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Recognition and Management of Pre-skin Cancer

Recognition and Management of Pre-skin Cancer. Dr Vanessa Good GP White Horse Medical Practice Speciality Doctor Dermatology, Great Western Hospital. Pre-skin cancer in general practice. Is it relevant? How does it affect us?. Incidence of skin cancer is rising. How does this affect me?.

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Recognition and Management of Pre-skin Cancer

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  1. Recognition and Management of Pre-skin Cancer Dr Vanessa Good GP White Horse Medical Practice Speciality Doctor Dermatology, Great Western Hospital

  2. Pre-skin cancer in general practice • Is it relevant? • How does it affect us?

  3. Incidence of skin cancer is rising

  4. How does this affect me? • Present to GP • Undifferentiated lesions • Referral pressures

  5. BOWEN’SDISEASE ACTINICKERATOSES

  6. OBJECTIVES Increase confidence in • Recognition of Bowen’s and actinic keratoses • Treating within primary care • Knowing when to refer

  7. RED SCALY PATCH

  8. Red scaly patch – what is it? • Bowens Disease • Superficial BCC • Tinea • Discoid Eczema • Psoriasis • other

  9. History clues • Age • Growth rate • Lesion itchiness • Response to previous treatments • Dermatological history • Sun exposure history

  10. History Red Flags PATIENT FACTORS • Older • Previous skin cancer • Significant UV exposure • Immunosuppression LESION FACTORS • Not itchy • Unresponsive steroids • Persistent growth

  11. Examination clues • Location • Number of lesions • Edge • Texture • Scale • Crusting

  12. LOCATION Bowens Superficial BCC Psoriasis Discoid Eczema

  13. NO OF LESIONS

  14. EDGE BOWEN’S DISEASE SUPERFICIAL BCC TINEA PSORIASIS ECZEMA

  15. EDGE BOWEN’S DISEASE SUPERFICIAL BCC TINEA PSORIASIS ECZEMA

  16. EDGE BOWEN’S DISEASE SUPERFICIAL BCC TINEA PSORIASIS ECZEMA

  17. EDGE BOWEN’S DISEASE SUPERFICIAL BCC Centrifugal clearing TINEA PSORIASIS ECZEMA Raised marginated edge

  18. EDGE BOWEN’S DISEASE SUPERFICIAL BCC TINEA PSORIASIS ECZEMA

  19. EDGE BOWEN’S DISEASE SUPERFICIAL BCC TINEA PSORIASIS ECZEMA

  20. TEXTURE PSORIASIS TINEA DISCOID ECZEMA ECZEMA

  21. TEXTURE PSORIASIS TINEA DISCOID ECZEMA ECZEMA

  22. TEXTURE PSORIASIS TINEA DISCOID ECZEMA ECZEMA

  23. TEXTURE PSORIASIS TINEA DISCOID ECZEMA ECZEMA

  24. TEXTURE PSORIASIS TINEA DISCOID ECZEMA ECZEMA

  25. SCALE PSORIASIS TINEA

  26. SCALE – Bowen’s Disease

  27. Superficial BCC CRUST

  28. REMINDERS

  29. RED SCALY PATCH – WHAT NEXT?

  30. Guidelines for the management of Bowen’s Disease: 2006 UpdateBritish Association of Dermatology • No one treatment superior for all cases • 10% recurrence rate • Size, wound healing, number of lesions relevant • Consider patient factors • Consider doctor factors • Follow up in 3 months

  31. Bowen’s treatment options

  32. THE SCALY SCALP

  33. History Clues • Age • Growth rate • Pain or tenderness • Bleeding • Sun exposure history • Dermatological history • Other risk factors • Social history

  34. Examination clues • Location • Skin appearance • Lesion features including: • Base • Induration • Ulceration

  35. Location – sun-exposed sites

  36. Multiple actinic keratoses

  37. Squamous cell carcinoma

  38. The tricky ones – in-betweenies!

  39. Is it a squamous cell cancer? INDURATION ULCERATION

  40. Case example

  41. Top tips

  42. RED FLAGS PATIENT FACTORS • Immunosuppression • Previous skin cancer • Previous PUVA LESION FACTORS • Rapid growth/evolving • Tenderness/ pain • Ulceration /bleeding • Raised base • Induration • Lips • Poor treatment response

  43. THE SCALY SCALP – WHAT NOW?

  44. Should I treat actinic keratoses? • 15-25% spontaneous regression per year • SCC transformation <1 in 100 per lesion /yr • 10 lesions, 14% risk invasive SCC in 5 years • Cannot predict invasive behaviour • Monitoring an option – informed choices • Treat high risk patients

  45. Treatment choices • Emollients / keratolytics/ sunblock • Diclofenac 3% gel ( Solaraze) • 5-fluorouracil cream (Efudix) • Imiquimod ( Aldara) • Cryotherapy • Curettage and cautery/ excision • Photodynamic therapy – secondary care only

  46. Which treatment to use? • Isolated lesion or multiple? • Location • Thick or thin? • Patient preference

  47. Which treatment to use?

  48. Which treatment to use?

  49. What to tell your patient? • Sun damage • Risk of developing skin cancer • Changes to be concerned about • Sun protection measures • Emollients • Treatment options • Patient information leaflet and website info • Treatment information leaflet

  50. Cryotherapy • Quick, economical, well tolerated • 70-75% clearance with 2 freeze-thaw cycles • 5-10 sec FTC • Risks: hypopigmented macular scar, inflammation, blistering • Reduce keratin first – an insulator • Poor healing in tibial area

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