Skin Cancer for Dental Professionals

Home , Actinic keratosis, Keratoacanthoma, Melanoma, Sunburn

©iStockphoto/Thinkstock 1 ARTICLE 09 melanoma (MM). skin cancer (NMSC),and malignant collectivelywhich comprise non-melanoma and squamous carcinoma cell (SCC), carcinoma cell basal recognised: (BCC) S screening, says Visiting thedental practice for isavaluable opportunity skincancer Hull Royal Infirmary School; general dental practitioner, Medical student, Hull York Medical BDJ Team for dental professionals types. total of 424,128cancers of all registered UKout inthe of a 2010, 112,367skin cancers were form of cancer UK.In inthe kin

cancer is commonest the 1 Three maintypes are Skin cancer Ben J. Steel

there exists avaluable opportunity for aform proportion of population the passing through, adult population. dentist, representing some 52.1%of the 29.6 million people UKattended inthe a In two the years leading to September 2012, incorporated be easily into structure. this and neck skin for suspicious lesions could lymph nodes. andtissues, soft jaw joints and cervicofacial oral examination to check hard facial the normalthe dental check-up, as is an extra- mucosal conditions is an accepted of part of oral squamous carcinoma cell and other © 2014 Macmillan Publishers Limited. Allrights reserved . Examination of oral the mucosa for signs 1 2 Abrief at look head the 3 With such aconsiderable year 2004and between 2006. registeredleast 48,000cases inEngland each and any indeed cancer, UK,with inthe at Thisthe commonestis type cancer, of skin Epidemiology BASAL CELL CARCINOMA amongseen dental patients UK. inthe three forms of skin cancer most likely to be surgeon for management. further practitioner (GP)or an oral and maxillofacial referredcould be to general their medical malignancy. Patients with suspicious lesions of screening adhoc for and head neck skin This article will Thiswill present article the of an overview www.nature.com/BDJTeam 4 This is believed believed This is CPD: ONE HOUR ARTICLE

from a young age, keratinising odontogenic tumours, skeletal abnormalities and plantar and palmar pits. It is thought around 2% of people with BCCs before the age of 45 have this condition.11 Other rare conditions include Bazex-Dupré-Christol syndrome and Rombo syndrome.

Clinical presentation BCCs typically cause no symptoms and may Fig. 1 Noduloulcerative BCC not be noticed by the patient. Three main variants are recognised: noduloulcerative, superficial and infiltrating. The noduloulcerative type represents the typical and most common form of BCC. The appearance is initially a firm red or pink painless papule, which slowly enlarges and forms a central area of ulceration surrounded by a raised semi-translucent margin with telangiectasia (visible tiny blood vessels coursing through it) (Fig. 1). At this Fig. 2 Superficial BCC stage it is also known as a rodent ulcer. The lesion may bleed occasionally but does not heal. A pigmented variant shares the same morphology but is pigmented by melanin deposition – appearing tan, brown, black or bluish. The pigment is usually not distributed evenly, whereas that in a benign melanocytic lesion (mole) would be. Superficial type lesions are the second most common form, and occur more often on the trunk, appearing as flat or raised, red or pink, scaly eczematous areas, sometimes Fig. 3 Infiltrating BCC with ulceration or crusting (Fig. 2). It may be darkly pigmented. The borders are well- locally destructive neoplasm, which may demarcated and can be slightly raised or over time infiltrate underlying tissues such rolled, with a ‘threadlike’ appearance. They as bone and cartilage; however, metastasis may be mistaken for a patch of eczema or is extremely rare. If neglected BCCs may psoriasis and can be multiple. reach a substantial size and deaths have been Infiltrating lesions are insidious lesions and reported, albeit very rarely. The vast majority less common than the other forms, tending to of cases are sporadic and caused by ultraviolet be more aggressive. Their appearance mimics (UV) radiation, specifically UV-B.9. Both scar tissue, being flat skin-coloured, pink or to be an underestimate, with the real number chronic and acute exposure (as sunburn) whitish lesions that are firm to palpation. The of cases likely to be 55,000-60,000 a year.5 are implicated, which damage DNA via both borders are indistinct and may be slightly It is becoming more common – increasing direct effects and indirectly via production elevated (Fig. 3). Their insidious nature means by 1.4% and 1.9% for males and females of oxygen or nitrogen radical species, or there may be more invasion before they are respectively between 1992 and 2003, which induction of inflammation. As well as age and noted than the other forms. was most marked in the 30-39 age group.6 male gender, having fair skin is a risk factor, It is known that having one BCC increases as is having fair or red hair, or freckles. People Investigations and treatment the likelihood of having other lesions, both of Celtic ancestry are most at risk. Most cases BCCs with a typical appearance are generally at the same time and later.7 There is regional occur on sun-exposed areas such as the face not biopsied and are instead diagnosed variation – the age-standardised incidence in and neck, scalp, forearms, hands, lower legs clinically. Treatment depends on the location, the south west of England is 121.3 per 100,000 and feet.8 Intraoral lesions are vanishingly size and histology of the lesion. Surgical compared to 93.7 across England as a whole.8 rare, and when reported often thought to have excision is most commonly employed, either The incidence increases with age, above the been misdiagnosed.10 with direct edge apposition or local flap age of 55 having a male predominance. Several genetic conditions predispose to closure, typically under local anaesthetic. BCCs, notably nevoid basal cell carcinoma This may be done by GPs in primary care, Pathology and risk factors syndrome (NBCCS), also known as Gorlin- or by a range of specialties in hospital. A BCC is a malignant neoplasm of keratinocyte Goltz syndrome. Typical manifestations 4-5 mm surgical margin gives a 95% cure stem cells. It behaves as a slowly growing are multiple, aggressive BCCs occurring rate,12 although infiltrating and large BCCs www.nature.com/BDJTeam BDJ Team 10 © 2014 Macmillan Publishers Limited. All rights reserved ARTICLE

