cancer and actinic damage皮肤癌和皮肤光化性损伤课件

Diagnosis of skin lesions and treatment of actinic damage Dr Philip Hampton RVI Aims Melanoma and pigmented lesions Clinical features Non melanoma skin cancer Clinical features BCC SCC Actinic damage Clinical features Diagnosis and management Pigmented lesions Melanocytic Lentigo Simplex Maligna Naevi Junctional, compound, intradermal Melanoma Non-melanocytic pigmented lesions Seborrhoeic warts Dermatofibroma (BCC) Assessment of pigmented lesions History Change Bleeding Clinical Asymmetry Borderline Colour Diameter Dermatoscopy Significance of clinical signs Major features Change in size of lesion Irregular pigmentation Irregular border Minor features Inflammation Itch/altered sensation Lesion larger than others Oozing/crusting Lentigo Lentigo Pigmented macule Normally sun exposed Increased melanocytes Growth within basal layer of epidermis Lentigo simplex Lentigo maligna (freckle increased melanin, normal melanocyte number) Melanoma Sun exposure ( not acral MM) Worse prognosis Head and neck ulceration Thicker Breslow Breslow ThicknessApproximate 5 year survival 4 mm50% Assessment Clinical Asymmetry Borderline Colour Diameter Referral details Melanoma screening clinic 2WW choose and book 80-140 per week On average 4 MM per week Basal cell skin cancer Most common cancer Incidence increasing High risk / low risk Numerous clinicalsubtypes Nodular Superficial Morphoeic Pigmented BCC: diagnosis Types of BCC Nodular Cystic Morphoeic Superficial Pigmented BCC- morphoeic Scar like Ill defined edges Risk of recurrence MOHS surgery recommended if critical site BCC referrals Choose and book New Monday afternoon BCC clinic from August Aim to see all BCCs within 4 weeks If on eyelids or nose Dermatology Surgery Written referral preferable Some patients directed to the joint dermatology surgery and occuloplastic clinic Keratinocyte dysplasia Actinic damage Actinic keratosis Hypertrophic actinic keratosis Bowens disease Bowenoid actinic keratosis Keratoacanthoma Squamous cell carcinoma Differentiation status: well, moderate, poor KERATIN HORN Actinic damage Keratinocyte dysplasia Epidermis only Variable extent Actinic Keratoses Bowens disease Intra epithelial dysplasia Full thickness of epidermis dysplastic Keratoacanthoma An SCC Very well differentiated May spontaneously regress Squamous cell carcinoma Chance of recurrence Site Head and neck Lips, ear Differentiation state Well, moderate, poor Invasion of skin structures Vessels, nerves, lymphatics Immunosuppression Recurrent lesion Actinic damage: When to treat in the clinic Diagnosis- must be made Epidermal proliferation/ Lesion thickness AK or SCC- can be hard to tell clinically Thickness of scale Any erosion Location Lips- high risk -always refer Lower legs-often poor response AKs: When to treat Malignant transformation of solar keratoses to squamous cell carcinoma. Marks R et al Lancet 1988 1689 people (40yrs), 21,905 AKs, over 5 years Transformation risk within one year less than 1 in 1000 Spontaneous remission of solar keratoses: the case for conservative management. Marks R et al Brit J Dermatol 1986 1040 people (40yrs) 224 (36.4%) had lesoins that spontaneously resolved SCC incidence 0.24% for each solar keratosis present Treatment Nothing, emollients, sun protection Liquid nitrogen Curettage and cautery Excision Topical Efudix Imiquimod (Solaraze) Solaraze Does it work? Diclofenac sodium 3% gel Trials have very short follow up 30days Int J Dermatol 2002 Complete clearance 47% vs 19% (placebo) Well tolerated 5-flurouracil- Effudix Inhibition of thymidylate synthase Interference with pyrimidine synthesis Apoptosis of rapidly dividing cells Patient education is crucial Appropriate review appointments Imiquimod 5% cream Immune response modifier Binds Toll like receptor 7 (TLR-7) Increased INF, IL-6, TNF Activation of immune system Innate adaptive Apoptosis Potential problems of topical treatment Inflammation Education Patient expectations Infection Polyfax ointment antibiotics Treatment failure Compliance ? Wrong diagnosis SCC and AK referrals SCC 2 week wait SCC clinic Faxed referrals to RVI AK GP treatment South of Tyne Community Dermatology service Routine choose and book referral to RVI. Summary Pigmented le