HOW TO TREAT 31 of occasions in her 20s . Lisa is Fitzpatrick skin type II and previously had a superficial BCC on her back which was treated with imiquimod 5 % cream a few years ago . She is otherwise well with no past medical history and does not take regular medications .
ausdoc . com . au 11 OCTOBER 2024
HOW TO TREAT 31 of occasions in her 20s . Lisa is Fitzpatrick skin type II and previously had a superficial BCC on her back which was treated with imiquimod 5 % cream a few years ago . She is otherwise well with no past medical history and does not take regular medications .
Her father is currently receiving immunotherapy for a melanoma , which prompted Lisa to come in for a skin check today . She has not noticed any new lesions of concern .
On examination , Lisa ’ s diligent GP finds a subtle but suspicious thin papule on the right tip of her nose ( see figure 1 ). On closer examination with a dermatoscope , it appears translucent , pale and has arborising telangiectasia across its surface that are in focus . The remainder of the full skin examination is unremarkable .
Her GP is concerned that this may be a BCC and performs a 2mm punch surgeon who excises the lesion and repairs the defect with a bilobed flap repair . Lisa returns to her GP for suture removal 10 days postoperatively and the wound heals well . She continues to have regular full skin examinations and reviews with her GP . At each one , her GP diligently reminds her about the importance of UV protection including wearing a sunscreen daily , protective clothing , wearing a hat and being aware of the UV index .
Case study two
Peter , a 68-year-old retiree , presents to his GP for two new mildly pruritic lesions on his lateral left brow . These lesions have grown in size over the past two months .
Peter has a history of a nodular BCC that was surgically removed a year ago and a few actinic keratoses on his neck and arms that were treated with cryotherapy . He has a
Superficial skin surgery with C & C may be used for large and resistant warts that have failed topical treatment .
Figure 4 . Seven days post full-thickness skin graft and resection of a nodulocystic BCC of the left ala . biopsy because of the cosmetically sensitive location . Histopathology confirms a BCC of nodular subtype , measuring 1.3mm in thickness . There is associated dermal inflammation but no perineural or lymphovascular invasion .
These results are explained to Lisa and her GP takes the time to discuss the different treatment options ( surgical excision , Mohs surgery , radiotherapy , and C & C ) including the risks , benefits , complications and approximate recurrence risk of each one .
Lisa is given adequate time to consider these options and later decides to elect for Mohs micrographic surgery given the lower rates of recurrence and anatomical site of the lesion where tissue preservation is important .
Her GP refers Lisa to a local Mohs past medical history of type 2 diabetes mellitus , hypertension and hypercholesterolaemia , for which he takes metformin , amlodipine and rosuvastatin . Peter previously worked outdoors as a gardener , and although he regularly wore a hat and long sleeves , he did not routinely apply sunscreen .
On examination , Peter ’ s GP notes that both lesions on the left lateral eyebrow are well demarcated , scaly and erythematous ( see figure 8A ). The lateral lesion is slightly more raised than the medial one .
The GP wonders if both lesions may be SCCs and takes a 2mm punch biopsy from each because of the cosmetically sensitive location .
Histopathology shows atypical keratinocytes with full thickness epidermal atypia but no evidence of dermal invasion . This confirms
Figure 5 . Infiltrative BCC of the right lower lip vermillion border and Bowen ’ s disease of the chin .
Box 3 . A practical guide for the application of cantharidin
• Preparation : — Following informed consent , cleanse the wart with an alcohol swab or other antiseptic solution . — Pare back the wart / debulk any keratotic material with a curette or a scalpel blade . — Dry the skin thoroughly to ensure proper adhesion of the cantharidin solution .
• Application : — Apply a thin layer of the cantharidin 0.7 % solution directly to the wart using a disposable applicator or fine-tipped brush . — Take care to avoid contact with the surrounding healthy skin , as it can cause irritation or blistering .
• Protective measures : — Protect the treated area by covering with a non-porous occlusive dressing , such as adhesive tape or a transparent film dressing .
• This helps to increase the efficacy and protect from accidental contact with other skin .
— After 4-8 hours , the cantharidin should be washed off with soap and water .
• Post-treatment care : — Blistering , often accompanied by erythema , pain or pruritus , will likely occur within 2-24 hours . — Simple analgesia can be given if required .
• Follow-up : — Schedule a follow-up appointment for three weeks to assess treatment response , where a repeat application may be administered . — Some 4-10 or more treatments may be necessary to achieve complete clearance of the wart .
Figure 6 . Biopsy-proven Bowen ’ s disease of the right cheek , on a background of actinic damage . Surgical excision was planned .