are thought to require larger margins. For ■ SCC, MM or metastatic malignancy larger lesions, or where surgery is declined ■ Cutaneous T cell lymphoma or inappropriate, radiotherapy alone can be ■ Darier disease employed. Mohs micrographic surgery, a ■ Eczema technique where tissue samples are viewed ■ Keratoacanthoma – see SCC section microscopically during the operation, can be ■ Lichenoid keratosis. used to ensure complete excision of recurrent or poorly-defined lesions. A range of other SQUAMOUS CELL CARCINOMA modalities – curettage, electrocautery, Epidemiology cryotherapy, photodynamic therapy or This is the second most common skin cancer carbon dioxide laser ablation, are sometimes in the UK and worldwide. Reported age- used to destroy low-risk lesions, but are standardised incidences for cutaneous SCC not recommended for high-risk lesions.13 range from around 16 per 100,000 in London Imiquimod is an immune response modifier, to around 36 per 100,000 in the south west Fig. 4 Seborrhoeic keratosis used topically as a 5% cream applied to the of England, equating to at least 10,000 cases lesion five times a week for six weeks, and per year in England and Wales (compared to appears to be effective in treating small around 5,000 cases of intraoral SSCs).1 superficial lesions.14 Data suggest an increase in incidence in A new treatment licensed in the UK recent years.13 in August 2013 is the biological agent Vismodegib. It is only used in locally Pathology and risk factors advanced tumours whose position prevents SCC is a malignant neoplasm of keratinocytes surgical removal, or if recurrence has that occurs predominantly in sun-exposed occurred after resection and radiotherapy areas of the body, but can occur on any skin has already been used. Its use is not yet or mucosal surface. It is prone to invade widespread but early results are promising.15 locally and metastasise. SCC pathogenesis

‘SQUAMOUS CELL CARCINOMA IS A MALIGNANT

NEOPLASM OF KERATINOCYTES THAT OCCURS

PREDOMINANTLY IN SUN-EXPOSED AREAS OF THE BODY, BUT CAN OCCUR ON ANY

SKIN OR MUCOSAL SURFACE...’

