Transcript Module 2 - 10.97 MB

“THE SKIN SHOW”
Aging Dermatology and Disease
Module #2
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
981320 UNMC
Omaha, NE 68198-1320
[email protected]
Web: geriatrics.unmc.edu
402-559-7512
All photos were reprinted with permission from the American Academy of
Dermatology. All rights reserved.
Slides adapted with permission from GRS 5th edition: Dermatologic diseases and disorders
PROCESS
Series of 4 modules and questions on
Etiologies, Evaluation, & Management
Step #1 Power point module with voice
overlay
Step #2 Case-based question and answer
Step #3 Proceed to additional modules or
take a break
Objectives
Upon completion the learner will be able to;
1) List the normal age related skin changes
2) Identify and treat the common skin
disorders of aging
3) Identify malignant versus non malignant
skin conditions in aged
PHOTOAGING
The effects of UV exposure
on skin
• Shorter wavelengths are more
biologically active (UVA and UVB)
• UV light causes:
• DNA damage
• Decreased DNA repair
• Oxidative and lysosomal damage
• Altered collagen structure
PHOTODAMAGED SKIN
• Appears wrinkled,
coarse, or rough
• Has mottled
pigmentation,
hypopigmentation,
telangiectasias
PREVENTING
PHOTODAMAGE
• Use broad-spectrum sunscreens:
SPF 15 or greater
• Avoid direct sunlight ( especially 10am -2 pm)
• Use protective clothing, including hats
• Use sunglasses
TREATING
PHOTODAMAGE:
TOPICAL AGENTS
• Only agent shown to be effective: topical
retinoin used at high concentrations for
long periods
• Increases thickness of superficial skin layers
• Reduces pigmentary changes and roughness
• Increases collagen synthesis
• Claims that other agents decrease
photodamage are not well-substantiated
PHOTODAMAGED SKIN
1) Actinic keratosis &
cutaneous
malignancies more
common
2) Source of term “red
neck”
3) What is the
erythematous lesion
with central white
scale behind his ear?
Answer:
ACTINIC KERATOSES
• macular
• hyperkerototic scale
overlying erythematous brown macules
• Scale; dry, hard, rough
• on sun-exposed skin from
chronic UV radiation
• premalignant.
Alias: solar keratoses,
• “better felt than seen”
Used with permission images.MD.
ACTINIC KERATOSES
Considered premalignant, but
majority resolve without
treatment
Up to 20% progress to
squamous cell cancer
Prevention: See PREVENTING
PHOTODAMAGE
Treatment:
• Cryotherapy with
liquid nitrogen
• Topical 5-fluorouracil
• Excision
used with current mission from images.M.D.
What is the lesion on his shoulder?
Answer:
SQUAMOUS CELL
CARCINOMA
Description
Chronic erythematous
papules, plaques, or
nodules with scaling,
crusting, or ulceration
•
Affects people in mid-to-late life
•
Occurs most commonly in
chronically sun-exposed areas
•
Second most common form of
skin cancer
•
Propensity to occur in
longstanding nonhealing
wounds and in burn and
radiation scars
TREATMENT OF
SQUAMOUS CELL
CARCINOMA
• Surgical excision
• Mohs’ micrographic surgery in
cosmetically important areas
• Cryotherapy or local radiation for
patients unable to tolerate
surgery
What’s this?
Answer:
Basal cell
carcinoma
Nodular: most common
• pearly, fleshy, waxy
papule
• can be ulcerated in the
center
• has a characteristic rolled
border
• rarely pigmented
• can have overlying
telangiectasias
MAJOR CLINICAL PATTERNS OF
BASAL CELL CARCINOMA
Clinical Pattern
Nodular
Morpheaform
Superficial
Description
Most common variant: waxy,
translucent papule with overlying
telangiectasias
Scar-like appearance: can look
atrophic
Erythematous macule or papule
with fine scale or superficial
erosion
•
BASAL CELL
CARCINOMA
Most common cancer in United States
• Risk factors: Fair skin, chronic sun exposure
• Prevention: Sun protection, regular skin examinations
Treatment:
• Surgical excision
• Mohs’ micrographic surgery may be needed to ensure adequate
excision and tissue sparing
• When surgery is not feasible, it can also be treated with ablative
methods such as cryosurgery, radiation, curettage with
electrodesiccation
What’s this?
Answer:
MELANOMA
A-B-C-D mnemonic for MM
A symmetric shape &
border
B order irregular, blends
into normal skin
C olor: variation in
pigment (shades of
brown and blue-black)
D iameter ( usually > 6 mm
MELANOMA
• Incidence is increasing; affects adults of all ages
• Risk factors: fair skin, family history, dysplastic or
numerous nevi, sunlight exposure
• Prevention: Sun protection, regular skin
examinations and early recognition are key for
favorable prognosis
• Most common sites: Males: head, neck, trunk.
Females: distal lower extremities
• Treatment: surgical excision, possibly lymph node
dissection or adjuvant therapy
What’s this?
Answer:
ACRAL LENTIGINOUS
MELANOMA
• dark macular growth
• irregular borders
• volar surfaces of
palms, soles and nails.
• more common in
women
The End of “Skin Show”
Module Two
Post-test
• A 76-year-old man has an erythematous,
unpigmented, scaly lesion with a central
crust on the forearm. The lesion is 1 cm in
diameter and has irregular borders. The scab
has come off several times over the past
year. The skin on the dorsum of both hands
and forearms has irregular pigmentation and
numerous areas of roughness. Which of the
following is the most likely diagnosis?
Which of the following is the most
likely diagnosis?
A.
B.
C.
D.
E.
Basal cell carcinoma
Cutaneous horn
Keratoacanthoma
Melanoma
Squamous cell carcinoma
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Answer; E. Squamous cell
carcinoma
• This patient’s skin disorder is most likely the result of
damaging exposure to the sun. The numerous rough areas
surrounding the lesion are most likely actinic keratoses,
which are common premalignant skin lesions that can
progress to squamous cell carcinoma. A lesion that is
characterized by erythema and a nonhealing ulcer in a sunexposed area is most likely squamous cell carcinoma.
These lesions begin as thin erythematous patches and
progress to nonhealing ulcers. This patient should undergo
excisional biopsy. Treatment of the premalignant lesions
with 5-fluorouracil cream should be considered. In patients
with fewer actinic keratoses, application of liquid nitrogen
to the affected areas is appropriate. This patient is at risk
for other skin malignancies and should have annual skin
examinations.
• Basal cell carcinoma is characterized by a firm,
rolled telangiectatic border. Malignant melanoma
is a pigmented lesion that would not have a
scaling appearance or ulceration.
Keratoacanthomas are pseudo-cancerous lesions
that have a nodular appearance with a verrucous
central portion. These lesions develop rapidly,
have a tendency to spontaneously involute, and
would not be present for 1 year. A cutaneous horn
has a hornlike appearance and may resolve
spontaneously or contain a squamous cell
carcinoma at its base. end