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Family Medicine 16: 68-year-old male with skin lesion

User: Beatriz Duque

Email: [email protected] Date: September 14, 2020 3:00AM

Learning Objectives

The student should be able to:

Describe skin lesions with accuracy.

Define terms that describe the morphology, shape, and pattern of skin lesions.

Formulate the treatment principles of topical corticosteroid and local and systemic antifungal agents.

Apply the ABCDE criteria for the evaluation of hyperpigmented lesions as possible melanoma.

Describe common biopsy procedures, including shave biopsy, punch biopsy, and incisional and excisional biopsies.

Discuss the treatment modalities for squamous cell carcinoma.

Describe the importance and methods of prevention of skin cancers.

Develop initial workup and management of benign prostatic hyperplasia.

Knowledge

Primary and Secondary Skin Lesions

Primary skin lesions are uncomplicated lesions that represent initial pathologic change, uninfluenced by secondary alterations such as infection, trauma, or therapy.

Secondary skin lesions are changes that occur as consequences of progression of the disease, scratching, or infection of the primary lesions.

Primary Skin Lesions

Macule: A macule is a change in the color of the skin. It is flat, and if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. It is less than 1 cm in diameter. Some authors use 5 mm for size criterion. Sometimes “macule” is used for flat lesion of any size.

Patch: A patch is a macule greater than 1 cm in diameter.

Papule: A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter.

Plaque: A plaque is a solid, raised, flat-topped lesion greater than 1 cm in diameter. It is analogous to the geological formation, the plateau.

Nodule: A nodule is a raised solid lesion and may be in the epidermis, dermis or subcutaneous tissue.

Tumor: A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule.

Vesicle: A vesicle is a raised lesion less than 1 cm in diameter and is filled with clear fluid.

Bulla: A bulla is a circumscribed fluid filled lesion that is greater than 1 cm in diameter.

Pustule: A pustule is a circumscribed elevated lesion that contains pus.

Wheal: A wheal is an area of elevated edema in the upper epidermis.

Complete list of primary and secondary skin lesions with images.

Skin Cancer Screening Recommendations

The annual skin cancer screening by full body skin examination by health care provider is an I recommendation by USPSTF. I recommendation means that current evidence is insufficient to assess the balance of benefits and harms of a primary care clinician performing a whole body skin examination or a patient doing a skin self-examination for the early detection of skin cancers.

However, the American Cancer Society recommends appropriate cancer screening by a physician, including a skin examination, during a periodic health examination. The American Academy of Dermatology promotes free skin examinations by volunteer dermatologists for the general population through the Academy’s Melanoma/Skin Cancer Screening Program. It also encourages regular self-examinations by individuals.

In the context of apparently conflicting recommendations by different organizations and when there is no sufficient evidence for the benefit or harm of certain recommendations, (like USPSTF I recommendation), the best policy may be to discuss the recommendation with patients and ask their preference. Physicians, however, should be able to discuss the possible outcomes of

the patient’s choice.

Risk For Skin Cancer

Risk factors for nonmelanoma skin cancers include:

1.  Previous skin cancer of any type gives 36% to 52% five-year risk of second skin cancer

2.  80% of lifetime sun exposure is obtained before 18 years of age (single greatest risk factor) 3. Celtic ancestry

4.  Fair complexions

5.  People who burn easily

6.  People who tan poorly and freckle

7.  Red, blonde or light brown hair

8.  Increasing age

9.  Use of coal-tar products

10.  Tobacco use

11.  Psoralen use (PUVA therapy)

12.  Male >>> female

13.  Living near equator (UV exposure)

14.  Outdoor work

15.  Chronic osteomyelitis sinus tracts

16.  Burn scars

17.  Chronic skin ulcers

18.  Xeroderma pigmentosum

19.  Human papillomavirus infection

Risk factors for melanoma skin cancer include:

1.  Previous melanoma

2.  Celtic ancestry

3.  Fair complexions

4.  People who burn easily

5.  People who tan poorly and freckle

6.  Red, blonde or light brown hair

7.  Early adulthood and later in life

8.  “Intense, intermittent exposure and blistering sunburns in childhood and adolescence are associated with increased risk”

