Pictorial essay • CLINICAL PRACTICE The summer skin check Belinda Welsh, MBBS, MMed, FACD, is consultant dermatologist, St Vincent’s Hospital, Melbourne, Skin and Cancer Foundation, Carlton, and is in private practice, Sunbury, Victoria. BACKGROUND Skin cancer is a major public health problem in Australia and represents a substantial health cost. General practitioners provide the majority of care to patients with skin cancer, so becoming familiar with the clinical features and management of these tumours is important. OBJECTIVE To provide a pictorial essay on the common types of benign and malignant skin lesions encountered in general of suspicion is necessary in this population in women, the neck, shoulders and outer practice, and briefly describe key clinical • exposure to arsenic is a known risk factor arms are also sites of predilection4 features, differential diagnosis and for the development of basal cell carci- • scars should be checked for evidence of management options. noma (BCC)2 and Bowen disease3 recurrence of previously excised lesions - •a history of change or symptomatology in BCCs may develop within longstanding DISCUSSION any lesion – skin cancers are changing scars and ulcers5,6 Examination for skin cancer should be lesions and the time course for this change • lymph nodes should be assessed for the considered in the general practice setting is generally evident over a period of months. early detection of metastatic disease if for all patients over the age of 40 years, there is a history of melanoma or squa- particularly the elderly. A proper skin check Examination mous cell carcinomas (SCCs). requires a systematic approach and ideally The following factors are important in examination: an entire consultation should be set aside • good lighting, preferably natural light Management for this purpose. However, clinical • magnification – a dermatoscope can be Biopsy of a lesion (punch or shave) is advisable examination conducted for other purposes helpful in diagnosis of both melanocytic when a firm clinical diagnosis cannot be made or provides an opportunity for screening and and nonmelanocytic lesions when the treatment choice may be dictated by early detection of skin cancer. • positioning – patients should be the tumour type or pattern of growth. Multiple 2 undressed to their underwear, so a warm mm punch biopsies may be necessary to define History taking room or blanket for comfort is desirable. poorly demarcated tumours. Tailor each manage- Having the patient lie on the examination ment decision to the particular lesion in the The following points in history taking can help couch can be useful so the soles of the individual patient. In general, simple surgical exci- identify high risk patients: feet are not missed sion with primary closure is the treatment of • blistering sunburns • look closely – gently stretching the skin choice for most skin cancers, although some • occupational and recreational exposure to can often make BCCs more obvious. anatomical areas require particular care (Table 1) solar radiation • palpate – dermatofibromas for example and specialist referral may be desirable for tech- • family or personal history of melanoma or have a characteristic feel on palpation nically difficult excisions. Prevention should be multiple atypical (dysplastic) naevi • concentrate on high risk areas – the emphasised (Table 2) and changes to look for in • family or personal history of non- highest rates for NMSC are found on the suspicious lesions discussed. Follow up is rec- melanoma skin cancer (NMSC) face, especially the nasolabial fold, eyelid ommended for three reasons: detection of •immunosuppression – higher rates and and the nonmucosal skin of the lip fol- further primary tumours, detecting local persis- earlier onset of skin cancer is present in lowed by the ears, nose and cheek. In tence of previously treated tumours, and early transplant patients,1 therefore a high index men, the neck, back and shoulders, and detection of metastatic disease. Reprinted from Australian Family Physician Vol. 33, No. 1/2, January/February 2004 37 Clinical practice: The summer skin check Recurrence after excision is not Table 1. Problem areas uncommon as clinical margins are often requiring care in management underestimated Face – for cosmetic reasons and the possibility of nerve damage Eyelids – scarring can cause entropion Lips and helix of the ear – because of malignant potential Neck – where the accessory nerve is Figure 2. Seborrhoeic keratosis superficial Fingers – function is a major consideration later thickening to become brownish-black. Lower limb – healing can be very slow The surface is irregular and shows minute pits. Management Figure 4. Porokeratosis Table 2. Recommendations for When flat