Objectives:

— Describe and recognize benign and cancerous skin conditions commonly referred to surgery.

Tara L. Roberts, MSN, RN, ANP-BC — Discuss some medical/surgical treatments for Nurse Practitioner-General Surgery these common skin conditions. Central Texas Veterans Health Care System — Discuss pharmaceutical management for these TNP Fall Conference common skin conditions. September 9, 2017

Overview of Benign Skin Lesions Acrochordon (skin tag) — Acrochordon (skin tag) — Angiomas — Definition: pedunculated outgrowth of normal — Dermatofibroma skin; usually on a narrow stalk — Epidermal Inclusion Cyst (EIC) — Occur in approximately 25% of adults — Lipoma — Risk of developing skin tags increases with age — Neurofibroma — Nevi — May have a familial tendency — Seborrheic Keratosis (SK) — Occur at sites of friction (i.e. axilla, neck, — Actinic Keratosis (AK) inframammary and inguinal regions) — Hidradenitis

Acrochordon Acrochrodon (Skin tag) (Skin tags) Typical appearance Pedunculated skin of multiple tag in the axilla pedunculated skin tags in the axilla (Up To Date 2011: Copyright Logical Images, Inc.; (Up To Date 2011: Copyright www.visualdx.com) Logical Images, Inc.; www.visualdx.com) Acrochordon (Skin tag) Acrochordon — TREATMENT (Skin tag) — Removal indicated if they become irritated or patient desires removal for cosmetic reasons Irritated skin tag — After application of a local anesthetic skin tags can be:

(Up To Date 2011: Courtesy — Excised with forceps and scissors/scalpel (will require chemical of Beth G. Goldstein, MD or electrocautery to stop bleeding; larger lesions may require suturing) and Adam O. Goldstein, MD) — Cryosurgery with liquid nitrogen (effective for smaller lesions) — Electrodessiccation (effective for smaller lesions) — Inform patients they will likely develop new skin tags in the predisposed areas

Cherry Angioma (De Morgan spots) — Definition: A benign growth on the skin composed of Cherry mature capillaries Angiomas — Incidence increases with age Usually occur as — Most common on trunk multiple lesions on the trunk — Red/purple dome shaped lesions 0.1 to 0.4cm in diameter (Up To Date 2011: Copyright — Bleed easily when traumatized Logical Images, Inc.; www.visualdx.com) — Always blanch with pressure although fibrotic lesions may not blanch completely

Cherry Angioma Dermatofibroma — Definition: benign overgrowth of fibroblasts (cells found in — TREATMENT connective tissue that produce collagen) as a result of trauma, insect bites or unknown causes — No treatment indicated unless lesions are bothersome — Firm hyperpigmented nodules 0.3 to 1.0cm in size — New lesions likely to form following removal — Most common on lower extremities of adults — After application of a local anesthetic angiomas can be: — Usually asymptomatic but may itch or be subject to — Electrocauterized (small lesions) repeated trauma — Shave excision and electrocautery (larger lesions) — Non-tender — Dimple when pinched — Usually no history of change in appearance Dermatofibroma Dermatofibroma

Firm hyperpigmented Dimple Sign nodule on the shin (Up To Date 2011 : (Up To Date 2011:Copyright Goodheart, HP. Goodheart’s Logical Images, Inc.; Photoguide of Common Skin www.visualdx.com) Disorders, 2nd Edition, Lippincott Williams & Wilkins, Philadelphia 2003.)

Dermatofibroma Epidermal Inclusion Cysts (EIC) — Treatment — Definition: discrete nodules under the skin composed of normal epidermis that produce keratin; may occur anywhere on the body; — Generally no treatment indicated unless symptomatic, mistakenly called sebaceous cysts (there is no sebaceous component) increased size, change in color or bleeds — The epidermis that composes the wall of the cyst may become — For lesions that are raised and easily irritated d/t repeated lodged in the dermis d/t trauma or start as a “black head” (open trauma consider cryotherapy, shave excision w/cautery or comedone) complete excision (if lesion is changing) — Cysts can remain stable in size, increase in size or have spontaneous inflammation with rupture — Lesions may recur — Diagnosis is based on clinical appearance: the nodules are usually — Scar from removal may look worse than the lesion discrete, sometimes mobile on palpation and generally have a — Rarely develop into malignant lesions called visible punctum dermatofibrosarcoma protuberans — Differentiate from pilar cysts of the scalp and face which form in hair root sheaths