Fig. 5 Ulcerative SCC on the pinna Differential diagnosis is a stepwise process, in that a number of ■ Actinic keratosis – see SCC section sequential mutations of proto-oncogenes the immunosuppression. Genetic conditions ■ Seborrhoiec keratosis – common, usually and tumour suppressor genes are needed for such as xeroderma pigmentosum (defective asymptomatic, benign neoplasm, of carcinoma to be induced. The main risk factor DNA repair mechanisms after UV exposure) variable appearance but usually beginning for its development is UV radiation. Chronic and oculocutaneous albinism (reduced or with a sharply defined light brown macule, exposure, including from sunbeds,16 is mainly absent skin pigmentation) also carry an later growing a velvety, verrucous, or warty implicated,17 with acute exposure thought to increased risk of SCCs. surface with keratin plugs and coloured be less important.18 Human papillomavirus is pale brown to black (Fig. 4). Slowly grows a suspected risk factor19 although the evidence Clinical presentation over time, does not resolve and does not is not as strong as for other sites such as the SCCs may present as a new enlarging ulcer, malignantly transform, although the cervix and oropharynx. Increased age, male lump or red patch on the skin, changes to a presence of multiple lesions may make a gender and Caucasian ethnicity are associated pre-existing lesion or as a sore that does not malignancy difficult to notice. Can also be with increased risk, as are irradiation and heal. There is typically no pain although there confused with SCC and MM. No treatment exposure to chemicals such as arsenic and may be mild tenderness to touch. Rarely, is necessary polycyclic aromatic hydrocarbons. A recent with perineural involvement there may be ■ Angiofibroma meta-analysis19 found no association with localised pain, numbness, muscle weakness ■ Bowen disease – see SCC section cigarette smoking (unlike for oral mucosal or twitching. In the head and neck this may ■ Fibrous papule of the face SCC). It is known that transplant recipients manifest as cranial nerve deficits. ■ Molluscum contagiosum and the immunosuppressed (through drugs The appearance of SSCs is very variable but ■ Psoriasis or disease) are at increased risk; its magnitude the classic presentation is a raised indurated ■ Melanocytic naevus increases with the degree and chronicity of ulcer, with rolled margins, sometimes with

