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Pre-Cancerous LesionsActinic Keratoses Intra-epithelial Squamous Cell CarcinomaLentigo maligna
Skin CancerBasal Cell CarcinomaSquamous Cell CarcinomaMelanomaLymphoma
What are Actinic keratoses?
Epidermal dysplasiaAssociated with UV exposure
Sun exposed sitesElderlyOutdoor occupationsWarmer climatesLighter skin typesImmunosuppression
What are Actinic keratoses?
HistologicallyEpidermal cell disorganisationAcanthosisReduced granular layerParakeratosisHyperkeratosis
What is risk of malignancy?
?Less than 1:1000 per yearIncreased by
ImmunosuppressionIncreased numbers of lesionsCo-factors (radiation, exposure to tar)Prior Squamous cell carcinoma
Some lesions resolve spontaneouslyMost SCC’s are well differentiated
What do they look like?
ClinicallyAdherent scale (variable but always)Erythema (often)Light pigmentation (sometimes)Merge with surrounding skinUsually not indurated
Diagnostic difficulties
Cutaneous hornHypertrophic actinic keratosesInflammatory lesions
Often in immunosuppressed
What to treat
Lesions in immunosuppressed patientsLesions at high risk sites (e.g. lip)Where previous history of SCCInflamed Actinic keratosesLesions in younger age groupSymptomatic lesions
How to treat
CryotherapyCurettage & cautery5-fluorouracil creamDiclofenac gelImiquimod creamPhotodynamic therapy
Cryotherapy
Destruction by cold injury Cotton bud or cryospray 20-30 second freeze Moderate pain Immediate blistering Heals in 10 days
Suitable for small/few lesions Suitable where compliance poor
Curettage and cautery
Physical removal/thermal injury Requires local anaesthesia Moderate pain Eschar Heals in 10 days
Suitable for solitary/few lesions Suitable for cryo resistant lesions Suitable for hyperkeratotic lesions Suitable where histology required
5-fluorouracil cream
Inhibits DNA synthesis by inactivating thymidine synthase
4 weeks treatment Inflammatory reaction (moderate-severe) Little pain Interrupted treatment may be required
Suitable for multiple/extensive lesions Suitable for compliant patients
Diclofenac gel
Inhibits Cyclo-oxygenase (COX-2)8 weeks treatmentMild-moderate inflammatory reactionNo painLong term benefits uncertain
Suitable where intolerance to other treatment
Imiquimod cream
Toll-like receptor 7 agonist induces apoptosis
4-8 weeks treatment Inflammatory reaction (moderate-severe)Little pain Interrupted treatment may be required
Suitable for multiple/extensive lesionsSuitable for compliant patients
Photodynamic therapy
ALA induced protoporphyrin IX synthesis sensitizes cells to photodynamic effect
1-2 prolonged treatments Moderate pain Inflammatory reaction (moderate-severe) Heals in 10 days
Suitable for multiple/extensive lesions Suitable where compliance poor
Treatment summary
Cryotherapy small/few lesions 5-fluorouracil larger/multiple lesions
Curettage for hyperkeratotic lesions Solaraze for patients with poor tolerance
Imiquimod cream or PDT for resistant lesions