Epidermal Epidermal Inclusion Inclusion Cyst (EIC) Cyst (EIC)

Raised With Visible subcutaneous Punctum/Sinus nodule No visible punctum (Courtesy of associated with this Tara L. Roberts, NP) cyst (EIC)

(Up To Date 2011: Stedman's Medical Dictionary. Copyright © 2008 Lippincott Williams & Wilkins.) Epidermal Epidermal Inclusion Cyst (EIC) Inclusion — Treatment Cyst — Not indicated unless infected or desired by patient — Infected cysts — Empiric treatment with oral ABX such as Augmentin 500/125mg Inflammed/ or 875/125mg PO BID or Keflex 500mg PO TID (tetracycline or Infected EIC erythomycin are sometimes used for their antiinflammatory properties) — Incision and drainage using local anesthesia (obtain culture; change ABX as need based on C&S results) (Up To Date 2011: Courtesy of Beth G — Wound care until I&D site heals (wash site daily with soap and Goldstein, MD and Adam O water; pack wound daily with iodoform or plain gauze strip, Goldstein, MD.) cover with 4x4’s and paper tape) — Cysts may recur following I&D; recommend formal excision when not infected

Lipoma Lipoma — Definition: benign neoplasms composed of mature fat cells usually encased by a thin fibrinous capsule — Angiolipomas are similar to the typical lipoma but are commonly Multiple lipomas on painful and contain vascular structure/cells trunk — Can occur anywhere on the body where fat cells exist/combine — Etiology is not well known or understood (genetic vs. Scars from prior environmental?) excisions visible — Usually superficial in the subcutaneous tissues but may involve the (Up To Date 2011: Goodheart, fascia or be found intramuscularly HP. Goodheart's Photoguide of — Usually soft or rubbery and mobile; asymptomatic and do not grow Common Skin Disorders, 2nd Edition, Lippincott Williams & rapidly but may increase in size slowly over time Wilkins, Philadelphia 2003. — If suspected lipoma is painful, grows rapidly, restricts movement or Copyright © 2003 Lippincott is firm or has areas of firmness consider biopsy Williams & Wilkins.) — Malignant transformation to liposarcoma is rare

Lipoma — TREATMENT Lipoma — Surgical removal for pain, cosmesis, or tissue diagnosis — Depending on location, size and superficial vs. Single lipoma intramuscular removal is done in minor procedure setting right mid lower using local anesthetic vs. OR with sedation or general back anesthetic — Potential side effects of surgery include: scarring, (Courtesy of hematoma, seroma and occasionally recurrence Tara L. Roberts, NP) — If patient has multiple masses with similar appearance/texture that are asymptomatic; biopsy one for diagnosis and watch other masses; remove as they become symptomatic, grow or change Neurofibroma — Definition: benign tumors made up of cells of Lipoma neuromesenchymal origin — May occur as solitary lesions or as multiples in the setting Lipoma excised from the right lower back. of neurofibromatosis — Cutaneous neurofibromas are ususually asymptomatic, (Courtesy of Tara L. Roberts, NP) soft, flesh colored or hyperpigmented papules or nodules that are less than 2cm — The “button-hole” sign is when pressure is applied directly to the neurofibroma and it retracts into the skin (this is not true for all neurofibromas)

Neurofibroma Neurofibroma — TREATMENT Cutaneous, soft, — Removal is not necessary for cutaneous neurofibromas flesh colored papule/nodule — Surgical excision using local anesthetic such as 1% lidocaine consistent with a with epi can be done to remove the papule/nodule when solitary tissue diagnosis is indicated or patient desires removal d/t neurofibroma discomfort or cosmesis

(Up To Date 2011: www.visualdx.com. Copyright Logical Images, Inc.)

Nevus — Definition: abnormal/new growths (neoplasms) caused by an increase of the pigment producing cells of the skin Nevus (melanocytes) — Commonly referred to as “moles” Intradermal nevus — Usually present as pigmented macules, papules or (pink/flesh colored)

plaques (courtesy of Perri Dermatology, — macules are flat (“junctional”) Dr. Anthony J. Perri) — papules are elevated (“compound”) — plaques are raised, rough, scaly lesions — May also be flesh colored or pink (“intradermal”) Nevus Nevus

Melanocytic or Junctional Nevus Dysplastic nevus Flat pigmented macule

(courtesy of Dr. Kopes-Kerr) (Courtesy of Tara L. Roberts, NP 2011)

Nevus — TREATMENT Nevus — Generally not indicated unless nevus is bothersome for patient or for cosmesis Compound nevus with central elevation, — If there is concern for melanoma consider shave biopsy, uniform pigmentation and regular border punch biopsy or excision using local anesthesia

(Up To Date 2011: Courtesy of Jean L Bolognia, MD, and Julie V Schaffer, MD.)