sites are the face, scalp of bald men, forearm disease, typically with regimens including and dorsum of the hand. It is often easier cisplatin or 5-fluorouracil. Cetuximab is a to feel the sandpaper-like surface of these well-tolerated newer agent licensed in the UK lesions than to see them. Histologically it for use in locally invasive SCC of the head and encompasses a range from cellular atypia neck in combination with radiotherapy. at the basal layer only, to carcinoma in situ, Actinic keratoses do not always require where there is full thickness atypia and treatment – decisions are made based on abnormal maturation. The risk of progression individual circumstances. Cryotherapy, to invasive SCC has been variously quoted photodynamic therapy, or topical at between 0.25 and 20% a year.22 The same immunomodulator, diclofenac or keratolytic process occurring on the lip is known as creams are frequently used modalities.26 actinic cheilitis. Changes indicative of malignant transformation within an actinic Differential diagnoses Fig. 6 Cutaneous horn presentation of SCC keratosis include development of areas with ■ Actinic keratosis – see above sharp circumscription, increase in thickness ■ Keratoacanthoma – this has variously or the degree of scaling, and formation of an been considered as a distinct entity or exophytic lesion, indurated (hardness) or, a well-differentiated form of SCC. It particularly, the development of ulceration. presents on sun exposed skin, typically in elderly persons with fair skin, as a Investigations and treatment rapidly enlarging crateriform nodule The diagnosis of SCC is confirmed by biopsy, that may reach 2 cm or so in diameter, and the tumour graded and staged based becoming dome shaped with central on the size and involvement of underlying ulceration and typically lacking induration structures and lymph nodes, and the or fixation to underlying tissue (Fig. 8). Fig. 7 Actinic keratosis on the scalp presence or absence of distant metastases. Over subsequent months it generally Clinically positive lymph nodes are biopsied spontaneously involutes to leave a by fine needle aspiration or excisional node scar, although aggressive spread and biopsy, and if neoplastic cells are present, metastasis has occasionally been observed. regional lymph node dissection undertaken. Microscopically it can be difficult to Assessment for metastasis may be undertaken distinguish from SCC, and definite with computer tomography (CT) or positron histological criteria for keratoacanthomas emission tomography (PET) scans. SCC and keratoacanthoma-like SCCs are occurring within actinic keratosis is generally lacking.27 Due to diagnostic difficulties low risk, with a low risk of metastasis and a these are often excised in the same way as 20 Fig. 8 Keratoacanthoma favourable prognosis. other SCCs Standard treatment is surgical excision, ■ Bowens disease – an uncommon in situ with the margin determined by the risk status SCC, presenting as an irregular well- an erythematous periphery (Fig. 5). Other of the tumour. Low risk, smaller (less than 2 demarcated erythematous scaly keratotic surface changes include scaling, crusting and cm diameter) tumours are excised with a 4 plaque on sun-exposed skin, which is a cutaneous horn (a very thickened raised mm margin, and higher risk (tumours wider generally asymptomatic area of keratin) (Fig. 6). Less commonly than 2 cm or at high risk site – ear, scalp, ■ Seborrhoiec keratosis it may be a nodule with an intact pinkish eyelids or nose) with a 6 mm margin.23 Mohs ■ Atopic dermatitis surface. The most common sites are the lower micrographic surgery, as previously described, ■ Atypical fibroxanthoma lip, ear pinnae, pre-auricular regions, forehead leads to less recurrence than following ■ Congenital skin tumours, for example, and scalp. There may be palpable lymph excision alone.24 Curettage or cautery may be dermoid/dermolipoma nodes, in this context particularly the pre- used for small well-differentiated tumours, ■ Chemical burns auricular/parotid and upper cervical nodes. but guidelines advise cryotherapy be used ■ Contact dermatitis Various histiological subtypes are recognised, with caution.25 ■ Pyoderma gangrenosum but around 60% of invasive skin SCCs appear Radiotherapy may be used as a sole ■ BCC. within a pre-existing actinic keratosis.20 treatment for smaller lesions, particularly in Actinic keratosis, also known as solar areas of cosmetic and functional sensitivity, MALIGNANT MELANOMA keratosis, is premalignant for SCC, and is for example, lower eyelid, medial canthus, Epidemiology caused by exposure to UV radiation. It is lip, although is contraindicated in younger MM is the fifth most common cancer in the common in adults – 23% of over 60s had at patients as surgical scars usually have a UK, with 12,818 cases registered in the UK least one lesion in one UK study,21 although better cosmetic outcome. Post-operative in 2010, and a UK-wide age-standardised is rare under 40 years. It is asymptomatic but radiotherapy is also used as an adjuvant when incidence of 17.1 per 100,000.27 The UK may cause some mild irritation or itching. the excised specimen shows close margins, distribution is fairly even although it occurs Clinically it is an irregular scaly keratotic perineural invasion or other high-risk more in the south west of England. The age plaque, coloured from pink to white or grey, histological features. distribution is younger than for other skin sometimes with an erythematous background, Chemotherapy is used in selected cases cancers. Incidence increases steadily with and is often multiple (Fig. 7). The commonest following surgical resection or in unresectable age, with a female predominance below age www.nature.com/BDJTeam BDJ Team 12 © 2014 Macmillan Publishers Limited. All rights reserved ARTICLE

