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Family Medicine 16: 68-year-old male with skin lesion

User: Beatriz Duque

Email: bettyd2382@stu.southuniversity.edu Date: September 14, 2020 3:00AM

Learning Objectives
The student should be able to:

Describe skin lesions with accuracy.

Define terms that describe the morphology, shape, and pattern of skin lesions.

Formulate the treatment principles of topical corticosteroid and local and systemic antifungal agents.

Apply the ABCDE criteria for the evaluation of hyperpigmented lesions as possible melanoma.

Describe common biopsy procedures, including shave biopsy, punch biopsy, and incisional and excisional biopsies.

Discuss the treatment modalities for squamous cell carcinoma.

Describe the importance and methods of prevention of skin cancers.

Develop initial workup and management of benign prostatic hyperplasia.

Knowledge
Primary and Secondary Skin Lesions

Primary skin lesions are uncomplicated lesions that represent initial pathologic change, uninfluenced by secondary alterations such as infection, trauma, or therapy.

Secondary skin lesions are changes that occur as consequences of progression of the disease, scratching, or infection of the primary lesions.

Primary Skin Lesions

Macule: A macule is a change in the color of the skin. It is flat, and if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. It is less than 1 cm in diameter. Some authors use 5 mm for size criterion. Sometimes “macule” is used for flat lesion of any size.

Patch: A patch is a macule greater than 1 cm in diameter.

Papule: A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter.

Plaque: A plaque is a solid, raised, flat-topped lesion greater than 1 cm in diameter. It is analogous to the geological formation, the plateau.

Nodule: A nodule is a raised solid lesion and may be in the epidermis, dermis or subcutaneous tissue.

Tumor: A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule.

Vesicle: A vesicle is a raised lesion less than 1 cm in diameter and is filled with clear fluid.

Bulla: A bulla is a circumscribed fluid filled lesion that is greater than 1 cm in diameter.

Pustule: A pustule is a circumscribed elevated lesion that contains pus.

Wheal: A wheal is an area of elevated edema in the upper epidermis.

Complete list of primary and secondary skin lesions with images.

Skin Cancer Screening Recommendations

The annual skin cancer screening by full body skin examination by health care provider is an I recommendation by USPSTF. I recommendation means that current evidence is insufficient to assess the balance of benefits and harms of a primary care clinician performing a whole body skin examination or a patient doing a skin self-examination for the early detection of skin cancers.

However, the American Cancer Society recommends appropriate cancer screening by a physician, including a skin examination, during a periodic health examination. The American Academy of Dermatology promotes free skin examinations by volunteer dermatologists for the general population through the Academy’s Melanoma/Skin Cancer Screening Program. It also encourages regular self-examinations by individuals.

In the context of apparently conflicting recommendations by different organizations and when there is no sufficient evidence for the benefit or harm of certain recommendations, (like USPSTF I recommendation), the best policy may be to discuss the recommendation with patients and ask their preference. Physicians, however, should be able to discuss the possible outcomes of

the patient’s choice.

Risk For Skin Cancer

Risk factors for nonmelanoma skin cancers include:

1. Previous skin cancer of any type gives 36% to 52% five-year risk of second skin cancer
2. 80% of lifetime sun exposure is obtained before 18 years of age (single greatest risk factor) 3. Celtic ancestry
3. Fair complexions
4. People who burn easily
5. People who tan poorly and freckle
6. Red, blonde or light brown hair
7. Increasing age
8. Use of coal-tar products
9. Tobacco use
10. Psoralen use (PUVA therapy)
11. Male >>> female
12. Living near equator (UV exposure)
13. Outdoor work
14. Chronic osteomyelitis sinus tracts
15. Burn scars
16. Chronic skin ulcers
17. Xeroderma pigmentosum
18. Human papillomavirus infection

Risk factors for melanoma skin cancer include:

