top dermatological tips on diagnosing skin lesions for busy gps! louise moss gp moss valley medical...
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Top Dermatological Tips on diagnosing skin lesions
for busy GPs!
Louise MossGP Moss Valley Medical
Practice, Eckington 28th March 2012
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Aim for today
To feel more confident about how to diagnose and treat some common skin lesions within general practice.
Remember,common things occur commonly!
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So what do we need to cover?
• In 2009 I reviewed the sorts of skin conditions referred to my GPwSI clinic to see if this would help plan teaching for GPs, practice nurses & registrars.
• 229 patients were seen from 3 neighbouring practices in a GPwSI community clinic
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Outcomes
DX rate 60%
FU Rate 16%
Referred to Hospital Dermatology service 24%
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A rash lesion?
60% were lesions
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Rashes
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Rashes: Frequency of condition
Frequency
Cumulative frequency %
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– Possible Skin cancer– Benign naevi– Seborrhoeic warts– Actinic Keratosis
• How can you increase your confidence?
80% of lesions referred include…
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• The majority of these can be managed in primary care
• Benign Naevi• Actinic keratosis• Seborrhoeic Keratoses
• Also need to be able to identify common skin cancers
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Top tips for lesion recognition
• Take a good history- sun exposure, pmh/fh• Have a careful look with good light &
magnification• Touch and feel- stretch the skin, if there’s a
crust what’s beneath?• Look elsewhere for other examples• Is there a pattern?
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Make sure you look properly......
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If there’s a crust take it off..........
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What’s that?
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DESCRIBING SKIN LESIONS
Site and size- record measurementColourSurface or TextureType of lesionBorder/shapeAttacehment to other structuresSingle or multiple/ arrangement of lesions
IF YOU LOOK CAREFULLY YOU WILL BE ABLE TO DIAGNOSE WITH MORE CONFIDENCE!
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Macule < 1cm
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Patch >1cm
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Plaque
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Papule <1 cm
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Nodule >1cm
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Pustule <1cm
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Vesicle <1cm
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Bulla >1cm
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Types of skin cancer
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Non melanoma skin cancer
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Basal cell carcinoma
What to look for..........• Shine• Superficial telangectasia• Rolled edge• Spots of pigmentation• Ulceration
• A history of slow growth & bleeding on sun-damaged skin
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Don’t forget there are different types……
• Nodular/cystic• Superficial• Morpheic• Pigmented
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Stretch the skin and look from the side.............
• YOU NEED TO TOUCH!
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Benign naevi?
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Squamous cell carcinoma
• Rapidly growing• Tender• Indurated base• On sundamaged skin• ? Immunosupression• ? Worked in tropics
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Solar (Actinic) Keratoses
• Common sun exposed sites in older people
UK >40yrs 15%men, 6%women• Forehead, face, back of hands, bald
scalp of men, and ladies legs• Rough, raised and irregular, like
stuck on cornflakes
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Importance
• Marker of sun damaged skin (so BCC/SCC/Melanoma risks all raised)
• Malignant change MAY occur in AK– Quantitative evidence poor– Probably <1/1000– Some remit spontaneously
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Treating Actinic Keratoses in primary care
• Why – very common • NICE IOG skin cancer 2006 : Patients with precancerous
lesions may be treated entirely by their GP
Exclusions: Diagnostic uncertainty Thick lesions Indurated or tender base – risk of scc
Lesions in immunosupressed patient
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• Do nothing- age/life expectancy/thin lesions• Single or multiple scattered AKs
– Cryotherapy 5-10s FTC - – Curettage & cautery – useful if slight uncertainty/ensure base is
included in histology specimen
– Efudix – 5 flurouracil cream– Solareze – diclofenac 3% ( Bd for 3/12)– Excise if malignancy is suspected
• Thick/tender/indurated/rapid growth
• Multiple AKs/Field change – Efudix secondary care may use imiquimod ( Aldara)
Can use Solareze – less irritant/ less effective
Top up with Li N2 if needed for few residual lesion
AK- Treatment options
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How to use Efudix.....
• Topical fluorouracil (5FU) is a topical cytostatic preparation that selectively destroys sun damaged skin cells with little injury to normal skin.
Useful for treating actinic keratoses that occur over a wide area and for Bowens Disease.
Not for very large or thick lesions with an infiltrated base:- refer these to exclude Squamous Cell Carcinoma.
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Efudix treatment.......• Apply at night with a finger or cotton-bud.....
• Avoid the eyes, lips and nasolabial folds. Don’t do too much at once!
• Wash off the following morning....
• Apply daily for 2 weeks, unless the skin becomes tender and sore before then. If there is little or no change at 2 weeks then apply twice daily until ...
The skin becomes red, tender and a bit weepy. It may resemble a
superficial burn.
This signals effective treatment and should take 10-28 days. Stop & allow to heal. Review after 1 month.
Early redness with mild stinging is not a sufficient end point!
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Treating AK in primary Care
• Look for other skin lesions• Advice re sun protection – 25% of lesions
may regress• Inform patients that they may develop more
lesions and which changes need to be reported
Resources: Efudix leafletsPCDS.org.uk
NED guideline
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Solar (Actinic) Keratoses
ALWAYS EXCISE (or refer) IF THICK, INDURATED OR TENDER LESIONS.
• Be careful of causing a leg ulcer by excessive cryotherapy or Efudix on the lower leg
• CUTANEOUS HORNS are better excised or curretted off with a good chunk of base
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Cutaneous horn
• Can arise from AK, keratoacanthoma,viral wart or SCC
• Need excising to get histology
• If no induration –could be curretted off with a good scoop of base for histology
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Bowen’s disease
• Full thickness dysplasia
• 2-5% chance of developing SCC
• Common lower legs/ hands/ face
• Slow growing sharply demarcated scaly plaque
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Treatment of Bowen’s
• Confirm diagnosis with biopsy –may not be necessary if patients have had a previous patch
• Treat efudix, currettage/ cautery• Follow up to check lesion has resolved
Remember if treating lower leg you can cause a leg ulcer
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Benign skin lesions
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Benign naevi
‘ happy families’
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Benign naevi
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Seborrheic warts
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Dermoscopic appearance seborrhoeic keratosis
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Thin seborrhoeic keratosis
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Viral warts-use wart paint........
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QUIZ
While I’m here Doctor......