Table 1 The ABCDE rule for clinical features of MM

A Asymmetry

B Border irregularity

C Colour variation across the lesion

Fig. 9 Superficial spreading MM D Diameter of the lesion greater than 6 mm

E Evolution – rapid changes occurring in the lesion

those with more than 100 such lesions. Large Occasionally these are so poorly differentiated or giant congenital melanocytic lesions that pigment is absent, instead appearing confer a high risk, as does the presence of any pinkish red – an amelanotic melanoma. It atypical or dysplastic naevi, or if MM itself tends to grow in a more vertical pattern, in has previously occurred. Immunosuppression contrast to the horizontal pattern shown by Fig. 10 Nodular MM - therapeutic for solid organ transplant or the superficial spreading form. pathological in lymphoma and HIV/AIDS Lentigo maligna melanoma comprises - increases the risk, although the effect of 5-10% of MMs and develops within a lentigo antiretroviral treatment is unclear.30 Family maligna, which is an in situ melanoma history is also important – those with a first- occurring on sun-exposed skin. It is most degree relative with MM are at increased common on sun-exposed skin in the elderly. risk,31 and specific inherited conditions Clinically, lentigo maligna resembles a confer an additional risk so as to justify superficial spreading melanoma, being a routine screening by a dermatologist from large, flat lesion with irregular borders, and childhood – dysplastic naevus syndrome and shares the same variety of colours (Fig. 11). xeroderma pigmentosum. Increased overseas It enlarges slowly over many years, with the holidays, sunbathing, use of sunbeds32 and development of nodularity or induration outdoor recreational behaviour is thought to indicating a change to invasive melanoma. be responsible for most of the rise in cases in The risk of progression from lentigo maligna Fig. 11 Lentigo maligna recent years.28 to MM is controversial but thought to be 4.7% or less over a lifetime.33 55 (and a female:male ratio in the age group Clinical presentation A useful rule to judge the likelihood of 20-24 of 10:4) and male predominance above MM typically does not cause any symptoms malignancy in pigmented lesions is the 55. The number of MM cases in the UK and may be noticed as a new lesion on the ABCDE rule (Table 1). The presence of one or increased by 55% between 2000 and 2010. skin or as a change in a pre-existing lesion. more of these features may raise suspicion of Twenty-two percent of lesions in males occur Three main morphological and many a malignancy. in the head and neck area, compared to 14% histological subtypes of MM are seen in the in females.27 head and neck. The relationship between Investigations and treatment these morphological and histological variants Any lesion where MM is suspected is Pathology and risk factors is not always clear.21 photographed and subjected to excisional MM is a malignant neoplasm of melanocytes The superficial spreading form comprises biopsy with a 2 mm margin, in order to that can arise within a pre-existing benign 70% of skin MMs,21 and presents as a macular confirm the diagnosis of MM and provide melanotic lesion or de novo from apparently (flat) or slightly raised lesion that can be a information about the tumour thickness normal skin. It tends to invade locally and variety of colours (brownish, grey, black, (termed the Breslow thickness), and other metastasise, and can occur at any skin site, blue, whitish or pink). It is typically less than histological parameters of prognostic or the oral, genital, ocular or urinary 3 cm in diameter although can grow much importance. Incisional or punch biopsies epithelial surfaces. larger than this. The presence of induration or are generally not used. Following definitive UV radiation, especially UV-B, is the main surface nodules within these lesions indicates diagnosis, wide local excision of the area risk factor. Recent studies suggest MM of the likely deeper invasion (Fig. 9), as does the around the biopsy site is required – the head and neck is more strongly related to formation of satellite pigmented areas around Breslow thickness is used to determine the sunburn, and of the trunk to more chronic the original lesion. surgical margin required. With a thickness sun exposure.28,29 People with fair skin, blue The nodular form comprises around of 1 mm, a 1 cm margin is used, for 1-2 mm eyes, fair or red hair and those who burn 15% of MMs and is an exophytic nodular a 1-2 cm, 2-4 mm a 2-3 cm and more than 4 easily are at increased risk of MM, as are those lesion, usually deeply pigmented and often mm a 3 cm margin.34 with freckling and benign naevi, especially asymmetrical, that may be ulcerated (Fig. 10). Sentinel node biopsy (SNB) may be