9.  Radiation exposure

10.  Melanoma in 1st or 2nd degree relative

11.  Familial atypical mole-melanoma syndrome (FAMMS)

12.  Male > female (slight)

13.  Living near equator (UV exposure)

14.  Indoor work

15.  Higher incidence in those with more education and/or income

16.  Nonfamilial dysplastic nevi

17.  Large number of benign pigmented nevi

18.  Giant pigmented congenital nevi

19.  Nondysplastic nevi (markers for risk, not precursor lesions)

20.  Xeroderma pigmentosum

21.  Immunosuppression

22.  Previous nonmelanoma skin cancer

23.  Other malignancies

While incidence of skin cancer is higher among individuals with fair skin, patients with darker skin are also at risk for developing skin cancer and should also undergo regular screenings; conduct self examinations; and protect themselves from UV radiation.

Consent Form for Procedures

A procedure consent form aims to document adherence to one of the four principles of medical ethics: respect for autonomy. Patients can not be viewed as making their own autonomous decisions if they are not adequately informed as to the true nature of the decision. An autonomous decision to allow providers to perform a procedure requires an understanding of the the reason for the procedure, the nature of the procedure, as well as its risks, benefits, and alternatives.

Thus, a consent form should contain:

the name of the procedure the diagnosis

the risks of the procedure the benefits of the procedure

the alternative to the procedure that was proposed

Patient Education for Protection Against Sun Damage

The key to preventing a skin cancer is to stay out of the sun and not to use a sunlamp. If you are going to be in the sun, you should wear clothes made from tightly woven cloth so the sun’s rays can’t get to your skin. You should also stay in the shade when you can. Wear a wide-brimmed hat to protect your face, neck, and ears.

Remember that clouds and water won’t protect you from the sun’s rays. The sun’s rays can also reflect off water, snow, and white sand.

If you can’t stay out of the sun or wear the right kind of clothing, you should use sunscreen to protect your skin. But don’t think that you are completely safe from the sun just because you are wearing sunscreen.

Use sunscreen with a sun protection factor (SPF) of 15 or more. Put the sunscreen everywhere the sun’s rays might touch you, including your ears, the back of your neck, and bald areas on your scalp. Put more on every two to three hours and after sweating or swimming.

Patient Education on Skin Examination

What’s the best way to do a skin self-examination?

The best way is to use a full-length mirror and a hand-held mirror to check every inch of your skin.

First, you need to learn where your birthmarks, moles and blemishes are and what they usually look like. Check for anything new, such as a change in the size, texture or color of a mole, or a sore that doesn’t heal.

Look at the front and back of your body in the mirror, then raise your arms and look at the left and right sides.

Bend your elbows and look carefully at your palms and forearms, including the undersides, and your upper arms. Check the back and front of your legs.

Look between your buttocks and around your genital area.

Sit and closely examine your feet, including the bottoms of your feet and the spaces between your toes.

Look at your face, neck and scalp. You may want to use a comb or a blow dryer to move hair so that you can see better.

By checking yourself regularly, you’ll get familiar with what’s normal for you. If you find anything unusual, see your doctor. The earlier skin cancer is found, the better.

Prostatitis Syndrome Symptoms

Prostatitis syndromes tend to occur in young and middle-aged males. The symptoms of prostatitis include pain (in the perineum, lower abdomen, testicles and penis, and with ejaculation), bladder irritation, bladder outlet obstruction, and sometimes blood in the semen.

Clinical Skills

Full Skin Exam

When performing a skin exam at annual visits and/or evaluating a patient presenting with a skin lesion — have the patient change into a gown so you can perform a full skin exam.

Skin Examination

Distribution

The distribution of the skin lesions is important in diagnosing skin diseases. Many conditions have typical patterns or affect specific regions of the body. For example, psoriasis commonly affects extensor surfaces of joints, and atopic eczema impacts flexor surface of joints. Involvement of the palms and soles is seen in erythema multiforme, secondary syphilis and eczema.

