1. Top Dermatological Tips on diagnosing skin lesions for busy GPs! Louise Moss GP Moss Valley Medical Practice, Eckington 28 th March 2012

2. 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!

3. 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

4. Outcomes DX rate60% FU Rate16% Referred to Hospital Dermatology service24%

5. A rash lesion? 60% were lesions

8. –Possible Skin cancer –Benign naevi –Seborrhoeic warts –Actinic Keratosis How can you increase your confidence? 80% of lesions referred include…

9. 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

10. 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 theres a crust whats beneath? Look elsewhere for other examples Is there a pattern?

11. Make sure you look properly......

12. If theres a crust take it off..........

13. Whats that?

14. DESCRIBING SKIN LESIONS Site and size- record measurement Colour Surface or Texture Type of lesion Border/shape Attacehment to other structures Single or multiple/ arrangement of lesions IF YOU LOOK CAREFULLY YOU WILL BE ABLE TO DIAGNOSE WITH MORE CONFIDENCE!

15. Macule < 1cm

16. Patch >1cm

17. Plaque

18. Papule <1 cm

19. Nodule >1cm

20. Pustule <1cm

21. Vesicle <1cm

22. Bulla >1cm

23. Types of skin cancer

24. Non melanoma skin cancer

26. 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

27. Dont forget there are different types…… Nodular/cystic Superficial Morpheic Pigmented

30. Stretch the skin and look from the side............. YOU NEED TO TOUCH!

32. Benign naevi?

33. Squamous cell carcinoma Rapidly growing Tender Indurated base On sundamaged skin ? Immunosupression ? Worked in tropics

35. 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

38. 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

39. 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

40. 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

42. 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.

43. Efudix treatment....... Apply at night with a finger or cotton-bud..... Avoid the eyes, lips and nasolabial folds. Dont 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!

45. 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 leaflets PCDS.org.uk NED guideline

46. 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

48. 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

50. Bowens disease Full thickness dysplasia 2-5% chance of developing SCC Common lower legs/ hands/ face Slow growing sharply demarcated scaly plaque

54. Treatment of Bowens 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

55. Benign skin lesions

56. Benign naevi happy families

57. Benign naevi

58. Seborrheic warts

59. Dermoscopic appearance seborrhoeic keratosis

60. Thin seborrhoeic keratosis

64. Viral warts-use wart paint........

65. QUIZ While Im here Doctor......