Seborrheic Keratosis (SK) — Definition: benign skin lesions composed of an Seborrheic overgrowth of immature keratinocytes (cells composing the Keratosis epidermis or outer most layer of the skin) Warty, “stuck on” — Lesions usually have the following characteristics: appearance — hyperpigmented (Up To Date 2011: Goodheart, HP. Goodheart's — Photoguide of Common Skin scaly Disorders, 2nd Edition, Lippincott Williams & — well circumscribed Wilkins, Philadelphia 2003. Copyright © 2003 Lippincott — warty Williams & Wilkins.) — “stuck on” — Commonly found on the trunk, face and upper extremities Seborrheic Keratosis (SK) Seborrheic — TREATMENT Keratosis — Generally not indicated but if patient desires treatment for Pigemented keratosis symptomatic lesions or cosmesis they can be removed by may be mistaken for melanoma one of the following means: (Up To Date 2011 — Liquid nitrogen for smaller, thinner lesions Goodheart, HP. Goodheart's Photoguide of Common Skin — Curettage, snip or shave excision using local anesthesia (1% Disorders, 2nd Edition, lidocaine with or w/o epinephrine) followed by electrodessication Lippincott Williams & Wilkins, Philadelphia 2003. Copyright of the wound bed © 2003 Lippincott Williams & Wilkins.) — Complete excision with scalpel using local anesthesia if ruling out a pigmented basal cell carcinoma, melanoma or other suspicious lesion

Actinic Keratosis (AK) Actinic — Definition: rough, scaly, erythematous patches, papules, or plaques that develop on sun damaged skin resulting in Keratosis atypia of the keratinocytes — Only develop on sun exposed areas Erythematous hyperkeratotic — Most AKs will not progress to invasive Squamous Cell plaque Carcinoma (SCC) of the skin; however, about 60% of all (Up To Date 2011 Courtesy SCC probably developed from an AK of James C Shaw, MD.) — Incidence increases with age

Actinic Keratosis (AK) Actinic Keratosis (AK) — TREATMENT — TREATMENT CONTINUED — Depends on the size, number and location of the lesions — Pharmacotherapy — Effudex (5-fluorouracil/5-FU) is a topical chemotherapuetic agent — Liquid nitrogen cryotherapy good for smaller superficial applied to areas of sun damaged skin with multiple AKs once or twice a lesions day for 2-4 weeks (1-2% face; 5% body) followed by a low potency cortizone cream twice a day once inflammation and ulceration occur — Surgical therapy (shave, curettage or excision) using local until skin is healed anesthesia for larger, thicker lesions; provides path — inhibits thymidylate synthetase, a critical enzyme in the synthesis of DNA; attacks fast-growing dysplastic cells, preventing cell proliferation specimen for tissue diagnosis resulting in cell death — Preventive Stratagies — the skin progresses through erythema, blistering, necrosis with erosion, and reepithelialization in approx. 4-6 weeks — avoid sun exposure — Usually prescribed by Dermatology — sun block — Other treatments include: diclofenac, imiquimod cream (Aldara), & — UV protective clothing retinoids Actinic Hidradenitis Suppurativa (HS) Keratosis — Definition: a chronic, suppurative process affecting the (AK) sweat glands; most likely d/t occlusion of follicles resulting in secondary inflammation and sometimes infection (“acne Inflammation inversa”) resulting from treatment with — Occurs where two skin areas touch or rub together, Effudex (topical 5- including: axilla, groin, perianal, perineal, genital and FU) inframammary regions (Up To Date 2011 Courtesy of James C Shaw, MD.) — More common in women than men (3:1) — Onset is usually between puberty and age 40 — Initially presents as small painful subcutaneous nodules that may progress to abscesses that rupture and drain purulent and/or serosanguineous material

Hidradenitis Suppurativa (HS) — Spontaneous or surgical drainage of abscesses usually Hidradenitis relieves pain Suppurativa — Over time this condition results in formation of deep Comedones and fluctuant cysts, sinus tracts/fistulas, hyperpigmentation, bridged scars in the scarring and pitting of the skin axilla — Differs from acne in that there is little involvement of the (Up To Date 2011: Ridley, CM, sebaceous glands Neill, SM (Eds), The Vulva 2nd ed, Blackwell Science, Oxford, — Unlike “boils” or “furuncles” the nodules are usually 1999, p.141.) deep, round and lack central necrosis — Diagnosis is based on clinical manifestations. Biopsy is not required and generally non-diagnostic.

