Transcript Dermatology in Primary Care

Dermatology in Primary Care
Eric J Milie, D.O.
Objectives
Understand the basic terminology used in
naming dermatological conditions
Recognize common dermatological
conditions and implement a treatment plan
for them
Discuss the risk factors for skin cancer, as
well as warning signs necessary for early
detection
Basic Terminology: Primary Lesions
 Macule
 Papule
 Nodule
 Vesicle
 Bulla
 Pustule
 Cyst
 Plaque
 Wheal
Macule
Circumscribed change in skin color without
elevation or depression, less than 1-2 cm
in size
May be result of hyperpigmentation (brown
as in lentigos), hypopigmentation (vitiligo)
or vascular dilation (erythema)
Macule
Papule
Small solid elevation of skin generally < 5
mm in diameter
Majority of the papule elevation projects
above the plane of the surrounding skin.
Papules may be flat-topped, as in lichen
planus; or dome shaped, as in xanthomas;
or spicular, if related to hair follicles.
Papule
Nodule
 Palpable, solid, round, or ellipsoidal lesion
 Depth of involvement and/or palpability
differentiate it from a papule rather than its
diameter (although nodules are usually larger
than papules: > 5 mm diameter)
 Can involve any layer of the skin and can be
edematous or solid
 Based on the anatomical component(s)
involved, there are five types of nodules:
epidermal, epidermal-dermal, dermal, dermalsubdermal, and subcutaneous.
Nodule
Vesicle
 Circumscribed, elevated lesion that is < 5 mm in
diameter containing serous (clear) fluid.
 Vesicle/bulla is the technical term for blisters
 Walls can be so thin that the contained serum,
lymph, blood, or extracellular fluid is easily seen
 Fluid can be accumulated within or below the
epidermis
Vesicle
Bulla
A vesicle with a diameter > 5 mm
Bulla
Pustule
 Superficial, elevated lesion that contains pus
(pus in a blister)
 May vary in size and shape
 The color may appear white, yellow, or greenishyellow depending on the color of the pus
 Pus is composed of leukocytes with or without
cellular debris. It may also contain bacteria or
may be sterile
Pustule
Cyst
An epithelial lined cavity containing liquid
or semisolid material (fluid, cells, and cell
products)
Most common are epidermal cysts, lined
by squamous epithelium and produce
keratinous material
Cyst
Plaque
Palpable, plateau-like elevation of skin,
usually more than 2 cm in diameter and
rarely more than 5 mm in height
Often formed by a convergence of
papules, as in psoriasis.
Plaque
Wheal
Transitory, compressible papule or plaque
of dermal edema
Typically intensely pruritic (result of allergic
reaction)
Wheal
Basic Terminology: Secondary Lesions
Scale
Ulcer
Crust
Erosion
Excoriation
Lichenification
Atrophy
Scar
Scale
 Accumulation or abnormal shedding of horny
layer keratin (stratum corneum) in perceptible
flakes
 The change may be primary or secondary
 Scales usually indicate inflammatory change
and thickening of the epidermis
 The may be fine, as in pityriasis; white and
silvery, as in psoriasis; or large and fish-like, as
in ichtyosis.
Scale
Ulcer
Circumscribed area of skin loss extending
through the epidermis and at least part of
the dermis (papillary).
Ulcer
Crust
Dried serum, blood, or pus on the surface
of skin
May be thin, delicate, and friable or thick
and adherent
Crusts are yellow, if from serum; green or
yellow-green if from pus; or brown or dark
red if formed from blood
Crust
Erosion
Moist, circumscribed, usually depressed
lesion due to loss of all or part of the
epidermis
Often results from eruptions of vesicles
and bullae
Erosion
Excoriation
Linear or punctate superficial excavations
of epidermis caused by scratching,
rubbing, or picking.
