcipotriol+betamethasone dipropionate 50+500 micrograms/g ointment or foam topically, once daily until skin is clear (usually about 6 weeks).
Mainly used for non response trunk/limb psoriasis.
calcipotriol takes about 6 weeks to be effective.
careful as calcipotriol is vitamin D and can lead to hypercalcaemia.
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What is this?
What is it commonly mistaken for?
What over-aching class of lesions does this fall under?
A. Bowen's disease
B. Psoriasis or eczema
C. SCC
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What is this a picture of?
What subtype?
What are the other subtypes? (3 in total)
1. BCC
2. Superficial BCC
3. Nodular (this picture),
superficial,
morphoeic
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If an excision is done for a Non-melanoma skin cancer, what would determine the need for a re-excision?
1. Positive margins on the biopsy
2. If it is an SCC the margin needs to be cleared by 0.5mm
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When should specialist removal of a NMSC (non melanoma skin cancer) be sought?
For lesions on the face or scalp.
The ears, eyes, nose and lips are potential danger areas. Skin cancers in these areas are often more aggressive and infiltrating and have a higher risk of recurrence and metastasising.
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List 8 steps when excising a non-melanoma skin cancer? Here is step 1
1. Mark out the lesion boundary with a marker pen
2. Measure the lesion diameter and the excision margin
3. Mark out the excision lines along tension lines
4. Consider any underlying structures to be avoided (eg. facial nerve).
5. Inject with local anaesthetic and adrenaline (eg. lignocaine 1% with adrenaline)
6. Excise the lesion: depth will depend on the size, type and position of the tumour but most excisions will be to subcutaneous fat.
7.Tie off any significant bleeding vessels.
8. Suture the wound. If there is significant tension, then subcutaneous sutures are advised. This reduces the risk of wound infection and wound dehiscence, and reduces scarring.
(9. send specimen in appropriate container for histological assessment)
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Treatment for this?
(topical steroid)
this is atopic dermatitis
trunk and limbs - go moderate
triamcinolone acetonide 0.02% ointment topically, once daily until skin is clear.
If severe or affecting flexure regions
(in this case it is in the flexure region, though the first answer is fine)
methylprednisolone aceponate 0.1% ointment or fatty ointment topically, once daily until skin is clear
OR
mometasone furoate 0.1% ointment topically, once daily until skin is clear.
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First line treatment, with dosing for this?
What would you do if there is no response in 7 days ?
Facial eczema
Hydrocortisone 1% cream, applied daily until clear.
Step up to a moderate strength (or for severe eczema)
Methylprednisolone aceponate 0.1% ointment , applied daily for 7-14 days
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Dosing for topical steroid to treat this?
Foot atopic dermatitis, go strong
betamethasone dipropionate 0.05% ointment topically, once daily until skin is clear
if not responding try wet wraps
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Presume this is eczema not seborrhoiec dermatitis. What is the treatment ? (dosing)
Scalp- go Strong steroid - but in lotion
betamethasone dipropionate 0.05% lotion topically, once daily until skin is clear
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Facial eczema is considered for mild steroids such as hydrocortisone or desonide.
The scalp is surprisingly for a strong steroid such as betamethasone dipropionate 0.05%.
What other area/s would be treated with hydrocortisone 1% cream as first line?
The axilla and groin
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In contrast to facial eczema, what potency steroid would you use for facial psoriasis to begin with?
Use a moderate strength such as
methylprednisolone aceponate 0.1% cream, ointment or fatty ointment topically, once daily until skin is clear
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Treatment of stable psoriasis is usually treated with what type of topical treatment?
tar and coal preparations such as
LPC 2%+salicylic acid 2% in aqueous cream topically, once daily at night, if on the face,
or stronger if on the limbs.
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Psoriasis of the palms and soles require quite a high potency treatment, if not the highest potency.
What two options are there?
Dosing required.
1. LPC 4 to 8%+salicylic acid 6% cream or ointment topically, twice daily for 1 month
2. calcipotriol+betamethasone dipropionate 50+500 micrograms/g ointment or foam topically, once daily until skin is clear (usually about 6 weeks).