Hidradenitis Suppurativa (HS) Hidradenitis Suppurativa (HS) — ENVIRONMENTAL/BEHAVIORAL/DIETARY CHANGES — TREATMENT (treatment is based on the severity/Stage of the disease) — Hurley Stage I-single or multiple abscess formation without sinus tracts and — Avoid trauma to involved areas scarring (MILD DISEASE) — Avoid heat, humidity, friction and sweating to involved areas — Topical antibiotics and intralesional steroids for inflammation — clinamycin 1% solution BID to affected areas — Encourage weight loss — triamcinolone acetonide (5-10mg/mL, 0.1 to 0.5mL injected into the center of individual, painful, small nodules once monthly for 1-3 times) — Encourage loose fitting breathable clothing (cotton vs. synthetic) — Oral systemic antibiotics for resistant cases — tetracycline 250-500mg PO QID for 7-10 days — Encourage smoking cessation — doxycycline 100mg PO BID for 7-10 days — Use gentle soaps with neutral pH — clinidamycin 300mg PO BID for 7-10 days — Augmentin 500-1000mg Q8H PO for 7-10 days — Use of antiperspirants is acceptable unless it causes irritation; — Concurrent therapy with anti-androgens avoid deodorants — Women: ethinyl estradiol/drospirenone oral contraceptive — Men: finasteride or dutaseride (5 alpha reductase inhibitors) — Avoid milk, milk products, casein and whey — Spironolactone 25 mg PO daily (may increase up to 100mg/day) — Retinoids-isotretinoin (Accutane) 1mg/kg PO x 4 months — Zinc gluconate 50 to 90mg PO daily (anti-inflammatory/anti-androgen properties) Hidradenitis Suppurativa (HS) Hidradenitis Suppurativa (HS)

— TREATMENT CONTINUED — TREATMENT CONTINUED — Hurley Stage II-recurrent abscesses with tracts and scarring; single or — Hurley Stage III-wide spread involvement or multiple interconnected tracts and abscesses /chronic multiple widely separated lesions (MODERATE DISEASE) draining fistulas (SEVERE DISEASE) — GOAL: to reduce activity to stage II and eventually stage I disease — GOAL: to reduce activity to stage I disease — Continue stage I and stage II baseline treatments — Continue stage I baseline treatments — Preoperative use of anti-inflammatory agents — prednisone (1mg/kg/day PO) — Antibiotics for moderate to severe disease may include: — cyclosporine (4 to 5 mg/kg/day PO) — rifampin 300mg PO BID and clindamycin 300mg PO BID x 3 months — TNF-alpha inhibitor (Infliximab 5mg/kg IV every 6 weeks) — dapsone 50-100mg PO daily — Concurrent use of preoperative antibiotics — clindamycin 300mg PO BID and rifampin 300mg PO BID concurrently — Glucocorticoids — Wide surgical unroofing, debridement and excision of all cysts, sinuses and scar tissue — prednisone for acute inflammatory flares (initial 3 to 4 day course of 40 to 60mg — generally performed in the OR tapered over 7 to 10 days) — healing is by secondary intention or with mesh grafting — Postoperative maintenance antibiotic therapy — Surgery — doxycycline 100-200mg PO daily — Incision and Drainage (I&D) of individual nodules/abscesses under local — dapsone 100mg PO daily anesthesia followed by packing to allow healing by secondary intention; relieves — Biologic medications pain of acute abscesses — adalimumab/Humira is the only FDA approved Biologic agent for treatment of moderate to severe HS — Initial dose (Day 1): 160 mg (given as four 40 mg injections on Day 1 or as two 40 mg injections per day on Days — Local or extensive unroofing 1 and 2) — Maintenance antibiotic therapy postoperatively: doxycycline 100-200mg PO — Second dose two weeks later (Day 15): 80 mg (two 40 mg injections in one day) daily or dapsone 100mg daily — Third dose (Day 29) and subsequent doses: 40 mg every week.

