Zero to GP - GP Revision Podcast

Skin Lesions - Essential GP Revision

• Thomas Watchman • Season 1 • Episode 12

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0:00 | 17:43
SPEAKER_00

Hi, this is Tom, and welcome back to the Zero to GP podcast. In this episode, we're going to be going through skin legions, and ideally, you can watch this as a YouTube video, in which case you can see illustrations of the skin legions. But for this podcast episode, I'll do my very best for trying by trying to describe what you're seeing with these skin legions. The format, as always, is going to be a question-answer explanation format. So I'll present the case and the skin legion, ask you questions. Your job is to come up with your answer, ideally say it out loud or write it down, and then we'll go through an explanation. If you're preparing for your AKT exam, the ideal bundle for AKT revision preparation is the AKT revision book from Zero2GP plus the zero2gp.com website where you can find practice questions, short answer questions, a fact trainer tool, and digital flashcards, as well as all the notes. So that's the ideal bundle. And if you can add on to that the AKT revision course, which I host myself and happens about twice a year. So have a look and see if there's a course available, but I definitely recommend the revision book and the zero to gp.com site. So let's get straight into this episode on skin lesions. So my first case for you is a 60-year-old woman, and she comes in because she's got this skin lesion for about eight weeks, and it's growing and changing. It's not really healing, it's kind of uh crusty and nasty, so she wants to get it checked out. So you can see the skin lesion is kind of an irregular, crusty, red, um, irritated, ulcerated lesion. So looking at the skin lesion, what's your suspected diagnosis? In this situation, I would be suspecting a squamo cell carcinoma. So this is a type of skin cancer. Um and the next question is what's the origin for this type of skin cancer? Where does where do squamocell carcinomas of the skin originate? They originate from the keratinocytes in the epidermis of the skin. The next question is: what are you gonna do with this patient?

SPEAKER_01

How are you gonna manage her?

SPEAKER_00

So squamous carcinoma is a type of skin cancer. It can be quite rapidly growing, it will invade the local tissues, can cause quite significant problems, and rarely it can metastasize. So this is a concerning thing, and she needs a two-week weight referral to dermatology, and she'll be managed on the suspected cancer pathway, she'll need a biopsy and removal of the skin lesion or treatment, and so on. Okay, next let's move on to the next skin lesion. This is a 58-year-old man, and he's had this skin lesion for about six months, and it's on his upper back. And let's say his wife told him he needs to go and get it checked out because it looks a bit funny. So here you can see it's kind of uh a round lesion, quite clear borders. It's slightly raised with a flat top and a brown colour and a kind of bumpy surface. In this situation, what's your suspected diagnosis? So this lesion is sebraic keratosis, also known as a sebreic wart. And this is probably the most common type of skin lesion that I see in clinical practice where patients come in and they're worried, could this be cancer? It's a newish kind of skin lesion, but all very often it's a sebreic keratosis or sebreic wart. The next question is what are the key features that would make you think of sebreic keratosis as the diagnosis? So the key features that you can see in this lesion are it's well defined, so you can clearly see where the borders are, the difference between the lesion and the normal skin. They can be raised or flat, and the surface on the top has a kind of bumpy, warty type of appearance. And the key thing that they they kind of the key description of these type of lesions is they have a stuck-on appearance. It looks like a kind of sticker or something has just been stuck onto the skin. It doesn't really look like it's blended in with the skin, it's it's stuck on. So what would be your management of this if you saw it in clinical practice. So really you're just reassuring the patient and advising them to monitor it. One of the key things I often advise patients is take a ruler or a tape measure, put it beside the lesion, and then take a photograph of it. And that way you can see the exact size, and in six months' time, if it's changed color or shape or appearance or size, you can look back at that uh photo that you took, see exactly how big it was, and see whether it's changed. Okay, on to the next patient. It's a 28-year-old woman, and she's had a skin lesion for about a year. She's kind of been keeping an eye on it, it's not really done anything, but it's not gone away. So she wants to get it checked out. She says, at first, I thought it was a bite. So she got like a red mark on her skin. She thought it was like an insect or a bug bite, and then it kind of turned into the lesion that it is now. And on examination, there's a kind of firm fibrous nodule, so a very firm bump in the skin. It's eight millimeters in diameter, and you can see here there's kind of a paler center, slightly pigmented border, and slightly raised bump on the skin. So in this situation, what's your suspected diagnosis? This is a dermatophibroma, a kind of fibrous uh nodule or tumor um in the skin there, but it's not a malignancy.

SPEAKER_01

So what's your management of this condition?

