Australian Doctor 11th Oct Issue | Page 25

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NEED TO KNOW
There are many treatment options for keratinocyte skin cancers ; consider the type , location , size and characteristics of the lesion , as well as patient factors and preference , when deciding on the most appropriate option .
Surgical excision is the most common treatment for basal cell carcinoma , especially when conservation of tissue is not a priority .
Curettage and cautery is a suitable treatment option for keratinocyte skin malignancies on accessible areas of the body , such as the trunk , extremities , head and neck .
Not all cutaneous warts require treatment , especially in children , where two-thirds of warts resolve spontaneously within two years .
Topical agents , including salicylic acid , podophyllin and cantharidin , are suitable treatment options for cutaneous warts .

Practical procedures in dermatology

Dr Vera Y Miao ( left ) Dermatology research fellow , Royal North Shore Hospital , Sydney , NSW .
Dr Rebecca B Saunderson ( right ) Dermatology head of research and staff specialist , Royal North Shore Hospital , Sydney , NSW .
Copyright © 2024 Australian Doctor All rights reserved . No part of this publication may be reproduced , distributed , or transmitted in any form or by any means without the prior written permission of the publisher . For permission requests , email : howtotreat @ adg . com . au .
This information was correct at the time of publication : 11 October 2024
INTRODUCTION
SKIN lesions are a very common
presentation in primary care . A systematic approach , combined with knowledge and experience of practical procedures , is required to successfully manage both benign and malignant skin lesions .
This How to Treat covers the diagnosis and treatment options for basal cell carcinoma , Bowen ’ s disease ( also known as squamous cell carcinoma in situ ) and cutaneous warts . It aims to ensure GPs can confidently diagnose and perform surgical excisions , curettage and cautery , and cantharidin application .
BASAL CELL CARCINOMA
BASAL cell carcinoma ( BCC ) is the
most common type of skin cancer , accounting for 70 % of all non-melanoma skin cancers . BCC rarely metastasises . However , if allowed to progress , it can cause significant morbidity and represents a significant burden on healthcare services . 1 BCC can develop anywhere on the body but is usually found on
sun-exposed areas of the head , neck and trunk . Chronic sun exposure is the greatest risk factor for the development of BCC , as its primary aetiology is linked with UV-induced mutations and impaired DNA repair mechanisms . 2
Other risk factors include advanced age , male sex , fair skin ( Fitzpatrick types I and II ), a personal or family history of skin cancer , exposure to ionising radiation , exposure to arsenic , being a pilot , cutaneous injury or thermal burn , and rare inherited syndromes which increase the risk of BCC , such as basal cell naevus syndrome ( Gorlin syndrome ), and xeroderma pigmentosum . 2 , 3
Furthermore , those who are immunosuppressed because of immune dysfunction or immunosuppressive therapies also have increased susceptibility to BCC . Notably , the risk of developing a BCC after transplantation is six times higher than in the general population . 4
Diagnostic evaluation of BCC entails a comprehensive clinical examination supplemented
by dermoscopy . When in doubt , a biopsy can confirm the diagnosis .
The clinical features and histopathology for the different types of BCC are outlined in table 1 . Not all clinical and histopathological features may be present for a specific lesion .
Differential diagnoses
Differential diagnoses vary depending
on the type of BCC . For a non-ulcer ated lesion , differential diagnoses include , but are not limited to , molluscum contagiosum , sebaceous hyperplasia , fibrous papule , trichoepithelioma , amelanotic melanoma , benign dermal or intradermal naevus and Merkel cell carcinoma .
Differential diagnoses for an ulcerated lesion include squamous cell carcinoma ( SCC ) and keratoacanthoma .
Treatment options
Deciding on the appropriate treatment
for a BCC necessitates a tailored approach ; this considers the type , location , size and characteristics of the lesion , as well as patient factors and preference .
Discuss the risks and benefits of various modalities with the patient
and utilise shared decision-making to select the favoured treatment . The most common treatment options are outlined below .
TOPICAL THERAPIES Topical therapies may be appropriate for superficial BCC less than 2cm in diameter .
One option is topical imiquimod 5 % once daily , five days a week for six weeks , or 30 applications spaced over a longer time period .
The alternative topical option is 5-fluorouracil cream twice daily for 3-6 weeks . However , several studies and clinical trials have shown that imiquimod 5 % cream is more effective than 5-fluorouracil for superficial BCC . 5 , 6
Counsel patients about the expected inflammatory effects , including pain , burning , itching , redness , flaking and scabbing , which will settle once treatment is discontinued . This reaction may start to occur after three or four applications , but generally becomes maximal at three weeks .
Although improved rates of clearance have been demonstrated with twice-daily dosing , this is often limited by the increased local