Transcript Psyche-Spots-Cancer 2016

Psyche: Spots:Cancer
November 2016
The Objectives
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As on the programme.
Take a multidisciplinary approach.
Relax.
Have time to think.
Enjoy the learning.
LEARN THE HOT TIPS
What’s your experience of the
psychology of skin disease?
What is the Origin?
• Having good skin is an attribute required for
beauty.
• Is this just for women?
• The maintenance creates enormous pressure
Hot Tip
• The level of psychological distress is not
necessarily proportional to the level of skin
disease.
• A small patch may be all that it takes.
So What Happens?
• The link between stress and exacerbation of
skin disease has been confirmed.eg. People
with vitiligo notice more patches and eczema
may get worse.
• The change causes an increasing fear of
rejection.
• The result is increased anxiety, depression and
the potential vicious cycle.
Hot Tip
• Many people with chronic skin disease have
never been asked about the psychological
aspects of their skin problem
Hot Tip
• Don’t forget delusional parasitosis
The Facts
• Acne is the most common skin condition seen
in the developed world.
• It is the 8th most prevalent disease worldwide.
• Most 15-17 year olds will have it and 20% will
be classified as moderate to severe.
• It is linked to puberty.
• 40% will have acne in their thirties
• It is more severe in male teenagers
Hot Tip
• Acne is associated with a significant level of
psychological morbidity
Risk Factors
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A FH doubles the risk
Diet ??
Over-exposure to sunshine
Drugs eg. Phenytoin, steroids, oral
contraceptives, depo-contraception, Mirena
• Excess androgen states eg. PCOS, congenital
adrenal hyperplasia
Hot Tip
• Always ask about medication and remember
that ‘The Pill’’ may not be considered a
medication!
Drug Induced Acne
• eg. Phenytoin, steroids, oral contraceptives,
depo-contraception, Mirena, lithium,
ciclosporin,
Excess Androgen States
eg. PCOS, congenital adrenal hyperplasia
What is the Underlying Mechanism?
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Increased sebum production
Hyperkeratosis of the pilosebaceous duct
Colonisation with P. acnes (bacteria)
Release of inflammatory substances eg.
Cytokines.
• Overall, chronic inflammation of the
pilosebaceous unit
So What Are The Lesions in Acne?
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So What Do Pharmacists Do?
WWHAM
Hot Tip
These Stand For
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W-Who is the preparation for?
W-What are the symptoms?
H-How long have the symptoms been present
for?
A-Action already taken?
M-Medication being taken
Add further ‘M’ for impact on mental health
Severity Guideline
Mild
<20 comedones or
<15 inflammatory lesions
Total count <30
Severity Guideline
Moderate
20-100 comedones or
15-50 inflammatory lesions
Total count 30-125
Severity Guideline
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Severe
>5 cysts or
Comedomes >100 or
Inflammatory lesions >50 or Total lesion count
>125
Hot Tips-Promoting Self-Care
Tell them not to pick or squeeze
Apply treatment regularly and be patient
Use gentle cleansers not harsh treatments
Avoid the hair being greasy and keep away from
forehead
Make-up is OK and try oil-free products.
What’s Available OTC?
OTC Products
• Benzoyl Peroxide-reduces bacteria but may
dry the skin so moisturise and perhaps apply
alternate days. Start low strength 2.5% eg. Oxy
10, Quinoderm
• Nicotinamide-anti-inflammatory managing
redness and tenderness eg. Nicam gel,
Freederm Treatment gel
• Salicyclic acid helps to promote shedding of
cells when acne not inflamed eg. Acnisal 2%
OTC Products
• Antiseptics/Antimicrobials act to reduce the
impact of bacteria-inflammation eg. Clearasil
Cream Wash, Quinoderm Face Wash
• Phycosaccharide AC-brown seaweed extract ?
reduces sebum production and bacteria
• Light Therapy-blue light or (blue/red light)
aims to kill P. acnes. May take time to work
and has to be maintained.
Management in Practice
Hot Tips
• The primary aim of treatment is to stop
scarring or at least keep it to a minimum.
• Nodular acne should be referred straightaway
Topical Treatments
• Comedomal acne-Retinoid eg. Adapalene,
isotretinoin or adapalene/BPO
• Papulo-pustular acne-add in BPO
eg.adapalene/BPO or clindamycin/BPO or
Clindamycin/tretinoin
Hot Tip
• Topical antibiotics are less effective against
non-inflammatory acne and cause resistance.
Combine with benzoyl peroxide (Duac)
• Topical retinoids may exacerbate acne when
first commenced eg adapalene, isotretinoin
Hot Tip
• There is increasing resistance to erythromycin
• Serial photographs will help to monitor
progress
Oral Antibiotics
• For severe acne
• Acne that doesn’t respond to topical
treatments
• Acne on the trunk
• Lymecycline first choice. Can try doxycycline
• Erythromycin
• Trimethoprim
Hot Tip
• Doxycycline may cause significant upper GI
symptoms eg. Oesophageal ulceration.
• Watch for phototoxic reactions
Sun Care
What Do You Do To Promote
Awareness?
Malignant Melanoma (C43): 1979-2013
European Age-Standardised Incidence Rates per 100,000 Population, by Sex, Great Britain
Source: cruk.org/cancerstats
You are welcome to reuse this Cancer Research UK statistics content for your own work.
