Current Burn Management –The Principles

Dr. David SY Wong  黃守仁醫生香港中文大學外科學系名譽臨床副教授

威爾斯親王醫院整形外科顧問醫生

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Burn Mortality

Healthy 21 years old:1950  LD50= 45%1990  LD50= 80%

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Burn Care

Immediate  Acute  ChronicImmediate  = ResuscitationAcute  = Wound closureChronic = Rehabilitation

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Definition of Burn

A burn is a type of injury caused by heat, electricity, chemicals, light, radiation or friction, affecting the integument and sometimes deeper tissues.

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What is a severe burn?

Adults : 20% TBSAChildren : 10% TBSA

FT BurnsElectrical/ Chemical burnsInhalation injuryPre‐existing morbid conditionsConcomitant trauma

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Severe burn ‐ sequelae

Burn wound = local injury + devitalized tissue

Systemic effects:What? SIRS  MODSWhy? 

Cytokines & chemokines  vascular permeabilityWhen >25% TBSAHow manifested? Generalized edemaWhere? The whole bodyEffects: 

MODS, hypermetabolism, immunosuppressionMagnitude:  Escalates with extent and depth

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What needs to be treated?

Injury = Physical + PsychologicalAn injured person=  The systems

The woundThe mind

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Strategy for severe burns

Reversal of wound, i.e. closure= early excision and wound coverage

Prevent burn wound sepsis/SepsisEnteral supportGeneral support –

Zones of Jackson (dynamic‐ first 48‐72 hrs), e.g. desiccation, infection, hypoperfusion, prolonged edema

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ICU admission

Ventilatory requirementSevere co‐existing injuries

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Remove the injuring agent

StrippeRemove Dilute and wash

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Early wound assessment

Healing vs ScarringTime to healing  Risk of scarring

14‐21 days :   33%> 21 days :   80%

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Severity Assessment

Depthenergy, in 4o (now Supf, supf/ deep PT, FT)

Bleeding, Sensation, Blanching, AppearanceExtent

TBSA: rule of 9’s, palm sizeCo‐morbid factors 

e.g. age, concurrent diseases, special sites

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Referral Criteria (i.e. severe)

2nd deg, >20% TBSA but >10% if <10 or >50 yrs old3rd deg, >5% TBSASpecial sitesElectricChemicalInhalational elementCircumferential injuryConcomitant illnessAssociated trauma

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Networking‐ care delivery organization

Disaster managementMulti‐disciplinary approach

Burn Centre:Acute to chronic care, education, research, commitment, physical set‐up

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Initial Assessment

Primary SurveyAirwayBreathingCirculationDisabilityExposeFluid

Secondary SurveyHead to toe exam

ATLS/ EMSB protocol

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History (AMPLE)

Injury:cause + mechanism + enclosed + smoke + chemicals + times + flushing + other trauma 

Medical:allergies + medications + pre‐morbid + last food + ATT

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First Aid

=  Stop burning (remove) + Cooling 

+ Analgesia + Coverage

Protect cervical spine Keep warm

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Immediate intervention

Acute stage surgeryAirway –

= Tracheostomy (after Intubation)Decompression –

Escharotomy/ FasciotomyIrreversible damage

Nerve 12‐24 hrMuscle 4‐12 hr

NB. Post fluid challengeAmputation –

Myoglobinuria

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Acute to Early intervention

Early debridement (+ wound closure)To remove devitalized tissueTo allow wound coverage

Problem: blood lossTourniquet/ Adrenalin infiltrationFascial excisionSerial surgery

Limits: massive transfusion/ prolonged operation/ pH changes/ bleeding tendency

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Priorities in excision & grafting

1. Large areas first, e.g. ant trunk, LLs2. Hands3. Face

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The Skin

Functions:

protectionretains fluidsregulates temperaturesensation

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Wound coverage

Insufficient donor skinMeshing (expansion)Re‐harvestingAllograft (cadaveric skin)Sandwiching techniquePostage stampingXenograft (porcine skin)Skin substitutes

Biobrane – nylon mesh + silicone membrane coated with porcine polypeptides, as dressingIntegra – silicone sheet + bovine collagen matrix as templateAlloderm – from cadaveric human skin, non‐antigenic, as regenerative matrix

CEA by keratinocyte culture

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Early mortality

1. ARF ‐ 1st week2. Sepsis ‐ 2nd week3. MODS ‐ 3rd week

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Severity risk factors

Inhalational injuryPoly‐traumaPersistent hyperglycaemiaElderliesPre‐existing organ system compromise

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Standard hospital stay

1 day per % TBSA burned

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The Aim

Restore:FormFunctionFeeling

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Principles of Management

Stop burning/ Universal precautions/ Airways/ Circulation/ NG tube/ Foley/ Pain relief/ Limb assessment/ Ventilatory assessment/ Emotional support/ Suicide management

