Psoriasis and Skin Cancer

1. Psoriasis and Skin Cancer Edward Pritchard

2. Long Cases • You could get these! • Last year’s finals! - Patient with recurrent SCC, with no symptoms. History focussing on skin exposure and social. Was asked about risk factors, macroscopic and microscopic appearance of different types of skin cancer and different treatments

3. Skin Examination • ScalpAuriclesFaceExtremities (upper) Chest (front and back)Abdomen (front and back)GenitaliaExtremities • If lesions – consider local lymph nodes etc.

4. Psoriasis

5. Definition • Relapsing and remitting chronic skin condition characterised by scaly plaques • Or inflammation of the dermis, with epidermal hyperproliferation

6. Epidemiology • ~2% of the population • Peak incidence in early 20s and 50s Precipitated by infection, drugs (antimalarials, B-blockers, lithium), sunlight, stress, scars, burns

7. Pathophysiology Immune mediated leads to increased speed of skin turnover (28 days to 4), causes thickening of the epidermis.

8. Symptoms and Signs Typically well demarcated red, scaly, symmetrical, non itchy plaques • 5 main presentations

9. Plaque – typically on extensor surfaces and scalp

10. Guttate – small eruptions over trunk – typically 2 weeks post B streptococcal throat infection

11. Pustular – widespread sterile pustules

12. Flexural – affects flexural aspects

13. Erythrodermic – extreme form affecting 90%+ of body – can be fatal

14. Management Conservative – diet, weight loss, smoking cessation, exercise advice Medical Topical • Emolients • Vitamin D analogues • Topical steroids (mild to moderate) • Coal tar • Salicylic acid Phototherapy • UVB • PUVA ( Psoralen + UVA) Systemic • Immunosuppresent – Methotrexate, ciclosporin • Biologics – Infliximab, Adalimumab Surgical – no real role

15. Skin Cancer

16. Aetiology/Risk Factors • Squamous cell – UV light exposure (sunbathing), fair skin, radiation exposure, carcinogens, metastasise quickly • Basal Cell – UV light exposure, radiation exposure, arsenic exposure, “never” metastasise – local tissue destruction • Malignant melanoma – UV light exposure, metastasise rapidly

17. Symptoms and signs • Squamous cell – rapidly enlarging lesion, ill defined (variable), pink colouration, may have ulceration, scaling, bleeding or weep • Basal cell – slow growing lesion, well demarcated papule, raised rolled pearly edges with central depression • Malignant melanoma – a new or changing mole.

18. Squamous Cell Carcinoma • ~20% of cutaneous malignancies • ~70% on head or neck • Premalignant conditions (Bowen’s disease, actinic Keratosis) • 95% cure rate with excision if localised disease. But metastasises rapidly to lymph with poor outcome

19. Basal Cell Carcinoma

20. Malignant Melanoma • Asymmetrical • Border irregularity • Colour variation • Diameter >6mm • Evolution

22. Investigations Biopsy/Excisional biopsy (Breslow depth, Clark level – for melanoma) Stage – CT/PET

23. Tx + Prognosis Management • Conservative – reduce risk factors, smoking cessation • Medical – if for chemotherapy • Surgical – excision biopsy +/- lymph node resections Prognosis • Basal cell – very good, fatality rare • Squamous cell – poor • Malignant melanoma – poorer (often metastasised at presentation)

24. Questions • Thanks