SPEAKER_00

So if you're confident about the diagnosis, it's a dermatophibroma, it's not changing, just a case of reassuring and monitoring. They're not malignant and they're benign, so they don't turn into cancer, so just keep an eye on it. Okay, on to the next case, which is a 78-year-old man. He's got this lesion in a sun-exposed area of his skin. So let's say his forehead or his forearm or somewhere that's had a lot of sun in the past. And this has been slowly growing over the past six months. So you can see the lesion here, it's got a kind of uh rolled over edge and a kind of central area in the middle that looks a bit nasty and ulcerated. What's your suspected diagnosis here? Suspected diagnosis here is a basal cell carcinoma. This is a type of uh skin cancer. What are the key features of basal cell carcinomas? So I'd say there's four kind of key features that stand out that would kind of make you think about a basal cell carcinoma. The first is a pearly appearance, so it's kind of pearly and shiny and glisteny, so a pearly appearance, a rolled edge, so this means the edge kind of rolls up over the top and into this central bit, central ulceration, so the middle of the lesion looks different to the rolled pearly edge. It's kind of ulcerated and looks a bit nasty. And the final thing is telangectasia, which are tiny little swollen capillaries, so little blood vessels within the lesion. If you see these things, think about a basal cell carcinoma.

SPEAKER_01

What kind of referral are you going to do for this patient?

SPEAKER_00

The guidelines recommend a routine referral for basal cell carcinomas, because while they are a type of skin cancer, they tend to be slow growing, they don't metastasize, unlike squamous cell carcinomas or melanomas, and they'll just invade the local tissues, but very slowly. Unless you have concerns. So, for example, they're very large in size or they're in a location that could be concerning, for example, near the eyes where they'd need more urgent treatment, in which case you do an urgent referral. On to the next um skin lesion. Got a 43-year-old woman, she's got a lesion on her abdomen, and it's been there for years. When you measure it, it's six millimeters in diameter. So you can see it here, it's kind of a uh a round lesion, it's a nice um coffee brown kind of colour, and that's about it really.

SPEAKER_01

So, what's your suspected diagnosis here?

SPEAKER_00

So here you're considering just a benign Nevis, which is just a simple mole. What are the reassuring features that would make you think, yeah, I think this is a kind of a simple mole, nothing to worry about? What features would reassure you? So the key things here are the duration. So if it's been there lifelong or for as long as they can remember, or for years, that's reassuring. There's no change, there's a lack of change here. So they say it's been there for years, not changed, not grown. That's obviously reassuring. A small size is reassuring. The fact it's a single colour, so it's one single colour, one kind of brown colour, um, as opposed to lots of different colours. There's a clear border to it, so you can see where the lesion starts and where the normal skin starts, and there's symmetry to them to the lesion. So it's a nice round symmetrical shape. All of these things are very reassuring that it's a nice simple mole, and we don't need to do anything about it. Okay, onto the next case, which is a 54-year-old man. He comes in with this kind of red lesion, or it could be a slight blue colour, but let's say a red lesion on his chest. It's four millimeters in diameter, and it's kind of a round, small red lesion.

SPEAKER_01

What's your suspected diagnosis here?

SPEAKER_00

This appearance is suggestive of a cherry angioma, which is also called a Campbell de Morgan spot. What's the basic pathophysiology?

SPEAKER_01

What are these cherry angiomas?

SPEAKER_00

These lesions are essentially proliferation of dilated capillaries. So the small blood vessels in the skin have dilated and grown, and that's what you're seeing, this this red round blob or dome on the skin. It's just proliferation of dilated capillaries.

SPEAKER_01

What's the significance of this?

SPEAKER_00

So these are benign lesions, they don't necessarily need any action, but they can bleed if they're injured. So you imagine there's lots of dilated capillaries in there, and something nicks the surface, they can bleed quite a lot. Okay, on to the last case, which is a 40-year-old woman, she's had a skin lesion for the past one month. It's growing and changing in colour. So she's a bit worried about it. And you measure it, and it's 14 millimeters at the widest diameter. So you can see here it's kind of an irregular-looking lesion with different colours, not very clear borders, and it's kind of uh raised in parts and flat in other parts. So what's your suspected diagnosis here? Here you're suspecting a malignant melanoma. What are the concerning features that would make you worried about a melanoma in a skin lesion? There is an ABCD epnemonic for kind of identifying the concerning features. A for asymmetry, so it's an irregularly shaped lesion, it's not symmetrical. B for border irregularity, meaning that the border is not clearly defined and sort of smooth and yeah, very well defined. It's it's difficult to determine where the border is. C is for color variation. So it's not just one uniform color, it's different colours within the same lesion. D is for diameter above or equal to seven millimeters, and E is for evolving, meaning, meaning that it's changing size, it's changing shape, it's changing appearance. All of these features are concerning features. So for melanomas, for the referral, there's this seven-point checklist with a referral triggered if a referral should be considered if they score three or more on this checklist. So a Legion will score two points if there's a change in size, a change in an irregular shape, or an irregular color. So each one of those scores two. So if there's a change in size, that scores two. If there's an irregular shape, that scores two, so now they're on four. And if there's an irregular color, um, that scores another two, so now they're on six, and that would trigger a feral. They also score one point if it's seven millimeters or more in diameter, there's inflammation, there's oozing, or there's a change in sensation. So each of these features will also score one point, and a referral is triggered or considered at three or more points. So I hope that um video was helpful. And uh if you do want, remember all of these lesions are there's illustrations and notes on all of those lesions in the AKT revision book, which is available now at zero to finalshop.com. And I hope you join us for the next video, which will be in about a week's time.