Excoriation
Lichenification
Chronic thickening of the skin along with
increased skin markings
Results from scratching or rubbing
Lichenification
Atrophy
Paper-thin, wrinkled skin with easily visible
vessels
Results from loss of epidermis, dermis or
both
Seen in aged, some burns, and long-term
use of highly potent topical corticosteroids
Atrophy
Scar
Replacement of normal tissue by fibrous
connective tissue at the site of injury to the
dermis
Scars may be hypertrophic, atrophic,
sclerotic or hard due to collagen
proliferation
Reflects pattern of healing in the affected
area
Scar
Basics of Therapy
Topical
Systemic
Surgical
Phototherapy
Topical Therapy
The advantage of direct delivery and
reduced systemic toxicity make topical
treatment quite attractive
There is often a vehicle which then
contains an active ingredient
“If lesion is wet, dry it; if dry, wet it”
Topical Therapy: Vehicles
Cream- a semi-solid emulsion of oil-inwater; contains a preservative to prevent
overgrowth of micro-organisms. Stabilized
by an emulsifier. Mostly water so mostly
evaporates; non-greasy so easy
application and removal
Gel – a semi-solid transparent non-greasy
emulsion
Topical Therapy: Vehicles
 Lotion – liquid vehicle, aqueous or alcohol
based, which may contain a salt in
solution. Lotions evaporate to cool the
inflamed/exudative skin
 Ointment – a semi-solid grease/oil, sometimes
also containing powder, but little or no
water. The active ingredient is
suspended. Usually, no preservative
needed. Ointments are best suited for dry skin
disorders – rehydrate and occlude. Because
they are greasy, they are difficult to remove.
Topical Therapy: Vehicles
 Paste – An ointment with a high proportion of
powder which gives a stiff consistency. Pastes
can be applied to well-demarcated lesions. Due
to its ointment base, they are difficult to remove.
 Emollients - Useful in dry-skin disorders due to
their ability to re-establish the surface lipid layer
and enhancing rehydration of the
epidermis. There are several emollient
ointments, creams and oils added to baths.
Topical Therapy: Quantity Needed
The whole body requires 20-30 g of
ointment per single dose. In an adult:
- face or neck – 1 g
- trunk (each side) – 3 g
- arm – 1 ½ g
- hand – ½ g
- leg – 3 g
- foot – 1 g
Topical Therapy: Steroids
Topical steroids are used in a variety of
skin disorders and are frequently
prescribed by primary care physicians.
Classified by strength and fluorination
High potency and fluorinated steroids
should not be used in face or
intertrigenous areas because of their side
effect profiles
Side Effects of Potent Topical Steroids
 Atrophy
 Telangiectasias
 Stria
 Ulceration
 Acneform Eruption
 Hyperpigmentation
 Hypopigmentation
 Hypertrichosis
 Adrenal Axis Suppression
Telangiectasia
Stria
Hypertrichosis
Low Potency Topical Steroids
Hydrocortisone*
Desonide *
Aclomethasone dipropionate (Aclovate)*
Low potency topical steroids can be used
on any portion of the body
* Indicates non-fluorinated topical steroid
Mid Potency Topical Steroids
 Hydrocortisone Valerate (Westcort)*
 Triamcinolone (Kenalog)
 Betamethasone valerate
 Betamethasone dipropionate
 Prednicarvate*
 Hydrocortisone butyrate*
 Hydrocortisone probutate*
 Mometasone furoate (Elocon)
 *Non-fluorinated
Mid Potency Steroids continued
Note that both Triamcinalone and Elocon
are fluorinated steroids
Should not be used on the face!
Triamcinolone frequently used because it
is cheap and efficacious when used
properly
High Potency Topical Steroids
Flucinonide (Lidex)
Desoximetasone (Topicort)
Amcinonide
Halcinonide
Diflorasone diacetate
All fluorinated
Super Potent Topical Steroids
Betamethasone dipropionate (Diprolene)
Diflorasone diacetate (Psorcon)
Halobetasol propionate (Ultravate)
Clobetasol (Temovate)
Should only be used under supervision of
dermatologist
Topical Steroids: General Guidelines
In general, primary care physician should
familiarize themselves with one steroid in
the following classes: low potency
(Hydrocortisone), mid potency nonfluorinated (Westcort), mid potency
fluorinated (Triamcinolone), and high
potency (Lidex or Topicort)
No fluorinated steroid on face or
intertrigenous areas!
Steroid Vehicles
In general, the ointment formulation of a
steroid is stronger than the cream
Use ointments on dry, scaling eruptions
Use creams or gels on moist, weeping
eruptions
Use alcohol based vehicles for the scalp
What is in Lotrisone?
 Combination of clotrimazole (antifungal) and
betamethasone, a moderate to high potency
topical steroid
 Indicated for inflammatory tinea on palms or
soles only
 Lotrisone should not be used in intertrigenous
areas (see side effects slide)
 More reasonable approach is to use antifungal
and Westcort or Hydrocortisone
Systemic Therapy
Indicated for serious dermatological
conditions and infections
Side effect profile not as favorable as
topical treatment
Some dermatological conditions may
require inpatient hospitalization for
intravenous antibiotics, steroids,
antifungals, etc.
