Skin Closure after Surgical Excision of Skin Lesion

Techniques to consider in order of preference (a guide only):
Most common technique
= primary closure
[Don't forget secondary closure - not 2nd on list, but not to be forgotten]
Then
- skin graft (split/not full thickness)
Flaps
- advancement
- rotational
- transformational
Finally
- skin graft (full thickness)

Dry Skin May Only Require Hydration with Emollients rather than Topical C.steroids

Dry skin is not necessarily inflamed

Emollients (good [greasy] ones) are essential and may be all that is required

However, [appropriately potent] topical c.steroid should be available

Molluscum contagiosum Rx

Rx

• EMLA cream 60 mins prior to Rx (especially in children)

• Curettage

• or

• Umbilicate

Other topical Rx messy, expensive and far less effective

NB:

• In cases of dermatitis, ensure this is treated too as MC more likely to spread
• Also, avoid baths to reduce risk of spread

Vit D Deficiency

People with dark skin at higher risk for vitamin D deficiency versus people with light skin

The Common Systemic Therapies

In psoriasis

• 1. methotrexate
• 2. acitretin
• 3. cyclosporin
• DON'T USE SYSTEMIC STEROIDS

In dermatitis (atopic)

• 1. prednisolone
• 2. methotrexate
• 3. cyclosporin
• 4. azothioprine - but evidence-base for efficacy and side effects is weak

Prednisolone

• side-effects
  • endocrine or metabolic
    • osteoporosis
    • diabetes
    • e.lyte imbalance
    • acute adrenal insufficiency (on withdrawal)
  • hypertension
  • ocular
    • glaucoma
    • cataracts

Methotrexate

• not sure how it works ?immune suppression
• taking folic acid tabs. for part of week may help ↓anemia incidence

• side-effects
  • nausea
  • diarrhoea
  • mouth ulcers
  • skin side-effects uncommon
  • More serious
    • hepatitis
    • cytopenia
    • teratogenesis
• Pre-Rx check
  • FBC
  • LFTs
  • UCEs
  • eGFR

Acitretin

• ↓cell proliferation
• LFT changes uncommon
• TG changes common (↑serum TGs)

• side-effects
  • skin side-effects common
    • dry, red skin/nose;eyes; lips
      • →artificial tears for eyes
      • cheilitis --> consider barrier ung; UV protection
  • alopecia
  • photosensitivity
  • more serious
    • hepatitis
    • cytopenia
    • teratogenesis

In pregnant woman or woman planning pregnancy or breastfeeding

• don't use
  • MTX
    • and until 3/12 after MTX ceased
  • tetracyclines
  • oral retinoid
    • isotretinoin
    • acitretin (and no pregnancy within 2 years)

Cyclosporin

• ↓inflammation
• only use under guidance of specialist experienced in its use
• side-effects
  • hepatitis
  • renal dysfunction
  • gum hyperplasia: swollen or bleeding gums can occur --> dental hygiene
  • hirsuitism
  • Pre-Rx check
    • FBC
    • LFTs
    • UCEs
    • eGFR
    • F.lipids
    • Blood pressure
  • If BP raised --> consider calcium antagonist to prevent renal loss

So, for MTX, retinoids and cyclosporin

- Pre-Rx check

• BP
• FBC
• LFTs
• UCEs
• eGFR
• (F.lipids)
• (pregnancy test in females)

- during Rx check

• BP
• FBC
• LFTs
• UCEs
• eGFR

So, for prednisolone

- Pre-Rx check (ideally)

• BP
• UCEs
• eGFR
• F.lipids and F.BSL
• Intra-ocular pressure

- during long-term Rx check

• BP
• UCEs
• F.lipids and F.BSL
• bone density
• eyes
  • intra-ocular pressure
  • lens ?cataracts

Biological Rx

• target T-cells or tumour necrosis factor alfa (TNF alfa)
• expensive and strictly limited
• can reactivate TB
• → before Rx → QuantiFERON-TB Gold test
  • indirect test for M.tuberculosis

Preg code X

• oral retinoids
  • isotretinoin
  • acitretin
• MTX

In case of skin cancer

In case of melanoma or non-melanoma skin cancer
- check local/draining lymph nodes

In case of melanoma
- refer to local melanoma unit

Dermoscopy: non-pigmented lesions & vessels

BCC
- serpentine branched vessels (arborizing telangiectasia)

SCC
- diffuse coiled vessels (glomerular) & red dots

Confocal clinical microscopy probably better than dermoscopy

Must use polarized AND non-polarized light