Credit us as authors by referencing Cancer Research UK as the primary source.
Suggested style: Cancer Research UK, full URL of the page, Accessed [month] [year].
Malignant Melanoma (C43): 2011-2013
Average Number of New Cases Per Year and Age-Specific Incidence Rates per 100,000 Population, UK
Source: cruk.org/cancerstats
You are welcome to reuse this Cancer Research UK statistics content for your own work.
Credit us as authors by referencing Cancer Research UK as the primary source.
Suggested style: Cancer Research UK, full URL of the page, Accessed [month] [year].
Malignant Melanoma (C43): 2002-2006
Five-Year Relative Survival (%) by Stage, Adults Aged 15-99, Former Anglia Cancer Network
Please include the citation provided in our Frequently Asked Questions when reproducing this chart: http://info.cancerresearchuk.org/cancerstats/faqs/#How
Note: Relative survival can be greater than 100% because it accounts for background mortality. A relative survival figure greater than 100 indicates that people
diagnosed have a better chance of surviving one (five) year(s) after diagnosis than the general population.
Prepared by Cancer Research UK
Original data source:
The National Cancer Registration Service, Eastern Office. Personal communication.
http://ecric.org.uk/
Skin Cancer
Risk Factors
• Solar radiation
• Sun beds (melanoma ,actinic keratosis
possibly SCC)
• Azathioprine (SCC
• Ciclosporin
• Genetics
Hot Tip
• Basal cell carcinomas (BCC, rodent ulcer) grow
slowly- 2-3mm/year
• They may be multiple so a full skin survey
should be completed
• They may show blood on the surface
Hot Tip
• Superficial spreading BCCs are becoming more
common
Hot Tip
• Don’t be afraid to feel the lesion. If it feels
inappropriately hard or ill-defined then be
suspicious.
Actinic Keratosis
• The result of long-term sun exposure
• Scaly crusty lesions on areas exposed to light
• Graded according to character and thickness
Yes
No
No
Make every contact count:
Smoking status
Alcohol consumption
BMI / physical inactivity /poor diet
Dangerous sun/UV exposure?
BMI ≥30, <150 mins PA / wk
Does the patient have one of the below?
Is it a non-healing lesion >6 weeks
Single lesion pathway
Smoker
>14 units/wk♀ >21 units /wk♂
No
New mole after onset of puberty
Changing mole – size, shape, colour
Lifestyle
advice
Is it a pigmented lesion?
KEY:
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Y
Questions for GP to ask
Urgent referral
Routine referral
Public health intervention
Audio-visual aids for patient and GP
Reassurance, information,
self-surveillance and
sunscreen advice
History - assessment of risk factors
• Fitzpatrick skin type
• Family history of skin cancer
• Level of UV exposure - episodes of • Immunosuppressed
sunburn / sunbed use
• Multiple naevi
• Personal history of skin cancer
Examination - Does the patient have any red flags?
Suspected melanoma Glasgow 7-point checklist
Lesions scoring 3 points or more are suspicious
Major features – 2 points each Minor features – 1 point each
Change in size
Irregular shape
Irregular colour
Yes
Fitzpatrick
skin type
Pictures of
SCCs and
melnanom
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Unsure
Diameter 7mm or more
Inflammation
Oozing
Change in sensation
Suspected squamous cell carcinoma (SCC) - enlarging non healing, scaly or
crusted area of skin or lump, often tender and commonly occurring on sunexposed sites
No
Is the lesion:
Pigmented?
-eg seborrhoeic keratosis, Pigmented basal cell carcinoma
Vascular?
-eg haemangioma
Crusted / scabbed/ulcerated?
-eg basal cell carcinoma, seborrhoeic keratosis, viral wart
Photographs of
most common
differential
diagnoses
Urgent Referral to Rapid Access Skin Cancer Clinic
Suspected malignant melanoma or squamous cell carcinoma
- refer as per 2 week cancer referral guidelines
Refer to dermatology triage
Suspected
Melanoma/ SCC
Suspected BCC
Benign lesion
2 week wait
referral
Fast track to
minor ops list for
biopsy
Refer back to GP
with advice
Useful links for
differential
diagnosis
Yes
Reassurance, information, selfsurveillance and sunscreen advice
Are you confident in your diagnosis and confident it is benign?
No
Refer to dermatology triage
Suspected
Melanoma/ SCC
Suspected BCC
Benign lesion
2 week wait
referral
Fast track to
minor ops list for
biopsy
Refer back to GP
with advice
Yes
Watchful waiting
review 8 weeks
Patient with persistent or slowly
evolving unresponsive skin conditions in
which the diagnosis is uncertain
Squamous Cell Carcinoma
• Risk Factor-exposure to sunlight
• Age
Melanoma
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4 types
Superficial spreading
Nodular
Lentigo maligna (face ad neck)
Acral melanoma (palms, soles, under nails)
Risk Factors
• High risk-strong family history and large
congenital naevi
• Moderate-Organ transplants, large number of
moles (atypical naevus syndrome)
• Slight increased rsik-Fh, skin that burns easily,
• Red/blonde hair
Hot Tip
• Most melanomas start de novo
EFG
• E-Elevation
• F-Firmness
• G-Growth (in the last 4-8 weeks)
Quiz