Phototherapy and Photochemotherapy
Sunlight (Ultraviolet A and Ultraviolet B)
Ultraviolet B
PUVA therapy
Ultraviolet B
 UVB (290-320 nm) is given 3 times a week
 Initial dose is determined from the patients skin type or
minimal erythema dose (MED)
 With each visit, the scheduled dosage is increased
 Commonly, 10-30 treatments are the normal course
 UVB can be used in children and pregnant women
 May be used in psoriasis, mycosis fungoides, atopic
eczema, and pityriasis rosea
 Side effects include acute sunburn and increase risk of
skin cancer.
PUVA
 UVA alone has minimal effect, thus it is used in combination with
photosensitizing psoralens given topically or systemically
 PUVA stand for Psoralens plus UltraViolet A
 Commonly, oral 8-methoxypsoralens is taken 2 hours before UVA
(320-400 nm). The psoralens is photoactivated, which results in
DNA cross-linking, inhibition of cell division, and suppression of cellmediated immunity
 Like UVB, the initial dose of UVA is determined by MED or skin type;
and dosage is increased a scheduled visits
 PUVA is usually given 2-3 times per week for 15-25 treatments
 PUVA can be combined with acitretin (RePUVA) but not
methotrexate
 Bath PUVA, bath containing a psoralen, is an alternative to
systemic-side effects of oral psoralens
 Local PUVA, topical psoralen, may be effective in psoriasis and
dermatitis involving the hands or feet.
PUVA continued
 PUVA may be given for psoriasis, mycosis
fungoides, atopic eczema, polymorphic light
eruption or vitiligo
 Acute side effects include pruritus, nausea,
erythema; long-term side-effects of premature
skin ageing and skin cancer depend on the
number an total dose of UVA
 Cataracts are possible and UVA-opaque
sunglasses must be worn for 24 hours after
taking psoralen.
Basic Surgical Procedures
Surgical removal is the treatment of choice
for suspicious lesions
Often times only definitive treatment for
several dermatological lesions
Basic Surgical Procedures continued
 Excisional Biopsy
Excision axis depends on skin creases /
Langer’s lines and its margins on the
lesion. Once the skin is numbed with local
anesthetic, the skin is incised vertically down to
the subcutaneous fat with the scapel, in a
smooth continuous manner to complete both
arcs of the ellipse. Using simple interrupted skin
sutures, the wound is apposed and slightly
everted. Absorbable subcutaneous sutures are
used for big excisions.
Basic Surgical Procedures continued
 Incisional Biopsy
Performed for diagnostic purposes. The
technique is comparable to an excision, but less
tissue is taken
 Punch Biopsy
A punch (normally about 4 mm in diameter) is
twisted into the skin: resulting cylinder of skin is
removed and the defect cauterized or sutured.
Basic Surgical Procedures continued
 Shave Biopsy
Used for benign lesions, usually intradermal nevi
or seborrheic keratosis. The lesion is shaved
parallel to and slightly above the skin’s
surface. Cautery may be used to achieve
hemostasis. Skin tags are removed by using
scissors to snip them off followed by
cauterization to any bleeding points.
Basic Surgical Procedures continued
 Curettage
After local anesthetic, the lesion is removed by a gentle scooping
motion with the curette. The base is then cauterized. Curettage
may be used in seborrheic keratosis, pyogenic granulomas,
keratoacanthomas, single facial viral warts, but not nevi.
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Cautery
Provides hemostasis and destroys tissue. The classic cautery
machine has an electrically heated wire and is self sterilizing. Silver
nitrate sticks or 35% aluminum chloride in 50% isopropyl alcohol
provide chemical cautery.
Basic Surgical Procedures continued
 Cryotherapy
Liquid nitrogen (- 196 °C) is delivered by cotton wool bud or spray
gun and injures cells by ice formation. After immersion into liquid
nitrogen, the cotton wool bud is applied to the lesion for 10-15
seconds until a thin frozen halo appears at the base. The spray gun
is used at a distance of 10 mm for a similar amount of time. Longer
freezing times are given for malignant tumors. Blisters may develop
within 24 hours. These are punctured and a dry dressing
applied. Side effect may include hypopigmentation of pigmented
skin, ulceration (especially on the lower legs of the
elderly). Treatment may be repeated in 4 weeks if warranted.
