1. Northland DHB SKIN SERVICE Plastics update
Peter Allen, plastics moss
David J M Crabb FRACS (GEN), FRACS (plastic)

2. The DHB SKIN SERVICE Plastic section Nested within general surgery
Primary triage Peter Allen
Secondary triage D. Crabb
supported by Clinic staff, Pathway coordinator
General surgery, Gypsy service network, combined clinics with Opthalmology
and TBA with ENT.

3. Introduction non surgical treatment of skin cancer
The Hutt DHB Plastics visual scale
Non Melanomatous lesions
categorizes the clinical picture at glance
includes full spectrum of progression
useful tool to decide approach
helpful to decide surgery/topical
combined with photo, biopsy ,growth rate

4. The clinical Picture Is mixed Presenting lesion
with background of many others
Deciding which are surgical?
Which are non surgical? 2

5. The borderline digital palpation
Thickened lesion implies dermal invasion
Ulceration
Failure to respond
Beware the Morphoeic BCC
exception, scarring feels flat
Biopsy, biopsy, biopsy

6. Progression and evolvement is non linear
Problem can be staged
Progression and evolvement is non linear
Background photo-ageing
Ephemeral solar keratosis, comes and goes
in various places
Persisting solar keratosis, waxes and wanes in same place
progresses to established lesion, such as superficial BCC but may be SCC or more aggressive lesion

7. Irradiation damage UV+UVB
Total life time dose in exposed areas, about 100,000hrs
graduated change over life course
Accelerates in older age
Made worse by suppressed or impaired immunity
Related to genetics of skin type and evolutionary biology

8. Biological Anthropology
all Humans migrating from Africa were black, 65,000 yrs
Migration behind melting ice sheets required adaptation to lower northern light levels
skin becomes whiter/lighter and thinner
Allows penetration of available light for Vit D synthesis
Nature very precisely calibrates the skin, thickness and color
Optimised for Vit D production without collateral damage

9. 36 degree latitude is same as southern spain or northern morocco
stem cells in dermal base have 5 different enzymes to repair fragmented nucleic acids
Dendritic cells that mediate immunity have large target nuclei, vulnerable
Treatment Principles Require
reduced irradiation into dermis equivalent to (pureblood) maori skin
repair/restoration assistance to dendritic and stem cell population
assisted apoptosis of abnormal cell population
treat the whole problem

10. Treatment A screening cream with equivalent protection to Maori skin
addition of anti oxidants into cream to assist self repair by damaged cells to assist
Stem cells for cell replacement and Dendtritic cell for cell monitoring/tagging
Result
Clears ephemeral solar keratoses
dampens cellular background activity
Assists Dendritic cell role in Apoptosis
When combined with seasonal therapeutic creams (Effudix/Aldara) will dramatically reduce frequent flyers

11. Atumn check repose, identify non responders, surgical propositions
seasonal Treatment
My practice
winter 5 flurouracil to treat background ephemeral and some persisting solar keratoses, 3 pulsed cycles
Atumn check repose, identify non responders, surgical propositions
Summer then escalate Aldara / cryotherapy
winter back to 5FU if needed
spring check up prior to aldara/screening cream, surgical propositions

12. Seasonal topical treatment cycle Winter1
Winter topical, 5 Fluorouracil given in pulsed mode 3 to 4 cycles
With Hydrocortisone 1% in rest periods
Ideal for the multiple persisting solar keratotic background activity
Hutt stage 1 and above will be present in all lesions as a background to the presenting lesion
Patient is often motivated to act on prevention after surgical episode

13. Seasonal topical treatment cycle Atumn
Persisting solar keratosis if it is non responsive to 5FU
(suitable Hutt 1 and 2, not all may respond)
will need Aldara or cryotherapy
Aldara ideal for early lesions including Hutt 3 superficial BCC
Suitable for up to 6 lesions, otherwise systemic effect
5 weeks, 5 days and then stop, pm application
combined with Am screening cream

14. Seasonal topical treatment cycle summer3
Superficial BCC with little infiltration should respond To Aldara but may not
Adjacant Hutt 1 and 2 will go with Effudix
Cryotherapy about the same effectiveness to Aldara
Good for scalp and non facial area
often more convienant than topical ie shorter
White scar on face
If not effective first time unlikely second will do
Surgery for non responders

15. Surgical reconstructive treatment
All incomplete removals come forward to frozen section
all prior surgery and scar must be removed
F/S control for all margins and then immediate or delayed reconstruction
Same for significant primary tumours involving sensitive structures in the face
Perineurial invasion on SCC treated as Melanoma
Reconstructive surgery is often but not always staged

16. Avoiding the unescessary escalation

17. Fat grafting for subcutaeous contour regeneration
additional toolbox in staged reconstruction
two flap nose and cheek extensive BCC
frozen section clearance
fat grafting compensates for loss of cheek sub cutaneous volume

18. Recontruction often multi staged with large step escalation
small lesions can be much larger on Frozen Section
large defects with lining often need tissue expansion

19. where do we start first consult body check background activity
history of lesions/prior surgery/recurrence
get your fingers on it
surgical propositions first
Screening cream with anti oxidant will calm and treat S/K
Aldara for 6 worst non surgical ones/repeat
Cryotherapy about equivalent to Aldara but white mark
Effudix given early if needed or delayed to winter

20. summary, treat the entire problem
Early lesions need management
train the patient to self manage
A stitch in time saves 9
biopsy is a wonderful operation
if you cant get it all don't try it might need a really big hole
Multiple biopsies give useful information
If in doubt always skin graft as local tissue is precious
Thank you for your attention
Best of luck its a big problem