Shape

Descriptions like oval, round, linear etc. can be used to describe the shape of the lesions. Annular lesions are circular with normal skin in the center. Annular macules are observed in drug eruptions, secondary syphilis and lupus erythematosus. Iris lesions are a special type of annular lesion in which an erythematous annular macule or papule develops a second ring or a purplish papule or vesicle in the center (target or bull’s eye lesion).

Arrangement

A linear arrangement of lesions may indicate a contact reaction to an exogenous substance brushing across the skin. Zosterform refers to lesions arranged along the cutaneous distribution of a spinal nerve.

Size

It is important to measure some lesions, especially nevi and skin malignancies like squamous cell carcinoma. Squamous cell carcinoma of the skin greater than 2 cm in diameter is regarded to be high risk for recurrence and metastasis. Nevi larger than 6 mm in diameter are more likely to be malignant than smaller nevi.

Associated symptoms

Associated symptoms, like itching, pain, or burning sensation are helpful to make a diagnosis of certain skin diseases. Eczema tends to be itchy compared to fungal skin infections. Pain is usually associated with herpes simplex or herpes zoster.

Management

Eczema Treatment

Eczema treatment: Medium-strength corticosteroid cream to decrease inflammatory process. In addition, regular use of emollient to soften the lesion and prevent exacerbations. If the lesion is dry, ointment may be a better vehicle for the corticosteroid.

Topical Corticosteroids

Accurate diagnosis

An accurate diagnosis is essential in selecting a topical corticosteroid. Topical corticosteroids are effective for conditions that are characterized by hyperproliferation, inflammation, and immunologic involvement. They can also provide symptomatic relief for burning and pruritic lesions.

Vehicle

The vehicle, or base, is the substance in which the active ingredient is dispersed. The base determines the rate at which the active ingredient is absorbed through the skin. There are several types of vehicles:

Creams: The cream base is a mixture of several different organic chemicals (oils) and water, and usually contains a preservative. It can be used in nearly any area and therefore most often prescribed. It is cosmetically most acceptable. It has a drying effect with continuous use, therefore best for acute exudative inflammation.

Ointments: The ointment base contains a limited number of organic compounds consisting primarily of grease such as petroleum jelly, with little or no water. Ointment is desirable for drier skin and has a greater penetration of medicine than a cream and therefore has enhanced potency.

Lotions and gels: Lotions contain alcohol, which has drying effect on an oozing lesion. Lotions are most useful in the scalp area because they penetrate easily and leave little residue. Gels have a jelly-like consistency and are beneficial for exudative inflammation, such as poison ivy.

Potency

The anti-inflammatory properties of topical corticosteroids result in part from their ability to induce vasoconstriction to the small blood vessels in the upper dermis. The potency of corticosteroids are tabulated in seven groups, with group I the strongest and group VII the weakest.

Potency

Examples

Use to treat

Group I

Augmented betamethasone dipropionate 0.05%, Halobetasol propionate

0.05%

Psoriasis, lichen planus, severe hand eczema, and alopecia areata.

Group II

Desoximetasone, Fluocinonide 0.05%

Psoriasis, lichen planus, severe hand eczema, and alopecia areata.

Group III

Betamethasone dipropionate 0.05%, Triamcinolone acetonide 0.5% (ointment or cream)

Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.

Group IV

Floucinolone acetonide 0.025% (ointment), Triamcinolone acetonide

0.1% (ointment)

Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.

Group V

Floucinolone acetonide 0.025% (cream), Triamcinolone acetonide 0.1%

(lotion) or Triamcinolone acetonide 0.025% (ointment)

Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.

Group VI

Alclometasone dipropionate 0.05%, Desonide 0.05%

Dermatitis in eyelids and diaper area, mild dermatitis on face, and mild intertrigo.

Group

VII

Hydrocortisone 1%, 2.5%

Dermatitis in eyelids and diaper area, mild dermatitis on face, and mild intertrigo.