Overview of Cancerous Skin Lesions Hidradenitis Suppurativa

Sinus tract; surgical unroofing would involve — Basal Cell Carcinoma (BCC) opening the skin between the tracts using local anesthesia — Squamous Cell Carcinoma of the skin (SCC)

(Up To Date 2011: FW — Keratoacanthoma Danby, MD and LJ Margesson, MD.) — Melanoma

Basal Cell Carcinoma (BCC) Basal Cell Carcinoma (BCC) — Definition: a common skin cancer arising from the basal layer — RISK FACTORS of the epidermis — Commonly called “epitheliomas” — UV light exposure — Low metastatic potential (<0.5%) but can be locally invasive, — Chronic arsenic exposure aggressive and cause destruction of the skin and surrounding — Ionizing radiation structures — More common in light/fair skinned populations — Immunosuppression — Uncommon in dark skinned populations — Genetic factors/inherited disorders — Incidence increases with age — Actinic keratosis — Presence of one BCC increases risk for subsequent BCC — Lifestyle factors — 30% higher incidence in men — smoking — Excellent prognosis Basal Cell Carcinoma (BCC) Basal Cell — PREVENTION Carcinoma — protection from sun exposure (BCC) — smoking cessation Nodular BCC — CLINICAL PRESENTATION A pearly papule with — 70% occur on face; 15% on trunk; 15% misc. telangiectasias

— 60% are nodular (pink or flesh colored pearly papules typically on (Up To Date 2011: face; telangiectasias may be present; ulcerations may be present) www.visualdx.com. Copyright Logical Images, — 30% are superficial (typically occur on trunk; scaly pink papules or Inc.) plaques) — 5-10% are morpheaform (smooth, flesh colored or mildly erythematous papules or plaques; firm or indurated; ill-defined)

Basal Cell Basal Cell Carcinoma Carcinoma (BCC) (BCC) Superficial BCC Morpheaform BCC

erythematous, slightly May present as an indented/indurated scaly patch/plaque scar as seen here or as a firm whitish plaque (Up To Date 2011: www.visualdx.com. (Up To Date 2011: Copyright Logical Images, www.visualdx.com. Copyright Inc.) Logical Images, Inc.)

Basal Cell Carcinoma (BCC) Basal Cell Carcinoma (BCC) — DIAGNOSIS — TREATMENT CONTINUED — Diagnosis can be made by shave or punch biopsy or complete — Surgery: excision of lesion under local anesthesia (1-2% lidocaine with or w/o — Cryosurgery-freezing lesions/tumors with liquid nitrogen (may require epi depending on location) local anesthesia) — Mohs surgery-a specialized micrographic surgical technique that optimizes control of tumor margins while minimizing loss of normal — TREATMENT tissue; generally reserved for high risk lesions in cosmetically sensitive — Topical: areas — 5-fluorouracil (5-FU/Effudex) 5% cream or solution BID to affected areas — Electrodesiccation & curettage (ED&C)-technique of shaving or for 3-6 weeks scrapping the lesion followed by cauterization of the wound bed under local anesthesia; generally reserved for low risk lesions on trunk or — Imiquimod 5% cream daily to affected areas for 6-12 weeks extremities — Misc: — Excision-can be used for low risk and high risk lesions; generally under — Radiation therapy can be used for patients who are poor surgical local anesthesia in the outpatient setting candidates Squamous Cell Carcinoma (SCC) Squamous Cell Carcinoma (SCC) — Definition: a cutaneous cancer that may present as papules, — RISK FACTORS plaques or nodules as well as smooth, hyperkeratotic or ulcerated lesions — UV light exposure (UVB/UVA radiation) — Can develop on any cutaneous surface (head, neck, trunk, extremities, oral mucosa, — Ionizing radiation (used to treat cancer, acne, psorias) periungual skin and anogenital regions) — Second most common skin cancer behind BCC (approx. 20% of non-melanoma skin — Immunosuppression cancers) — More common in fair skinned populations — Chronic inflammation (scars, burns, chronic ulcers, sinus — More common in sun exposed areas except in dark skinned tracts or inflammatory skin conditions) populations — Chronic arsenic exposure — Incidence increases with age — Genital and periungual SCC is rare and usually related to HPV infection — Genetic factors/inherited disorders/family hx of SCC — SCC lesions on the ear, preauricular regions or at mucocutaneous — HPV infection interfaces (lips/genitalia/perianal) tend to be more aggressive and have higher rates of metastasis (10-30%) — Lifestyle factors (smoking and diet)