Cryotherapy may be used for viral warts, seborrheic keratosis,
molluscum contagiosum, intraepidermal carcinoma.
Basic Surgical Procedures continued
 Mohs’ Surgery
Excision of malignant tumor which is mapped
and microscopically examined to define its
extent and the completeness of the excision.
 Dermabrasion
A rotating mechanical head wounds the skin
down to the dermis
Basic Surgical Procedures continued
 Laser (Light Amplification by Stimulated Emission of
Radiation)
High intensity light energy is applied to the tissue. Laser
surgery is a rapidly changing field in which new types of
lasers, as well as the conditions amenable to treatment,
are continually being introduced. Lasers vary from a
continuous-wave carbon dioxide laser to a short-pulsed
pigment Q-switched ruby laser. Uses for lasers are
equally varied and include: port wine stain nevi,
telangiectasia, viral warts, some tumors, and tattoos.
Common Dermatological Conditions
Encountered by Primary Care Physicians
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Acne
Eczema
Seborrheic Dermatitis
Psoriasis
Contact Dermatitis
Tinea Corporis
Onychomycosis
Herpes Simplex
Varicella Zoster
Seborrheic Keratosis
Actinic Keratosis
Skin Cancer
Acne Vulgaris
 Follicular disorder that affects susceptible
pilosebaceous follicles, primarily of the face,
neck, and upper trunk, and is characterized by
both non-inflammatory and inflammatory lesions
 Condition of unknown origin; however, multiple
factors are known to contribute to its
pathogenesis and its aggravation
 Acne is not limited to adolescence. 12% percent
of women and 5% of men at age 25 years have
acne. By age 45 years, 5% of both men and
women still have acne.
 Primary lesion is the comedone
Closed Comedone
Open Comedone
Treatment of Acne Vulgaris
Comedones
-Tretinoin (Retin A)*
-Adapalene (Differin)*
-Tazarotene (Tazorac)
*Retinoids
Treatment of Mild Papulopustular Acne
Retinoids: Reverse abnormal
keratinization
Topical Antibiotics
Benzoyl Peroxides: Caution as will bleach
clothing, bed clothes, etc.
Sodium Sulfacetamide
Azelaic Acid
Mild Papulopustular Acne
Treatment of Moderate to Severe
Papulonodular Acne
Tetracycline: Mainstays of treatment
Minocycline: Use in summer
Doxycycline: Photosensitizing
Sulfonamides: If tetracycline allergy
Others (OCPs, spironolactone)
Moderate Acne Vulgaris
Treatment of Severe Cystic Acne
Isotretinoin: Known teratogen, pregnancy
category X. Patient must be on birth
control prior to prescribing the drug, along
with negative pregnancy test. ? Link
between drug and depression.
Severe Cystic Acne
Acne Rosacea
 Common condition affecting skin of face
 Most common presentation is red “flush”
appearance
 Usually occurs initially between 35-50 years of
age, women more than men
 Enlargement of nose- rhinophyma
 No comedones
 May have ocular involvement
 Mainstay of treatment is topical metronidazole
Acne Rosacea
Rhinophyma
Ocular Rosacea
Eczema
 Ill defined erythematous patches with or without
excoriations, lichenification, scale,
hyperpigmentation
 Nummular eczema- round, ill defined
erythematous patches
 Family history of allergies, asthma, or hay-fever
 If present at puberty, most likely life-long
problem
 Men with nummular eczema: Alcohol abuse
Eczema
Nummular Eczema
Treatment of Eczema
 Mild soaps and emoliants: No deodorant soaps
 Topical Steroids: emoliant base
 Antihistamines
 Pimecrolimus cream (Elidel)*
 Tacrolimus (Protopic)*
 Topical or systemic antibiotics in presence of
secondary infection
*Questionable Association with Lymphoma
Seborrheic Dermatitis
Classic lesions are ill-defined, scaling,
erythematous patches in the nasolabial
folds, in the ey brows, on the scalp, and
behind the ears
Other areas potentially affected include
the chest in hairy chested men, the groin,
pubic area, and axilla
Seborrheic Dermatitis
Seborrheic Dermatitis
Seborrheic Dermatitis Treatment
Ketoconazole shampoo
Topical steroids (Gel or alohol based for
the scalp)
Non-fluorinated topical steroids for face
and ears
Anti-fungal or anti-yeast cream for skin
involvement
Tacrolimus or pimecrolimus
Psoriasis
Classic lesions are well defined,
erythematous, thickly scaling plaques
Areas of predilection include elbows,