Administration

Once or twice daily application is recommended for most preparations. More frequent administration does not provide better results.

Side effects

The most common side effect of topical corticosteroid is skin atrophy. It also can cause hypopigmentation. This is more apparent with darker skin tones. Topically applied high and ultra high potency corticosteroids can be absorbed well enough to cause systemic side effects. Hypothalamic-pituitary-adrenal suppression, glaucoma, septic necrosis of the femoral head, hyperglycemia, hypertension and other systemic side effects have been reported.

When to Treat with Systemic vs Local Antifungal Agents

Systemic Therapy

Tinea capitis

Oral therapy is required to adequately treat tinea capitis, as they are able to penetrate the infected hair shaft where topical therapies cannot.

Griseofulvin is the first-line oral antifungal treatment approved for use. Suggested dosing is 20-25 mg/kg/day using the microsize formulation, for 6-12 weeks. Where the ultramicrosize formulation is used, a dose of 10-15 mg/kg/day is suggested, as it is more rapidly absorbed than the microsize form.

Terbinafine hydrochloide was also approved by FDA in 2007 for tinea capitis for children ages 4 years and older. The approved pediatric dose of terbinafine granule is 125 mg, 187.5 mg, or 250 mg for children weighing less than 25 kg, 25 to 35 kg, and more than 35 kg, respectively, once daily for 6 weeks.

In multiple studies, terbinafine was consistently more effective than griseofulvin against tinea capitis caused by Trichophyton tonsurans. However, in children with microsporum infection, new evidence suggests that the effect of griseofulvin is better than that of terbinafine.

Tinea unguium

Though griseofulvin is approved for tinea infection of the nails, its affinity for keratin is low and long-term therapy is required. The oral therapy regimens for tinea unguium (onychomycosis)are as follows:

terbinafine 250 mg/day for 12 weeks (toenails) or 6 weeks (fingernails only) itraconazole 200 mg twice daily as pulse therapy one pulse: 1 week of itraconazole followed by 3 weeks without itraconazole two pulses: fingernails three pulses: toenails Local Therapy

Tinea pedis, tinea manuum, tinea corporis, and tinea cruris can be treated with topical antifungal medications.

A wide variety of topical agents are available, in cream, gel, lotion, and shampoo formulations. A majority of the agents are of the ‘azole’ antifungal family (clotrimazole, miconazole, econazole, coiconazole, ticonazole, etc.). Terbinafine and naftifine represent the ‘allylamine’ family of agents. Both families of drugs are known for their high efficacy against the dermatophytes.

Cure rates of tinea corporis/tinea cruris/tinea pedis are high, with infections resolving with two to four weeks of topical therapy.

Skin Biopsy

Type of biopsy

Procedure

Tool & specimen size

Incisional /

punch biopsy

Incisional biopsy means taking out a part of the skin lesion

Punch biopsy is a specific incisional biopsy using a cylindrical dermal biopsy tool.

Disposable punches are very convenient and available from two to eight millimeters in size.

A full thickness of skin can easily be obtained with a punch biopsy.

If a lesion is less than three millimeters in size, it does not need stitches after biopsy.

Excisional biopsy

Excisional biopsy involves removing the whole lesion with a two to three millimeter margin, depending on the nature of the lesion.

Larger-sized punches may be useful for excisional punch biopsies.

Diagnostic method of choice if there is a strong suspicion of malignant melanoma.

Shave biopsy

Shave biopsy is feasible when the lesion is elevated above the surface.

Some experts occasionally elevate the lesion with lidocaine and shave in certain circumstances in order to avoid stitches.

Skin Lesion Therapy

Therapy

Conditions treated

More details

Surgical excision

Most widely used treatment for cutaneous squamous-cell carcinomas (SCCs), particularly high risk lesions.

Well defined, small (< 2 centimeters) SCC lacking any high-risk features requires a four millimeter margin of normal tissue around the visible tumor to result in 95% histologic cure rate.