considered where Breslow thickness exceeds 1 term was coined to reflect a perceived Examination mm and no nodes are clinically evident. This high risk of malignant transformation, To identify lesions a thorough and systematic involves injection of a radiolabelled substance, however, this is controversial, although it is examination technique is essential. This and later a blue dye, close to the tumour, generally believed the risk is higher than a includes all head and neck skin, paying and then identification and biopsy of the melanocytic naevus – they may represent particular attention to the lower eyelid, nose, node(s) showing the greatest uptake. Around premalignant lesions or risk factors for ear pinnae, lips, and in bald people, the 20% of SNBs are positive, and many of these de novo lesions or both. Histologically, scalp. Malignant lesions may be very subtle patients may go on to have completion this lesion is diagnosed if architectural so diligence is required. Any suspicious lymphadenectomy. The role of SNB is and melanocytic atypia are demonstrated. lesions identified are examined more closely. controversial, as no survival benefit has been Dysplastic naevus syndrome is an Important details to note on inspection demonstrated,35 and it is not universally inherited autosomal dominant condition include: location, size, shape, border, colour, employed in the UK. There is no benefit to giving high numbers of benign and symmetry and uniformity, surface keratin/ elective neck dissection in MM. dysplastic naevi, with a lifetime risk of MM ulceration/bleeding, and blood vessel Clinically-evident nodes are investigated approaching 100% pattern and morphology. Palpation follows, with fine needle aspiration biopsy and treated, ■ Lentigo maligna – see above to distinguish soft from firm or indurated if positive, with formal block dissection. ■ Seborrhoiec keratosis lesions. Palpation of the regional lymph nodes When there is no evidence of nodal ■ Pigmented actinic keratosis may reveal lymphatic metastasis, in particular disease (stages I and II) no further imaging ■ Histiocytoid haemangioma including the pre- and post-auricular, investigations are required, otherwise whole ■ Epithelioid tumour occipital and upper cervical nodes. Rarely, body CT, and sometimes a PET scan, may ■ Atypical fibroxanthoma locally invasive lesions may affect facial or be used to search for metastases, which, if ■ SCC trigeminal nerve function, or cause proptosis, present, may be treated with surgical excision, ■ Metastatic tumour. diplopia or ophthalmoplegia, which would or carbon dioxide laser ablation if on the surface. There is some evidence that adjuvant ‘INCREASED OVERSEAS HOLIDAYS, SUNBATHING, radiotherapy improves local control, although not survival. Conventional chemotherapy USE OF SUNBEDS AND OUTDOOR generally gives no survival benefit, although a small effect on overall and relapse-free survival has been noted for interferon. RECREATIONAL BEHAVIOUR IS THOUGHT TO Research into signal transduction pathways involved in MM pathogenesis is leading to BE RESPONSIBLE FOR MOST OF THE RISE IN new biological therapies targeted to specific identified genetic mutations.36 CASES IN RECENT YEARS...’ Prognosis The 5-year-survival for patients with melanomas of Breslow thickness less than CLINICAL APPROACH FOR THE necessitate formal cranial nerve testing, and 1 mm is 97% (stage IA), falling to 81% with DENTAL PRACTITIONER require specialist evaluation. thickness up to 4 mm (stage IIA), 40% with The suggested role of the dental practitioner is Dermoscopy is an examination technique palpable lymph node involvement (stage as follows and summarised in Table 2: for skin lesions using good lighting and IIIC), and around 20% with widespread 1. History and risk factor evaluation magnification, typically around 10x. Various disseminated disease (stage IV).21 2. Examination – general and focused commercially-produced devices are available 3. Counselling on risk factors and self- and are commonly used by GPs to identify Differential diagnoses monitoring benign lesions that do not require urgent ■ Benign melanocytic naevus – commonly 4. Onward referral. referral and identify premalignant lesions known as a ‘mole’, either congenital (non- and BCCs. neoplastic malformation) or acquired History and risk factor evaluation (benign neoplasm), almost universal It is unlikely a patient would volunteer Counselling on risk factors among the white population with concerns of a skin lesion to the GDP but if The main modifiable risk factors for skin incidence peaking between age 40-50. this occurs salient points to question in the cancer are chronic and acute sun exposure. There is an increased risk of malignant history include the duration and evolution British Association of Dermatologists advice37 transformation to MM, especially with the of the lesion and any features such as pain, suggests people should stay out of sunlight congenital form, although the incidence itchiness, numbness or surface bleeding. during the hottest part of the day (midday to is not known. They are macular or slightly Similar questions would be used to ask about 3 pm), avoid using sunbeds and keep babies raised with uniform colour, and lacking any lesion found on examination. As part of and children out of strong sun altogether. A any suspicious features of the ABCDE rule the history-taking process risk factors should hat and UV-impenetrable clothing should be (see Table 2) be evaluated, in particular personal and worn in direct sunlight. Suncream should be ■ Dysplastic/atypical naevus – an acquired family history of skin cancer, sun exposure at least factor 30 to protect against UV-B and naevus that is thinly papular and relatively though work, recreational activities and have the circle logo and/or four or five UV-A broad, often with a fried egg appearance sunbed use, both chronic and sunburn, stars to protect against UV-A, and should be (more darkly pigmented centre). The medical/drug history and patient complexion. applied 30 minutes before exposure. www.nature.com/BDJTeam BDJ Team 14 © 2014 Macmillan Publishers Limited. All rights reserved ARTICLE