Squamous Cell Carcinoma (SCC) Actinic — PREVENTION Keratosis — Protection from sun exposure — Chemoprevention (AK) — Oral/topical retinoids (role still being investigated) — CLINICAL MANIFESTATIONS Erythematous — Actinic keratosis: rough, scaly, erythematous macules that develop on sun damaged skin (~60% of SCCs arise from AKs) hyperkeratotic — Keratoacanthoma: rapidly growing epithelial tumors that resemble SCC on physical and plaque histological exam; found in areas of actinic change; may be benign or involve SCC — Wounds & Scars: Marjolin’s ulcer refers to tumors/SCC that develops at sites of chronic non-healing wounds/ulcers/scars (Up To Date 2011 Courtesy of James C Shaw, MD.) — SCC insitu (Bowen’s disease): well defined scaly patch or plaque (erythematous, skin colored or pigmented); asymptomatic and slow growing — Invasive SCC: — well-differentiated lesions are usually firm/indurated, hyperkeratotic papules, plaques or nodules; with or w/o ulceration; 0.5-1.5cm in size but occ. Larger — poorly differentiated lesions are usually fleshy, soft granulomatous papules or nodules lacking hyperkeratosis; may have ulceration, hemorrhage or necrosis

Marjolin’s Keratoacanthoma Ulcer

Dome shaped or SCC can form at crateriform nodule sites of chronic with central inflammation keratotic core/plug including wounds, (Courtesy of ulcers and scars Tara L. Roberts, NP 2011) (courtesy of Wikipedia 2006) Squamous Invasive Cell Squamous Carcinoma Cell Insitu Carcinoma

Also known as An erythematous, Bowen’s Disease hyperkeratotic papule on the skin (Up To Date 2011: (Up To Date 2011: www.visualdx.com. www.visualdx.com. Copyright Logical Images, Inc.) Copyright Logical Images, Inc.)

Squamous Cell Carcinoma (SCC) Squamous Cell Carcinoma (SCC) — DIAGNOSIS — TREATMENT CONTINUED — Diagnosis can be made by shave or punch biopsy or complete — Surgery: (1-2% lidocaine with or excision of lesion under local anesthesia — Cryosurgery-freezing lesions/tumors with liquid nitrogen (may require w/o epi depending on location) local anesthesia; for small, superficial low risk lesions and SCC insitu) — Mohs surgery-a specialized micrographic surgical technique that — TREATMENT optimizes control of tumor margins while minimizing loss of normal — tissue; generally reserved for high risk lesions in cosmetically sensitive Topical: areas — 5-fluorouracil (5-FU/Effudex) 5% cream or solution BID to affected areas for 3-6 weeks — Electrodesiccation & curettage (ED&C)-technique of shaving or scrapping the lesion followed by cauterization of the wound bed under — Imiquimod 5% cream daily to affected areas for 6-12 weeks local anesthesia; generally reserved for small, superficial low risk lesions — Misc: on trunk or extremities — Radiation therapy can be used for patients who are poor surgical — Excision-can be used for low risk and high risk lesions; generally under candidates local anesthesia in the outpatient setting

Malignant Melanoma Malignant Melanoma — Definition: a skin cancer involving the melanocytes which — RISK FACTORS are the cells that produce the pigment (melanin) of the — Personal or family hx of melanoma — Sun/UV exposure skin — Presence of multiple and/or atypical nevi — The most serious form of skin cancer — Phenotypic traits: light skin, hair and eye color; freckling — PREVENTION/EVALUATION th — The 6 most common cancer in North America — Protection from sun exposure — Incidence increases with age — ABCDE rule — Asymmetry — Higher incidence in men — Border irregularities — Tends to be aggressive and can metastasize throughout — Color variegation (3 or more: brown, red, black or blue/gray, and white) — Diameter >=6mm the body — Evolving: a lesion that is changing in size, shape, color or a new lesion — Survival depends on the stage of the disease at diagnosis — The “ugly duckling” sign (when a patient with multiple nevi has a pigmented lesion that looks different from the surrounding lesions) — Patient self-examination of skin — Clinical examination of skin Malignant Melanoma — SUBTYPES Malignant — Superficial spreading melanoma: most common (70%); can Melanoma occur anywhere on the body; a macule or plaque with irregular border and variable pigmentation Superficial spreading — Nodular melanoma: 2nd most common (15-30%); darkly melanoma, (asymmetry, pigmented,pedunculated or polypoid nodules irregular border, color variegation ) — Lentigo maligna melanoma: 10-15%; occurs most often in sun damaged areas of older adults; begins as a tan-brown macule (Up To Date 2011: www.visualdx.com. Copyright that gradually increases in size developing asymmetry and Logical Images, Inc.) variation in color — Acral lentiginous melanoma: <5%; most common in dark- skinned populations; usually develops on palmer, plantar and subungual surfaces