Patients with any nonmelanoma skin cancer greater than two centimeters,

The surgeon can immediately review the pathology to confirm complete excision during a staged excision. Since this allows removal of the least

Mohs

microscopic surgery

lesions with indistinct margins, recurrent lesions, and those close to important structures, including the eyes, nose, and mouth, should be considered for referral for complete excision via Mohs micrographic surgery, with possible plastic repair.

necessary amount of tissue, this procedure is indicated in cosmetically sensitive areas. This ability to immediately confirm pathology is also useful in lesions with indistinct margins where more tissue than clinically apparent may require removal. If a difficult repair is anticipated or a poor cosmetic result is expected, referral is appropriate. To learn more about Mohs surgery, read an article from the American Academy of Family Physicians.

Topical 5fluorouracil

(5-FU)

Approved by the United States Food and Drug Administration (FDA) for the treatment of actinic keratoses.

Although topical 5 -FU is not approved for the treatment of Bowen’s disease (squamous-cell carcinoma in-situ) and superficial SCCs, it is widely used in these diseases when other treatment modalities are impractical and for patients who refuse surgical treatment.

Cryotherapy

Useful for small, well defined, low risk invasive SCCs and Bowen’s disease.

Destroys malignant cells by freezing and thawing. Cryotherapy does not permit histologic confirmation of the adequacy of treatment margins; thus, a substantial amount of training and experience is required to achieve consistently high cure rates.

Radiation therapy

An option for the initial management of small, well-defined, primary SCCs, especially older patients and those who are not surgical candidates.

However radiation therapy is contraindicated on tumors located on trunk and extremities. These areas are subjected to greater trauma and tension than skin on the head and neck, and they are more prone to break down and ulcerate as a result of the atrophy and poor vascularity of irradiated tissue.

Management of Symptomatic Benign Prostatic Hyperplasia (BPH)

Behavior modifications to decrease lower urinary tract symptoms:

avoiding fluids prior to bedtime or before going out

reducing consumption of mild diuretics such as caffeine and alcohol limiting the use of salt and spices maintaining voiding schedules

Alpha-adrenergic antagonists decrease urinary symptoms in most males with mild to moderate BPH. Alpha-adrenergic antagonists include tamsulosin, alfuzosin, terazosin and doxazosin. The American Urology Association (AUA) Guidelines Committee believes that all four medications are equally effective.

5-alpha-reductase inhibitors are more effective in males with larger prostates. Their effect on preventing acute urinary retention and reduction in need of surgery require long term treatment for more than a year. There are two 5-alpha-reductase inhibitors approved in the United States: finasteride and dutasteride.

In males with severe symptoms, those with a large prostate (>40 g), and in those who do not get an adequate response to maximal dose monotherapy with an alpha-adrenergic antagonist, combination treatment with an alpha-adrenergic antagonist and a 5-alpha-reductase inhibitor may be desirable.

In general, if bladder outlet obstruction is creating a risk for upper urinary tract injury such as hydronephrosis, renal insufficiency, or lower urinary tract injury such as urinary retention, recurrent urinary tract infection, or bladder decompensation; surgical intervention is needed. Surgery also should be considered if combination treatment fails to improve symptoms of BPH.

Benign Prostatic Hyperplasia (BPH) Treatment

BPH treatment focuses on relieving symptoms.

Instruct patients to:

Give yourself time to urinate completely.

Do not drink alcohol, drinks with caffeine in them (coffee, tea, colas), or other fluids in the evening. Do not take decongestants like Sudafed.

Do not take antihistamines like Benadryl.

For moderate to severe symptoms (AUA score of 8 or more), prescribe alpha blockers to cause the muscles of the urethra to relax. Side effects of alpha blockers: feeling tired or sleepy.

Studies

Clinical manifestation

Lower urinary tract symptoms (LUTS)

hesitancy urgency weak urinary stream

These symptoms typically appear slowly and progressively over a period of years.

Other conditions with similar symptoms

urinary tract and prostatic infections medication side effects, overactive bladder prostate cancer

Complications of untreated BPH

urinary tract infections acute urinary retention obstructive nephropathy

When evaluating for BPH, perform:

Digital rectal exam should be done to assess prostate size and consistency and to detect nodules, indurations, and asymmetry — all of which raise suspicion for malignancy. Rectal sphincter tone should also be determined.