knees, gluteal cleft, sacrum, and scalp
Koebner phenomenon- development of
lesions in areas of trauma
Nail involvement with pitting, onycholysis,
subungal keratosis, and oil spots
Psoriasis
Psoriasis
Koebner Phenomenon
Psoriasis- Nail Involvement
Psoriasis Treatment
 Topical steroids
 Calcipotriene (Dovonex): Associated with kidney
stones
 Tazarotene (Tazorac)
 Anthralin
 UVB, PUVA
 Acitretin (Soriatane): Teratogen, liver toxicity
 Methotrexate, cyclosporin
Tinea Corporis
 Superficial dermatophyte infection of the skin of
the trunk and extremities
 A pruritic annular plaque is characteristic of a
symptomatic infection
 Occurs in all age groups, adolescents most
common
 Immunosuppressed population may get most
severe symptomatology
 The most common cause of tinea corporis
worldwide and in the United States is T rubrum
Tinea Corporis
Tinea Corporis Treatment
Topical clotrimazole, itraconozole, or
ketoconazole for localized infections
Nystatin and mycostatin treat tinea only
Consider systemic agents for more
generalized infections
Onychomycosis
 Fungal infection of the toenails or fingernails
 May involve any component of the nail unit,
including the nail matrix, the nail bed, or the nail
plate
 Affects men>women, adults>children
 6-13% of U.S. adult population
 Usually asymptomatic; therefore, patients
usually first present for cosmetic reasons without
any physical complaints
Onychomycosis
Onychomycosis Treatment
 Document infection by culturing a true
dermatophyte
 Consider systemic treatment with itraconazole
(Sporanox) or terbinafine (Lamisil)
 Black box warning with Sporanox and CHF
patients
 Beware drug interctions, liver toxicity
 Consider topical treatments
 Nails positive for candidia can be treated with
topical antifungals or itraconazole
Contact Dermatitis
Characterized by triad of:
1. Erythema
2. Edema
3. Vesiculation
• Treatment consists of removing offending
agent, steroids (systemic and or topical),
and antihistamines or emolians for
symptomatic relief
Contact Dermatitis
Contact Dermatitis
Contact Dermatitis
Herpes Simplex
Recurrent history of grouped vesicles on
an erythematous base in the same general
location
Lesions usually preceded by a prodrome
of burning or stinging
Herpes Simplex
Herpes Simplex
Treatment of Herpes Simplex
Acyclovir 200mg 5 times a day for 5 days
Valacyclovir 2g BID for 1 day
Famciclovir 125mg BID for 5 days
Suppression of Herpes Simplex
Acyclovir 200mg TID
Valacyclovir 500mg-1g QD
Famciclovir 250mg BID
Herpes Zoster
Grouped vesicles on an erythematous
base following a dermatomal distribution
Prodome of pain, burning, or stinging is
common
Complications of Herpes Zoster Infection
 Secondary infection
 Dissemination
 Encephalitis
 Pneumonitis
 Transverse myelitis
 Post-Herpetic neuralgia
 Motor paralysis
 Gangrenous zoster- immunocompromised host
Herpes Zoster
Complications of Herpes Zoster Involving
the Face
Post-herpetic neuralgia, especially with
ophthalmic zoster
Granulomatous angiitis of cerebral vessels
Keratitis, scleritis, uveitis, glaucoma,optic
neuritis, and others
Ramsay-Hunt syndrome: vertigo, tinnitus,
ipsilateral hearing loss, and facial paresis
Herpes Zoster Ophthalmicus
Treatment For Herpes Zoster
 Analgesics
 Compresses
 Antivirals
-Acyclovir 800mg 5x/day for 7-10days
-Famciclovir 500mg TID for 7 days
-Valcyclovir 1g TID for 7 days
*Immunocompromised patients may require
inpatient treatment with IV Acyclovir
Seborrheic Keratosis
Raised growths on the skin
Seborrheic-greasy; keratosis-growth
Waxy appearance, “stuck on”
No malignant potential, no relationship to
sun exposure
May become irritated from catching on
clothing
Seborrheic Keratosis
Actinic Keratosis
 Most common premalignant lesions in humans
 The incidence is much higher in the Sun Belt and is
directly related to light skin and sun exposure
 Lesions are erythematous, scaly plaques that measure
3-10 mm in diameter
 Incidence is much higher in individuals with fair skin and
blue eyes and is lower in individuals with darker skin
types
 Distribution of actinic keratoses is related to sun
exposure and skin type
 Can occur in patients aged 20-30 years but are more
common in patients aged 30-60 years.