Furthermore the patient can be educated at Table 2 Suggested approach to skin cancer for dental practitioners this point about what constitutes a suspicious skin lesion. By having this awareness they are How long has it been there? better placed to monitor their own skin and History of How has it changed over that period? approach their GP early should they notice any suspicious changes. lesion Does it cause any symptoms? In particular pain/itching/ numbness/bleeding/irritation? Onward referral

Any previous skin cancers? The 2006 NICE guidelines state that the diagnosis and treatment of all suspicious Assess degree of sun exposure – pigmented lesions, lesions that may be Occupation – outdoor-based? MM, SCC or high risk BCCs, or any lesion General Any outdoor recreational activities? where the diagnosis is unclear, ‘should be history History and Any previous sunburn? carried out only be specialists (normally 38 risk factor dermatologists)’. Precancerous lesions such Any sunbed use? evaluation as actinic keratosis may be, and usually are, Any family history of skin cancer? managed in primary care by a GP or GP with a special interest, unless there are particular Any immunosuppressive disorders, for example, individual circumstances, such as a difficult Medical heamatological malignancy, HIV, solid organ lesion location, to warrant hospital referral. history transplantation etc? In hospital, care is organised by the skin Any high-risk syndromes? cancer network: either local hospital or specialist skin cancer multidisciplinary teams Drug history Any immunosuppressive medications? (MDT). GPs can refer directly into this service and all skin cancer cases, regardless of Family history Any family history of skin cancer? which speciality the patient is referred to, feed into this MDT. At the MDT meetings these patients are discussed and the management General Fair skin/fair or red hair/blue eyes? decided. Dentists can refer either to the GP or examination Celtic ancestry? directly to the oral and maxillofacial surgery department in secondary care. This would be Head Thorough and systematic examination of head and neck done as an urgent referral under the two-week and neck skin, including scalp, lower eyelids, nose, pinnae and lips rule. The interest of OMF surgeons in head examination and neck skin cancer management varies but many units are active in this area. The best Note in particular: route of referral will therefore vary depending Examination Location on local circumstances. Size CONCLUSIONS Shape Focused Skin cancers are common in the UK, and examination Border BCC, SCC and MM are the main forms. of lesion Colour Most skin cancers will present as a lesion Symmetry and uniformity that has features characteristic of that form, and thus if the clinician is aware of these Surface keratin/ulceration/bleeding usual presentations and examines for them, Blood vessel pattern and morphology they would be well placed to spot them opportunistically. Such ad hoc screening Referral GP or oral and maxillofacial surgeon for head and neck skin cancer fits well into the existing convention for the extra- oral examination a dentist would normally Avoid exposure to direct sunlight between 11 am and 3 pm perform. Earlier recognition of suspicious lesions, and informing patients about risk Keep babies and children out of direct sunlight Counselling factors and self-monitoring, may lead to Wear a hat and UVimpenetrable clothing in direct sunlight on risk improved outcomes. Use appropriate suncream factors and self- Avoid use of sunbeds 1. Cancer Research UK. UK Cancer incidence monitoring Educate about the appearance of suspicious skin lesions, encourage 2010. Cancer Research UK, 2012. self-monitoring and early presentation to their GP if they notice anything 2. Faculty of General Dental Practitioners in the future at the Royal College of Surgeons of England. Clinical examination and record keeping: good practice guidelines. London:

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