Perineal/perianal Skin Flashcards

Question

STDs in the perineal/perianal skin

Answer 1

Particularly MSM, HIV positive men Ulcers Syphilis (treponema pallidum) - primary chancre (primary syphilis), condylomata lata (secondary syphilis), granulomatous gumma (tertiary syphilis) Gonorrhoea (neisseria gonorrhoea) - oedema, discharge, fissures, erosions Lymphogranuloma venereum (chlamydia trachomatis) - ulcerative haemorrhagic proctitis mimicking Crohn’s colitis Granuloma inguinale, Donovanosis (klebsiella granulomatis) - PAINLESS papules/nodules that ulcerate, risk SCC Chancroid (haemophilus ducreyi) - PAINFUL ulcers, inguinal lymphadenopathy HPV - anal warts (not always STD) HSV 2 - ACUTE PAINFUL ulcers, proctitis without perianal ulcers Pubic lice (phthiriasis pubis)

Answer 2

Infective - HSV CMV Syphilis I.e. primary chancre (treponema pallidum) Lymphogranuloma venereum (chlamydia trachomatis) Amoebiasis Anal sepsis (perianal abscess, fistula) Malignancy - Kaposi sarcoma Non-Hodgkin lymphoma SCC Idiopathic I.e. aphthous ulcer Structural - Anal fissure Haemorrhoids Other - Trauma Pruritus ani

Answer 3

Commonest viral STD in this region HPV types 6, 11 - benign warts HPV types 16, 18 - anal intraepithelial neoplasia, anal CA Higher in men, especially MSM

Answer 4

Ano-receptive sex Increase lifetime sexual partners Immunosuppression

Answer 5

``` Hyperkeratosis Parakeratosis Papillomatosis Acanthosis Coarse keratohyaline granules in the granular layer Koi located in the granular layer ```

Answer 6

``` Molluscum contagiosum Condyloma lata (secondary syphilis) Lichen planus Anal intraepithelial neoplasia Anal CA ```

Answer 7

Risk of ano-genital neoplasia, oropharyngeal CA If immunosuppressed, higher risk of progression to anal intraepithelial neoplasia and anal CA If MSM, higher risk of HIV

Answer 8

REFERRALS - Genito-urinary medicine specialist needs full sexual health screen Colorectal if intra-anal disease suspected INVESTIGATIONS - Biopsy of diagnosis in doubt or dysplasia suspected ``` TREATMENT - First line - 5% imiquimod cream - Podophylin - Podophylotoxin - TCA ``` Second line - cryotherapy - electrocautery - excision - ablative laser Third line - - topical, intralesional, systemic interferon (not recommended as routine)

Answer 9

HPV 16, 18 Older women MSM Can affect anal, perianal, vulva, cervix, penis

Answer 10

``` MSM (esp with HIV) Receptive anal sex Hx ano-genital warts Lifetime number of sexual partners Smoking Immunosuppression I.e. renal transplant ```

Answer 11

``` Epidermal Cytological atypia Dyskeratosis Nuclear pleomorphism Nuclear hyperchromatism Mitoses Koilocytes may be present p16 (proliferative biomarker) can be useful for grading of severity ```

Answer 12

``` Often asymptomatic Can be itchy, bleeding Solitary vs multifocal Intra-anal lesions may be papillomatous, red, white, pigmented, fissured Induration/ulceration (sign of invasion) ``` Variants - - Perianal Bowen disease - asymptomatic red shiny scaly plaque, may be continuous with dysplastic lesions in anal canal, Risk of progression to invasive SCC - Bowenoid papulosis - solitary/multiple reddish brown/pigmented/flesh-coloured flat/verrucous papules, unknown risk of progression to invasive CA

Answer 13

Anal CA HPV infection Psoriasis Lichen planus

Answer 14

Risk of progression to anal/perianal SCC poorly understood

Answer 15

Biopsy - confirm Dx, evidence of invasive disease | High resolution anoscopy with mapping biopsies of suspicious areas

Answer 16

Aims - Alleviate symptoms Prevent progression to anal CA Close follow up General measures - MDT approach Examine genital skin for associated diseases I.e. warts Colorectal - Digital rectal exam, anoscopy (determine if any intra-anal disease) Gynae for females - exclude concomitant CIN ``` First line - Top 5% imiquimod Top 5-FU Electrocautery CO2 Laser ablation Excision (small solitary perianal lesions) —> risk of anal stenosis, faecal incontinence ``` Second line - PDT Screening/prevention - HPV vaccine in MSM No national screening program Controversial use of anal cytology, high resolution anoscopy due to cost-effectiveness Recommended in high risk population I.e. MSM, HIV

Answer 17

Primary - intraepithelial adenoCA from apocrine gland ducts intraepidermal cells/pluripotent keratinocyte stem cells (neoplastic cells showing glandular differentiation), CA in situ but can become invasive, metastatic Secondary - epidermal involvement from an internal neoplasm, either by direct extension or metastasis Secondary EMPD Associations - Ano-rectal adenoCA (especially with perianal EMPD) Bladder/urethra adenoCA Other adenoCA Pruritus Burning Perianal bleeding Red plaques/erosions, moist, hyperkeratotic “strawberries and cream” Sharp border Solitary vs multifocal Variable hyperpigmentation Thickened/ulcerate (sign of invasion) Sites rich in apocrine glands I.e. vulva, Anogenital skin, scrotum, penis, axilla Perianal lesions can extend into anal canal Vulval lesions can extend to introitus ``` DDx - Psoriasis Eczema Vulval/anal intraepithelial neoplasia Bowen disease ``` Histo - Epidermal hyperplasia Paget cells (large vacuolated cells with circular nuclei, foamy pale cytoplasm) infiltrate epidermis ``` IHC primary + secondary EMPD - PAS + CAM5.2 + (LMW keratin) CK7 + (LMW keratin) CEA + Pankeratin - (excludes carcinoma) CK5/6 - (excludes carcinoma) S100 - (exclude melanoma) Melan A - (exclude melanoma) ``` Differentiating IHC for primary vs secondary EMPD = CK20, GCDFP-15 Primary EMPD CK20 - GCDFP-15 + (marker of apocrine epithelium) Secondary EMPD CK20 + GCDFP-15 - Investigations - Full exam for extent and an underlying adenoCA esp cervix, rectum Skin Biopsy Ensure cervical cytology/mammogram UTD (female) Consider bowel/urological investigation ``` Primary EMPD Treatment (combo often needed) - Excision with large margins (first line) MOHS Top 5-FU Top 5% imiquimod (widespread disease, for post-surgery recurrence) Top bleomycin Oral retinoids Cryotherapy PDT CO2 ablative laser RTX (adjunct to surgery or if surgery not possible) TCS if itchy Regular monitoring ``` Secondary EMPD Treatment - Treat underlying CA Course/prognosis - Indolent, but spreads by local extension and mets Recurrence common Excellent prognosis for primary intraepithelial disease, less so for invasive disease

Answer 18

EMPD BCC - predisposed from radiation, trauma, burns Melanoma LCH Carcinoma erysipeloides

Answer 19

Infiltration of the skin with neoplastic cells Infiltrated papules Associated malignancies - Bladder, prostate CA (perineum, thigh) Colon adenoCA (genito-crural region)

Answer 20

Anal canal or anal margin or both ``` Subtypes of anal cancer - SCC (usually preceded by anal intraepithelial neoplasia) AdenoCA Melanoma Lymphoma Kaposi sarcoma (HIV related) ```

Answer 21

HPV-16, 18 | Ano-receptive sex

Perineal/perianal Skin Flashcards

(45 cards)