Actinic Keratosis
Skin Cancer
Basal Cell
Squamous Cell
Melanoma
Basal Cell Carcinoma
Most common form of skin cancer
Arise in the basal cells, in the bottom layer
of the epidermis
Chronic exposure to sunlight is the major
cause, and lesions arise on sun exposed
areas of the body
Men > women, fair skin > dark skin
Slow growing and rarely metastasizes, but
can cause significant local destruction
Five Warning signs of BCC
1.
2.
3.
4.
5.
An Open Sore that bleeds, oozes, or crusts and remains open for three
or more weeks. A persistent, non-healing sore is a very common sign of
an early basal cell carcinoma.
Reddish Patch or irritated area, frequently occurring on the chest,
shoulders, arms, or legs. Sometimes the patch crusts. It may also itch or
hurt. At other times, it persists with no noticeable discomfort.
A Shiny Bump or nodule, that is pearly or translucent and is often pink,
red, or white. The bump can also be tan, black, or brown, especially in
dark-haired people, and can be confused with a mole.
A Pink Growth with a slightly elevated rolled border and a crusted
indentation in the center. As the growth slowly enlarges, tiny blood
vessels may develop on the surface.
A Scar-like Area which is white, yellow or waxy, and often has poorly
defined borders. The skin itself appears shiny and taut. Although a less
frequent sign, it can indicate the presence of an aggressive tumor.
Basal Cell Carcinoma
Basal Cell Carcinoma
BCC: Treatment
 Surgical:
 Curretage
 Surgical excision
 Mohs procedure
 Cryosurgery
 Antineoplastic Agents:
 5-FU
 Imiquimod (Aldara)
 Interferon α-2b
Squamous Cell Carcinoma
 Second most common skin cancer
 Occur on all areas of the body including the
mucous membranes, but are most common in
areas exposed to the sun
 Rarely metastasize, but metastatic disease can
be fatal
 Sun is major cause, but also in areas of injured
skin, ie scars, burns, radiation injuries, etc
 Relationship between SCC and actinic keratosis,
actinic chelitis, leukoplakia, and Bowen’s
disease
Warning Signs for SCC
1. A wart-like growth that crusts and occasionally
bleeds
2. A persistent, scaly red patch with irregular
borders that sometimes crusts or bleeds
3. An open sore that bleeds and crusts and
persists for weeks
4. An elevated growth with a central depression
that occasionally bleeds. A growth of this type
may rapidly increase in size
Squamous Cell Carcinoma
Squamous Cell Carcinoma
SCC Treatment
Medical therapy: early disease,
antineoplastic agents
Radiotherapy
Chemotherapy
Surgical resecttion
Neck dissection
Malignant Melanoma
 Melanoma is a malignancy of pigment-producing cells
(melanocytes) located predominantly in the skin, but also
found in the eyes, ears, GI tract, leptomeninges, and oral
and genital mucous membranes
 Accounts for only 4% of all skin cancers; however, it
causes the greatest number of skin cancer–related
deaths worldwide
 The incidence of melanoma has more than tripled in the
white population during the last 20 years, and melanoma
currently is the seventh most common cancer in the
United States
 Responsible for more than 77% of skin cancer deaths ;
one death from melanoma every hour in the U.S.
