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Skin Pre-Cancerand Cancer Dr. Mary Cuthbert GPSI Dermatology.

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Presentation on theme: "Skin Pre-Cancerand Cancer Dr. Mary Cuthbert GPSI Dermatology."— Presentation transcript:

1 Skin Pre-Cancerand Cancer Dr. Mary Cuthbert GPSI Dermatology

2 Sun, sea and sand….

3 Theres no such thing as a healthy tan

4 The effects of UV exposure -ageing of skin

5 -skin cancer

6 This presentation will cover : Actinic keratosis Bowens disease Basal cell carcinoma Squamous cell carcinoma Malignant melanoma NICE guidance on skin cancer prevention

7 Actinic keratosis Rough,scaly spots on sun-damaged skin Represent abnormal skin development due to exposure to UV radiation Should be considered potentially precancerous(>10 AKs = 10-15% risk SCC) Common on exposed sites eg backs of hands,face,scalp and ears of bald men

8 Actinic keratosis

9 Actinic keratosis-treatment Diclofenac gel (Solaraze) CryotherapyCurettage/Excision 5-Fluorouracil cream (Efudix) Imiquimod 5% cream (Aldara) Photodynamic therapy (not available in Bradford)

10 Bowens disease Bowens disease is intraepidermal squamous cell carcinoma It is effectively carcinoma-in situ It may progress into squamous cell carcinoma (approximately 5%) Because of this, it is very important to treat it effectively

11 Bowens disease Presents as a pink or red,irregular scaly patch Usually develops in a sun –exposed area of skin Common sites include hands and face in both sexes, scalp in men, lower legs in women Diagnosis should be confirmed by biopsy

12 Bowens disease


14 Bowens disease-causes: UV radiation causes mutation in genes controlling skin cell growth UV radiation suppresses immune response in skin Arsenic ingestion Ionising radiation-very common in early 20 th century radiologists HPV virus causes genital IEN

15 Bowens disease-treatment: CryotherapyCurettage/excision 5 Fluorouracil cream (Efudix) Imiquimod 5% cream (Aldara) Photodynamic therapy

16 Basal cell carcinoma Affects fairskinned adults who have had a lot of sun exposure or repeated episodes of sunburn Gorlins syndrome-inherited tendency to multiple BCCs BCCs usually arise in normal-looking skin BCCs grow slowly over months or years Metastasis exceedingly rare but BCCs can cause destructive changes in surrounding tissues

17 Basal cell carcinoma-types: Nodular BCC-most common type Superficial BCC-common Morphoeic BCC-waxy,scar-like Pigmented BCC- can resemble melanoma Basisquamous BCC-mixed BCC/SCC Only the first two types are seen commonly in GP

18 Nodular BCC Most common type on face Small, shiny, skin-coloured swelling Telangiectasia cross the edge May have central ulcer or scab so edges appear rolled Often bleed spontaneously, then heal over Rodent ulcer is an open sore Facial BCC should be referred to plastic surgeon

19 Nodular basal cell carcinoma

20 Superficial BCC Often multiple Upper trunk or shoulders commonest site but can appear anywhere Pink or red scaly patch with raised edge on close examination Slowly growing over months or years Bleed or ulcerate easily

21 Superficial basal cell carcinoma

22 Why BCCs need treatment

23 BCC- treatment: Shave,curettage,cautery Excision biopsy, may need grafting or flap. Mohs micrographic excision Photodynamic therapy Imiquimod 5% cream-highly effective for superficial BCCs CryotherapyRadiotherapy

24 Remember-BCCs dont kill but can be locally destructive

25 Squamous cell carcinoma SCC is a common type of skin cancer It develops in the epidermis from squamous cells which produce keratin Usual presentation is a slowly –growing scaly or crusted lump Can present as a non-healing sore or ulcer punched out in appearance Sometimes growth is rapid over a matter of weeks

26 Squamous cell carcinoma



29 Squamous cell carcinoma,or is it?

30 Squamous cell carcinoma-causes: UV radiation-damages DNA in skin SCC may develop in an actinic keratosis or patch of Bowens disease Genetic predisposition to develop SCCs Smoking-especially SCC lip Thermal burns Chronic leg ulcers Immunosuppression-Azathioprine/Ciclosporin. Organ transplantation patients highly susceptible Organ transplantation patients highly susceptible HPV infection implicated in genital SCCs Pre-existing skin conditions eg lichen sclerosus and lichen planus can predispose to development of genital and oral SCCs

31 Squamous cell carcinoma- treatment If you suspect a possible SCC, refer via FAST TRACK pathway Histological diagnosis confirmed in Dermatology department Joint dermatologist/plastic surgeon assessment ideal, as happens in Bradford. Specialist Skin Cancer Nurse input helpful Surgery, possibly with skin graft Radiotherapy may be needed