and pigmented, seborrhoeic ker- prevention of skin cancer atoses may require biopsy to differentiate Porokeratoses them from lentigo maligna melanoma. These can be removed with a number of destructive Clinical features Where possible use clothing as the techniques such as cryotherapy, curettage, primary means of photoprotection – electrosurgery or shave excision. Porokeratoses (Figure 4) are uncommon, dis- preferably closely woven fabrics that aren’t transparent when held up to tinctive, benign lesions due to clones of the light Multiple eruptive seborrhoeic epidermal cells that show varying degrees of Wear hats and sunglasses keratoses are rare but may be a sign of dysplasia. They develop as annular dry internal malignancy (Leser-Trelat sign) plaques surrounded by a raised fine keratotic Seek shade. Avoid the sun in the middle of the day wall. Porokeratoses may be isolated or multi- ple and most often appear on the limbs. Use sunscreen – broad spectrum SPF15 or greater should be applied to Management all exposed areas of the skin as a last line of defence. Reapply every 2 hours None usually needed. If lesions are hyperkera- Advise against the use of sunbeds, totic or multiple, cryotherapy may be performed. tanning booths and tanning lamps The rare giant forms may be premalignant Figure 3. Dermatofibroma Dermatofibroma Clinical features Dermatofibroma (Figure 3) are benign tumours of fibroblasts that are firm, solitary Figure 1. Seborrhoeic keratosis dermal nodules usually found on the limbs of Figure 5. Solar keratosis younger people. They have an ‘iceberg’ effect Seborrhoeic keratoses in that they feel larger than they look. The Clinical features overlying epidermis is often lightly pigmented Solar keratoses and dimples when the nodule is squeezed. Seborrhoeic keratoses (Figure 1, 2) are very Management Solar keratoses (Figure 5) are common common benign tumours usually found on the lesions associated with dysplasia, particularly face and trunk. They develop gradually as No treatment is usually necessary, although within basal keratinocytes. They represent a slightly elevated, ovoid yellow-brown, well biopsy may be performed if the diagnosis potential precursor of SCC, although only a defined papules with a greasy appearance, is uncertain. small percentage evolve into invasive SCCs. 38 Reprinted from Australian Family Physician Vol. 33, No. 1/2, January/February 2004 Clinical practice: The summer skin check Clinical features to invasive SCC has not been established, Differential diagnosis but appears to be low.7 Solar keratoses are found on the chronically Differential diagnosis • SCC sun exposed sites of the head and neck, • Atypical fibroxanthoma dorsa of the hands, and the forearms, and • Superficial BCC • Merkel cell carcinoma present as erythematous macule with super- • Psoriasis • Amelanotic melanoma. imposed hyperkeratosis. Solar keratoses are • SCC Management options generally multiple and may be confluent. • If pigmented, may mimic superficial Differential diagnosis spreading melanoma. • Partial biopsy will almost always be Management options reported as a well differentiated SCC as Bowen disease, SCC, solar lentigo or lentigo pathology requires the entire architecture maligna if pigmented. • Surgical excision to suggest the possibility of keratoacan- Management options • Cryotherapy thoma. If in doubt, treat as a SCC • Imiquimod • Curettage +/- cryotherapy •No treatment • 5-flurouracil • Shave excision • Cryotherapy • Curettage and diathermy • Surgical excision • 5-flurouracil • Photodynamic therapy • Intralesional methotrexate • Imiquimod • Superficial radiotherapy • Superficial radiotherapy. • Curettage • Laser ablation. • Laser resurfacing. Extra caution is required in Due to extension of keratinocyte atypia, immunosuppressed patients as keratoa- Thickening and tenderness on down hair follicles recurrence after canthomas may progressively grow lateral palpation are indicators of possible treatment with superficial modalities rather than involute10 transformation into invasive SCC (eg. cryotherapy) can occur, particularly on the face Figure 8. Squamous cell carcinoma Figure 6. Bowen disease Figure 7. Keratoacanthoma Bowen disease Bowen disease (intraepidermal SCC) (Figure Keratoacanthoma 6) is associated with full thickness epidermal dysplasia with follicular involvement and is Keratoacanthoma (Figure 7) are lesions that classified as an intraepidermal SCC. Despite can be thought of as a well differentiated this, they tend to have a prolonged in-situ forms of SCC characterised by spontaneous Figure 9. Squamous cell carcinoma phase that may last many years. resolution. Clinical features Clinical features Squamous cell carcinoma Longstanding, slowly enlarging lesions that Keratoacanthoma are most common