Melanoma: ABCDEs
Asymmetry
Border (Irregular)
Color
Diameter (Greater then 6mm)
Evolving
Stage
TNM Class
Histology
5 year
survival
0
Tis N0 M0
Intraepithelial/in situ melanoma
100
IA
T1a N0 M0
<1 mm without ulceration and level II/III
>95
IB
T1b N0 M0
T2a N0 M0
<1 mm with ulceration or level IV/V
1.01-2 mm without ulceration
89-91
IIA
T2b N0 M0
T3a N0 M0
1.01-2 mm with ulceration
2.01-4 mm without ulceration
77-79
IIB
T3b N0 M0
T4a N0 M0
2.01-4 mm with ulceration
>4 mm without ulceration
63-67
IIC
T4b N0 M0
>4 mm with ulceration
45
IIIA
T1-4a N1a M0
T1-4a N2a M0
Single regional nodal micrometastasis, nonulcerated primary
2-3 microscopic positive regional nodes, nonulcerated primary
63-69
IIIB
T1-4bN1a M0
T1-4bN2a M0
T1-4a N1b M0
T1-4a N2b M0
T1-4a/b N2c M0
Single regional nodal micrometastasis, ulcerated primary
2-3 microscopic regional nodes, nonulcerated primary
Single regional nodal macrometastasis, nonulcerated primary
2-3 macroscopic regional nodes, no ulceration of primary
In-transit met(s)* and/or satellite lesion(s) without metastatic lymph nodes
46-53
IIIC
T1-4b N2a M0
T1-4b N2b M0
Any T N3 M0
Single macroscopic regional node, ulcerated primary
2-3 macroscopic metastatic regional nodes, ulcerated primary
4 or more metastatic nodes, matted nodes/gross extracapsular extension,
or in-transit met(s)/satellite lesion(s) and metastatic nodes
24-29
IV
Any T any N M1a
Any T any N M1b
Any T any N M1c
Distant skin, subcutaneous, or nodal mets with normal LDH levels
Lung mets with normal LDH
All other visceral mets with normal LDH or any distant mets with elevated
LDH
7-19
30-50
Malignant Melanoma
Malignant Melanoma
Malignant Melanoma: Treatment
 Medical Care: Numerous adjuvant therapies have been
investigated for the treatment of localized cutaneous
melanoma following complete surgical removal. No
survival benefit has been demonstrated for adjuvant
chemotherapy, nonspecific (passive) immunotherapy,
radiation therapy, retinoid therapy, vitamin therapy, or
biologic therapy
 Surgical Care: Mainstay of therapy
 Elective lymph node dissection
 Sentinel node biopsy/ dissection: Sentinel node status
(positive or negative) is the most important prognostic
factor for recurrence and is the most powerful predictor
of survival in melanoma patients
Question 1:
 A 70 year old male patient presents to your
office for a routine check-up. When examining
him, you note the following lesion on his back,
which measure 9mm in diameter (see next
slide). He states that this lesion has been there
“for years,” but thinks that it may have gotten
larger in the past 1-2 years. He states that the
lesion never bothered him, in fact, he gave it
very little thought over the years. After
completing your physical exam, what is the most
appropriate next step in the management of this
patient?
Question 1 continued
A. Observe the lesion for now, see the
patient back in six months for a follow up
appointment
B. Refer the patient to a surgeon for
excision with wide margins
C. Do a scrape biopsy in the office
D. Do nothing; this is a benign lesion and
treatment should be withheld until the
lesion is symptomatic
Question 2
 An 85 year old male presents to your office for
evaluation of a rash on his forehead (see next
slide). The rash began approximately eight days
ago. The emergence of the rash was preceded
by two to three days of burning pain, followed by
a vesicular eruption. He states that the pain is
now 10/10, and he note blurred vision and
decreased hearing in the effected side. Your
next best step in the management of this patient
is:
Question 2 continued
A. Start the patient on Acyclovir 800mg to be
taken five times daily. Follow up in
approximately one week to check his progress
B. Prompt referral to ophthalmologist for
evaluation of possible corneal involvement
C. Give the patient a prescription for an oral
analgesic, as the rash has been present for too
long to treat with antivirals
D. Instruct the patient to use a hot compress on
his eye, ibuprofen or acetaminophen for pain,
and reassure him that this ailment will pass
within the next week or so.
Question 3
 A sixteen year old female presents to your clinic
because of “acne.” She states she has tried
numerous over the counter products with little
effect. She states that she is sexually active, but
her boyfriend and her use condoms “almost
every time (they) have sex.” On physical exam,
you note cystic acne on the fact and trunk, with
both open and closed comedones. Which of the
following is NOT an appropriate treatment in this
patient?
Question 3 continued
A.
B.
C.
D.
Tertacycline
Oral contraceptive pill
Benzoyl peroxide
Isoretinoin
Works Cited
http://bmj.bmjjournals.com/index.dtl
http://www.blackwellscience.com/products/journals/BJD.HTM
http://dermatology.cdlib.org/
http://www.eblue.org/