Malignant Malignant Melanoma Melanoma

Nodular melanoma Lentigo maligna (a discrete nodule, usually with dark pigmentation, melanoma however, they may be develops in areas of sun- amelanotic (lacking damaged skin, especially the pigment) as in this picture head and neck; begins as a freckle-like tan-brown macule (Up To Date 2011: Courtesy of and gradually enlarges and James C Shaw, MD.) develops darker, asymmetric foci, raised areas, and color variegation

(Up To Date 2011: www.visualdx.com. Copyright Logical Images, Inc.)

Malignant Melanoma Malignant — STAGING Melanoma — Prognosis depends on stage of disease at time of diagnosis Acral lentiginous (thickness, mitotic rate and ulceration) melanoma — Early detection is vital to improve patient outcomes and Located on the palms, soles or survival nails these lesions have the asymmetry and color — There are 5 stages: variegation of typical melanomas — Stage 0 is in situ melanoma — (T1: <=1mm; 10 yr survival 92%) (Up To Date 2011: Courtesy of Stage I is localized cutaneous disease James C Shaw, MD.) — Stage II is localized cutaneous disease (T2: 1.01-2.00mm; 10 yr survival 80%) — Stage III is regional nodal disease (T3: 2.01-4.00mm; 10 yr survival 63%) — Stage IV is distant metastatic disease (T4: >4mm; 10 yr survival 50%) Malignant Melanoma References — DIAGNOSIS — asp.mednet.ucla.edu. Skin and Soft Tissue Infections. Accessed 5/9/2017. — Punch or incisional biopsy of larger lesions using local anesthesia — Buzaid, AC,Gershenwald, JE & Ross, MI. Tumor node metastasis (TNM) staging system and other prognostic factors in cutaneous melanoma. Up To — Excisional biopsy of smaller lesions with 1-3mm margin using Date May 2011. local anesthesia — Chartier, TK & Aasi SZ. Treatment and prognosis of basal cell carcinoma. Up — TREATMENT To Date May 2011. — Referral to Dermatology for clinical skin exam and biopsy — Geller AC & Swetter S. Screening and early detection of melanoma. Up To Date May 2011. — Referral to Surgery for biopsy and excision — Goldstein, BG & Goldstein, AO. Overview of benign lesions of the skin. Up — Referral to Hematology Oncology for advanced/metastatic To Date May 2011. disease (Interferon and Immunotherapy) — Lee, RA & Eisen, DB. Treatment of hidradenitis suppurativa with biologic — Referral to Radiation Oncology for palliative treatment of medications. https://www.ncbi.nlm.nih.gov/pubmed/26470624 ; unresectable locally recurrent disease or metastatic disease https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0- causing bone pain, spinal cord compression, CNS dysfunction or S0190962215020010.pdf?locale=en_US . March 2017 tumor hemorrhage — Lim JL & Asgari M. Clinical features and diagnosis of cutaneous squamous cell carcinoma (SCC). Up To Date May 2011.

References — Lim JL & Asgari M. Epidemiology and risk factors for cutaneous squamous cell carcinoma (SCC). Up To Date May 2011. — Schaffer, JV & Bolognia, JL. Acquired melanocytic nevi (moles). Up To Date May 2011. — Stewart, EG, Margesson, LJ & Danby FW. Pathogenesis, clinical features, and diagnosis of hidradenitis suppurativa. Up To Date May 2011. — Stewart, EG, Margesson LJ & Danby FW. Treatment of hidradenitis suppurativa. Up To Date May 2011. — Swetter, S & Geller, AC. Skin examination and clinic features of melanoma. Up To Date May 2011. — Wrone, DA & Stern RS. Epidemiology and clinical features of basal cell carcinoma. Up To Date May 2011. — http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/12505 7s397lbl.pdf. Accessed March 2017.