Top Dermatological Tips on diagnosing skin lesions

for busy GPs!

Louise MossGP Moss Valley Medical

Practice, Eckington 28th March 2012

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!

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

Outcomes

DX rate 60%

FU Rate 16%

Referred to Hospital Dermatology service 24%

A rash lesion?

60% were lesions

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Rashes: Frequency of condition

Frequency

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– Possible Skin cancer– Benign naevi– Seborrhoeic warts– Actinic Keratosis

• How can you increase your confidence?

80% of lesions referred include…

• 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

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 there’s a

crust what’s beneath?• Look elsewhere for other examples• Is there a pattern?

Make sure you look properly......

If there’s a crust take it off..........

What’s that?

DESCRIBING SKIN LESIONS

Site and size- record measurementColourSurface or TextureType of lesionBorder/shapeAttacehment to other structuresSingle or multiple/ arrangement of lesions

IF YOU LOOK CAREFULLY YOU WILL BE ABLE TO DIAGNOSE WITH MORE CONFIDENCE!

Macule < 1cm

Patch >1cm

Plaque

Papule <1 cm

Nodule >1cm

Pustule <1cm

Vesicle <1cm

Bulla >1cm

Types of skin cancer

Non melanoma skin cancer

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

Don’t forget there are different types……

• Nodular/cystic• Superficial• Morpheic• Pigmented

Stretch the skin and look from the side.............

• YOU NEED TO TOUCH!

Benign naevi?

Squamous cell carcinoma

• Rapidly growing• Tender• Indurated base• On sundamaged skin• ? Immunosupression• ? Worked in tropics

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

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

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

• 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

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.

Efudix treatment.......• Apply at night with a finger or cotton-bud.....

• Avoid the eyes, lips and nasolabial folds. Don’t 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!

 

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 leafletsPCDS.org.uk

NED guideline

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

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

Bowen’s disease

• Full thickness dysplasia

• 2-5% chance of developing SCC

• Common lower legs/ hands/ face

• Slow growing sharply demarcated scaly plaque

Treatment of Bowen’s

• 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

Benign skin lesions

Benign naevi

‘ happy families’

Benign naevi

Seborrheic warts

Dermoscopic appearance seborrhoeic keratosis

Thin seborrhoeic keratosis

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

QUIZ

While I’m here Doctor......