Urinalysis should be done to detect urinary tract infection and blood, which could indicate bladder cancer or stones. Serum prostate specific antigen (PSA) level determination is recommended for males with a life expectancy of 10 years or longer and for those whose PSA level may influence BPH treatment. This includes most patients who are considering treatment with a 5-alpha reductase inhibitor. This practice should be distinguished from recommendations about utilizing the PSA as a screening test. In this case, the patient actually has symptoms that could represent prostate cancer; screening is only for asymptomatic individuals.

Clinical Reasoning

Differential of Oval-Shaped, Erythematous 18 x 16 mm Patch

Most Likely Diagnoses

Eczema

Eczema can appear erythematous and is often pruritic.

Typically occurs behind the ears and on flexural areas.

Squamous cell

carcinomas

Squamous cell carcinomas are scaly and erythematous but, unlike actinic keratoses, tend have a raised base.

Lesions may take the form of a patch, plaque, or nodule, sometimes with scaling and/or an ulcerated center.

Borders are often irregular and bleed easily.

Unlike basal cell carcinomas, the heaped-up edges of a squamous cell carcinoma are fleshy rather than clear in appearance.

Squamous cell carcinoma comprises 20 percent of all cases of skin cancer.

History of significant sun exposure is a risk factor for squamous cell carcinoma and it typically occurs on areas of the skin that have been exposed to sunlight for many years, such as the extremities or face.

Actinic keratoses

Actinic keratoses are scaly keratotic patches that are often more easily felt than seen.

A history of significant sun exposure is a risk factor for actinic keratosis.

Basal cell carcinomas

Basal cell carcinomas may be plaque-like or nodular with a waxy, translucent appearance, often with ulceration and/or telangiectasia.

Usually there is no associated itching or change in skin color.

Basal cell carcinoma is common on the face and on other exposed skin surfaces but may occur anywhere.

Comprising 60 percent of primary skin cancers, basal cell carcinomas are typically slow-growing lesions that invade local tissues but rarely metastasize.

A long history of sun exposure is a risk factor for basal cell carcinoma.

In the United States, the median age at diagnosis of melanoma is 53, with about one in four new cases

Melanoma

occurring in those younger than 40 years.

Lesions that are growing, spreading or pigmented, or those that occur on exposed areas of skin are of particular concern for melanoma.

Although it comprises only 1 percent of all skin cancers, malignant melanoma accounts for over 60 percent of skin cancer deaths.

The lesions of superficial spreading melanoma are dark brown or black.

Slowly spreading irregular outline in the initial phase. Some areas may be a lighter shade.

Since not all malignant melanomas are visibly pigmented, physicians should be suspicious of any lesion that is growing or that bleeds with minor trauma.

More than half of melanoma in females occurs on the legs.

Sun exposure is a risk factor for melanoma; studies have shown that the prevalence of melanoma increases with proximity to the equator.

Persons with skin types that burns easily and tans with difficulty, and with red or blond hair, and freckles are at higher risk.

Although cumulative sun exposure is linked to nonmelanoma skin cancer, intermittent intense sun exposure seems to be more related to melanoma risk.

Fungal infection

Can have acute, erythematous appearance.

Less Likely Diagnoses

Psoriasis

Psoriasis is usually bilateral and involves extensor surfaces of elbows and knees.

Although psoriasis can present with involvement in patches, it usually plaque-like, with scaly, elevated lesions.

Lichen planus

Lichen planus typically presents as 2-10 mm flat-topped papules with an irregular, angulated border (polygonal papules) that are commonly located on the flexor surface of wrists and and on the legs immediately above the ankles.

Most of the times, the lesions are multiple.

Lichen planus is common in middle age.

Seborrheic keratoses

Elevated hyperpigmented lesions with a well-circumscribed border, stuck-on appearance, and variable tanbrown-black color and are most commonly located on the face and trunk.

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