Derm Lecture 4Skin issues associated with systemic disease

Skin CancersSystems IV 2013

Erythema nodusum 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

Things I’ve seen which are related to systemic disease

Erythema nodosumCommonly onlower leg

Splinter hemmorrhages-fingernail, toenail, fingertip or on toes-indicate subacute endo-Carditis. REFER

“Coin” lesions on hands withporphyria associated with Hep CCan be on palms as well. Get worse With stress or toxin exposure

“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

Actinic Keratosis (AK)

Can either heal on its own, remain unchanged or progress to a cancerous lesion, esp squamous 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

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.

Actinic Keratosis (AK)

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?

Review Question that is important to understand

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

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

Lentigo maligna melanoma (LMM) 10-15%◦ Typically found on face and neck, and sun exposed areas◦ Typically arise from previous lesions and have hypopigmented areas

Acral Lentiginous 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.

5 Histological Types of 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

Risk Factors 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.

Stats for Malignant Melanoma

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.

Malignant Melanoma Prognosis and Treatment

A AsymmetryB Borders irregularC Color black or dark blue with other

colorationD Diameter > 6 mmE Erythematous base

Diagnosing suspicious lesions

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

This is an invasive nodular type ofmelanoma. It is seen at an earlier age and more often in men. Again, you seean erythematous base with asymmetricborders, often with a tendency to crack and bleed.

This is a typically missed or questionable lesionthat is in fact, an invasive melanoma. Look closelyif you’re not sure and refer…

Lentigo maligna melanoma

Mucosal melanoma

AcralMelanoma

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

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%.

Basal Cell Carcinoma (BCC)

Basal Cell Carcinoma

Basal Cell Carcinoma

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 lesion associated with chronic damage to the keratinocytes

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)

Squamous Cell Carcinoma (SCC)

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.

Squamous Cell Carcinoma

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!!

Squamous Cell Carcinoma (SCC)