1. Psoriasis and Skin Cancer
Edward Pritchard

2. Long Cases You could get these!
Last year’s finals! - Patient with recurrent SCC, with no symptoms. History focussing on skin exposure and social. Was asked about risk factors, macroscopic and microscopic appearance of different types of skin cancer and different treatments

3. Skin Examination Scalp Auricles Face Extremities (upper)
Chest (front and back) Abdomen (front and back) Genitalia Extremities
If lesions – consider local lymph nodes etc.

4. Psoriasis

5. Definition
Relapsing and remitting chronic skin condition characterised by scaly plaques
Or inflammation of the dermis, with epidermal hyperproliferation

6. Epidemiology ~2% of the population Peak incidence in early 20s and 50s
Precipitated by
infection, drugs (antimalarials, B-blockers, lithium), sunlight, stress, scars, burns

7. Pathophysiology
Immune mediated leads to increased speed of skin turnover (28 days to 4), causes thickening of the epidermis.

8. Symptoms and Signs
Typically well demarcated red, scaly, symmetrical, non itchy plaques
5 main presentations

9. Plaque – typically on extensor surfaces and scalp

10. Guttate – small eruptions over trunk – typically 2 weeks post B streptococcal throat infection

11. Pustular – widespread sterile pustules

12. Flexural – affects flexural aspects
Flexual Psoriasis – occurs typically in later life, forms in the groins, natal cleft and submammary area

13. Erythrodermic – extreme form affecting 90%+ of body – can be fatal
Erythrodermic Psoriasis
erythrodermic psoriasis may develop as the result of slow or rapid progression of existing disease, or less commonly, de novo
plaques cover over 90% of the body surface
protective function of the skin is lost and problems with thermoregulation, septicaemia, dehydration, high output cardiac failure and metabolic changes due to increased cutaneous blood flow may occur (1)
erythrodermic psoriasis may be life threatening

14. Management
Conservative – diet, weight loss, smoking cessation, exercise advice
Medical
Topical
Emolients
Vitamin D analogues
Topical steroids (mild to moderate)
Coal tar
Salicylic acid
Phototherapy
UVB
PUVA ( Psoralen + UVA)
Systemic
Immunosuppresent – Methotrexate, ciclosporin
Biologics – Infliximab, Adalimumab
Surgical – no real role

15. Skin Cancer

16. Aetiology/Risk Factors
Squamous cell – UV light exposure (sunbathing), fair skin, radiation exposure, carcinogens, metastasise quickly
Basal Cell – UV light exposure, radiation exposure, arsenic exposure, “never” metastasise – local tissue destruction
Malignant melanoma – UV light exposure, metastasise rapidly

17. Symptoms and signs
Squamous cell – rapidly enlarging lesion, ill defined (variable), pink colouration, may have ulceration, scaling, bleeding or weep
Basal cell – slow growing lesion, well demarcated papule, raised rolled pearly edges with central depression
Malignant melanoma – a new or changing mole.

18. Squamous Cell Carcinoma
~20% of cutaneous malignancies
~70% on head or neck
Premalignant conditions (Bowen’s disease, actinic Keratosis)
95% cure rate with excision if localised disease. But metastasises rapidly to lymph with poor outcome

19. Basal Cell Carcinoma 75% of diagnoses
Moh’s Surgery – removal of obvious tumour and thin layer of tissue. Frozen and stained, then examined under microscope. If there are tumour cells present a further, deeper layer is removed and the process repeated until tumour free. Gives best cosmetic outcome –smaller lesions.

20. Malignant Melanoma Asymmetrical Border irregularity Colour variation
Diameter >6mm
Evolution

22. Investigations
Biopsy/Excisional biopsy (Breslow depth, Clark level – for melanoma)
Stage – CT/PET

23. Tx + Prognosis Prognosis Management
Conservative – reduce risk factors, smoking cessation
Medical – if for chemotherapy
Surgical – excision biopsy +/- lymph node resections
Prognosis
Basal cell – very good, fatality rare
Squamous cell – poor
Malignant melanoma – poorer (often metastasised at presentation)

24. Questions
Thanks