32 Metastatic Squamous cell carcinoma 5% SCCs metastasise, most commonly from primary lesion on ear or lip Commoner in transplant patients Patients with CLL Associated with increasing age Associated with alcoholism More likely if multiple skin cancers present

33 Malignant melanoma Melanocytes are found in the basal layers of the epithelium Non-cancerous growth of melanocytes results in moles or freckles Cancerous growth of melanocytes results in malignant melanoma

34 Malignant melanoma-risk factors: Sun exposure, particularly during childhood Fair skin which burns easily Blistering sunburn, especially when young Previous melanoma Family history of melanoma Previous non-melanoma skin cancer Large numbers of moles/ dysplastic moles

35 Common sites for melanoma: In men commonest site is the back In women commonest site is the leg Can occur on mucous membranes, eg lips or genitals Can occur under the nail Can occur in eye, brain or mouth BEWARE AMELANOTIC MELANOMA

36 Glasgow 7 point checklist: MAJOR FEATURES: Change in size Irregular shape Irregular colour MINOR FEATURES: MINOR FEATURES: Diameter > 7mm InflammationOozing Change in sensation

37 The ABCDE of melanoma A Asymmetry B Border irregularity C Colour variation D Diameter over 6mm E Evolving (enlarging or changing)

38 Malignant melanoma

39 Growth of melanomas Horizontal growth within epidermis=melanoma in situ Vertical growth through basement membrane into dermis=invasive melanoma Once melanoma penetrates dermis,it spreads via lymphatic and blood stream = metastatic melanoma = metastatic melanoma

40 Malignant melanoma

41 Histological classification: Breslow thickness: Breslow thickness: This is the thickness of the melanoma in mm Clarks level: Clarks level: This describes which layer of skin has been breached Clarks level 1-epidermis-melanoma in situ Clarks level 2-dermal invasion Clarks level 5- invasion of subcutaneous fat

42 Treatment of melanoma Refer suspected melanoma via FAST-TRACK pathway Surgical excision by Dermatologist with 2-3 mm margin Wider excision if histology confirms melanoma Thicker melanomas> 1mm-wider excision +/- sentinel node biopsy Widespread melanoma-surgery/chemotherapy

43 Prognosis of melanoma Breslow thickness< 1mm, almost 100% 5 year survival Breslow thickness > 4mm, only 50% 5 year survival 5 year survival Remember, melanoma is a major cause of death from malignancy in young people

44 Malignant melanoma




48 Advanced melanoma

49 How can we advise our patients regarding skin cancer prevention?

50 NICE Guidance- January 2011

51 Benefits of sun exposure: Increases peoples sense of wellbeing Allows synthesis of Vitamin D Provides the opportunity for physical activity to improve fitness

52 Skin cancer prevention measures: Should not discourage outdoor activities Should encourage people to use sensible skin protection

53 Who should be involved? Commissioners, organisers, planners of national primary prevention campaigns Local bodies including environmental health, education sector, workplaces Local practitioners eg GPs, HVs,school nurses, pharmacists, dermatologists

54 At-risk groups: Fair-skinned individuals Children and babies Outdoor workers Immunosuppressed People with personal/FH of skin cancer People with > 50 moles People who overexpose skin by sunbathing/use of sunbeds

55 What action should be taken? Ensure advice contains simple explanation of how UV light damages skin Ensure advice explains how people can assess their individual risk Ensure advice is balanced, including both risks and benefits of sun exposure Ensure advice includes a range of options to protect skin against UV light

56 Advice: Avoid sunburn If you need to be out in sun due to work, protect skin as much as possible Spend time in shade between and Wear broad-brimmed hat, long sleeves and trousers Choose close-weave fabrics

57 Advice: Sunscreens should be used IN ADDITION to above measures Choose sunscreen with UVA and UVB protection It should be at least SPF 15 to protect against UVB It should be at least 4 stars to protect against UVA Use water –resistant products,applied every 2 hours

58 How to give advice in a positive manner: Positive statements are more likely to help people to change behaviour: using sunscreen helps to keep skin healthy and young-looking using sunscreen helps to keep skin healthy and young-looking Keep it simple Mention ageing effects of sun-sometimes has more impact than cancer risks (remember the old lady on the beach!) (remember the old lady on the beach!)

59 In summary: We have looked at the effects of UV radiation and other risk factors on the skin We have discussed the management of pre- malignant actinic damage We have considered the locally destructive nature of BCCs We have looked in depth at SCC and melanoma, both of which are potentially fatal We have looked at current NICE guidance on skin cancer prevention

60 And finally…………

61 Remember-theres no such thing as a healthy tan!


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