1. Previous melanoma
2. Celtic ancestry
3. Fair complexions
4. People who burn easily
5. People who tan poorly and freckle
6. Red, blonde or light brown hair
7. Early adulthood and later in life
8. “Intense, intermittent exposure and blistering sunburns in childhood and adolescence are associated with increased risk”
9. Radiation exposure
10. Melanoma in 1st or 2nd degree relative
11. Familial atypical mole-melanoma syndrome (FAMMS)
12. Male > female (slight)
13. Living near equator (UV exposure)
14. Indoor work
15. Higher incidence in those with more education and/or income
16. Nonfamilial dysplastic nevi
17. Large number of benign pigmented nevi
18. Giant pigmented congenital nevi
19. Nondysplastic nevi (markers for risk, not precursor lesions)
20. Xeroderma pigmentosum
21. Immunosuppression
22. Previous nonmelanoma skin cancer
23. Other malignancies

While incidence of skin cancer is higher among individuals with fair skin, patients with darker skin are also at risk for developing skin cancer and should also undergo regular screenings; conduct self examinations; and protect themselves from UV radiation.

Consent Form for Procedures

A procedure consent form aims to document adherence to one of the four principles of medical ethics: respect for autonomy. Patients can not be viewed as making their own autonomous decisions if they are not adequately informed as to the true nature of the decision. An autonomous decision to allow providers to perform a procedure requires an understanding of the the reason for the procedure, the nature of the procedure, as well as its risks, benefits, and alternatives.

Thus, a consent form should contain:

the name of the procedure the diagnosis

the risks of the procedure the benefits of the procedure

the alternative to the procedure that was proposed

Patient Education for Protection Against Sun Damage

The key to preventing a skin cancer is to stay out of the sun and not to use a sunlamp. If you are going to be in the sun, you should wear clothes made from tightly woven cloth so the sun’s rays can’t get to your skin. You should also stay in the shade when you can. Wear a wide-brimmed hat to protect your face, neck, and ears.

Remember that clouds and water won’t protect you from the sun’s rays. The sun’s rays can also reflect off water, snow, and white sand.

If you can’t stay out of the sun or wear the right kind of clothing, you should use sunscreen to protect your skin. But don’t think that you are completely safe from the sun just because you are wearing sunscreen.

Use sunscreen with a sun protection factor (SPF) of 15 or more. Put the sunscreen everywhere the sun’s rays might touch you, including your ears, the back of your neck, and bald areas on your scalp. Put more on every two to three hours and after sweating or swimming.

Patient Education on Skin Examination

What’s the best way to do a skin self-examination?

The best way is to use a full-length mirror and a hand-held mirror to check every inch of your skin.

First, you need to learn where your birthmarks, moles and blemishes are and what they usually look like. Check for anything new, such as a change in the size, texture or color of a mole, or a sore that doesn’t heal.

Look at the front and back of your body in the mirror, then raise your arms and look at the left and right sides.

Bend your elbows and look carefully at your palms and forearms, including the undersides, and your upper arms. Check the back and front of your legs.

Look between your buttocks and around your genital area.

Sit and closely examine your feet, including the bottoms of your feet and the spaces between your toes.

Look at your face, neck and scalp. You may want to use a comb or a blow dryer to move hair so that you can see better.

By checking yourself regularly, you’ll get familiar with what’s normal for you. If you find anything unusual, see your doctor. The earlier skin cancer is found, the better.

Prostatitis Syndrome Symptoms

Prostatitis syndromes tend to occur in young and middle-aged males. The symptoms of prostatitis include pain (in the perineum, lower abdomen, testicles and penis, and with ejaculation), bladder irritation, bladder outlet obstruction, and sometimes blood in the semen.

Clinical Skills
Full Skin Exam

When performing a skin exam at annual visits and/or evaluating a patient presenting with a skin lesion — have the patient change into a gown so you can perform a full skin exam.

Skin Examination

Distribution

The distribution of the skin lesions is important in diagnosing skin diseases. Many conditions have typical patterns or affect specific regions of the body. For example, psoriasis commonly affects extensor surfaces of joints, and atopic eczema impacts flexor surface of joints. Involvement of the palms and soles is seen in erythema multiforme, secondary syphilis and eczema.

Shape

Descriptions like oval, round, linear etc. can be used to describe the shape of the lesions. Annular lesions are circular with normal skin in the center. Annular macules are observed in drug eruptions, secondary syphilis and lupus erythematosus. Iris lesions are a special type of annular lesion in which an erythematous annular macule or papule develops a second ring or a purplish papule or vesicle in the center (target or bull’s eye lesion).

 

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