Thermal – coverElectric – cardiac monitorChemical – flushing, remove powders, remove clothes, 

irrigation

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Laboratory Investigations

Hct/ NaK/ RFT/ Urine/ CXR/ Astrup/ ECG/ CarboxyHb/ Spot sugar

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Superficial partial thickness burn

Exudative phase –Cleansing lotion:

NS/ aqueous Hibitane/ Hibiscrub shower

Primary dressing: Bactigras/ JelonetSecondary dressing: Dry plain gauzeRetention: 

Hospifix/ Hyperfix

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Post‐exudative phase –Cleansing lotion: 

NS/ aqueous Hibitane/ Hibiscrub shower

Primary dressing: Porcine skin/ HydrogelSecondary dressing: Dry plain gauzeRetention: 

Hospifix/ Hyperfix

reassess, positioning, splintage

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Special sites –Face: OmidermAuricles: BactrobanHands: Flamazine cream bagGenitalia/ Perineum: Flamazine

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Deep partial thickness

Flammacerium= cerium nitrate + Ag sulphadiazine

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Surgical decision

Depends on the depth of injury, i.e. supf partial/ deep partial/ deep:

Deep ‐ operateWhen? Early, once stable, to eliminate burn toxins How?  Tangential or FascialClosure? Autografts, mesh +/‐ allografts (e.g. cadaveric, amniotic membrane), xenografts, dermal substitutes (e.g. Integra), CEA.

Supf/Deep partial ‐ If healing likely to be ≥ 2 wks, tx as deep.

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How much each time?

Limitation:1 blood volume20‐30% TBSA excision (tangential)4‐6 hrs

Must avoid/ stop:Acidosis (BE<10)Hypothermia not responsive to room tempHypotension requiring repeated pressors

McManus, US Army Institute of Surgical Research

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CO poisoning

Fatalities at the scene>50% carboxyHb/ anoxia250x affinity + binds cytochrome proteinsFalse PaO2 (metabolic acidosis)

Variable signse.g. cherry red, BR

Rx: 100% O2 mask (COAD)Half life of CO in vivo is:

250 min (on room air)40 min (breathing 100% O2 )

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Treatment for CO poisoning

100% humidified O2, 8L/min through a non‐rebreathing mask with a reservoirContinue treatment for 48 hours post injury

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Airways Injury

Mortality 20 – 50% admitted patients60 – 70% who died

Above glottisThermal injury usually only supra‐glotticGlottis edema may await fluid resuscitation

Below glottisUsually chemical, or, steam inhalation/ scalding liquid/ explosion breathing O2Impaired cilia, erythema, hypersecretion, edema, ulceration, congestion, spasm

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Mx of Airways Injury

Humidified 100% O2Prophylactic intubation (cricothyroidotomy)Escharotomy for ventilatory restrictionClose observation + reassessment? Fluid? Colloid/ crystalloidProphylactic antibiotics X

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Is there Inhalational Injury?

HxUnconsciousness/ noxious chemicals/ enclosed space/ <24 hrs

P/ECarbonaceous sputum/ singed nasal hairs/ hoarseness/ oro‐ or naso‐ pharyngeal erythema / signs of hypoxaemia/ rhonchi

* Tie ET tube with string

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Indication for intubation

History suggestive of inhalational injury with Respiratory distressIncreasing tiredness or confusion

Extensive burns over the HN regionSupraglottic oedema on endoscopic examHigh level of carboxyhaemoglobin

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Pulmonary infection

75% of mortalityNumerous causes

Inhalation, sepsis, ventilation, ARDS, fluid overloading, immune compromise, post operative collapse, prolonged immobilisation, chronic smoking, ..

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Why resuscitation?

Hydrostatic pressure

Oncoticpressure

Semi‐permeablemembrane

Ernest Starling, 1896

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Transvascular fluid shifts

plasma volume depletion + extracellular fluid

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The Result

HypovolemiaBP,  HR +  urine output 

Peripheral vascular resistance  and cardiac output 

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Oral Resuscitation

TBSA <10% in children or 15% in adults

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Oral fluids

Na is important 

Plain water 

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Who needs iv resuscitation?

Adults >15%TBSA

Children >10%TBSA

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Resuscitation considerations

Oedema is accentuated The least amount necessary be given Na is essential

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Amount of fluid needed

Affected by:volume of tissue injuredAgepre‐morbid dehydrationpre‐existing chronic illness 

Calculate from time of injury

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Crystalloids

Lactated Ringer's solution (Na 130 mM/l)

isotonic lower chloride load (110 mM/l)

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Parkland Formula

First 24 hrs,LR 4 ml/kg/% (½ 1st 8 hrs)

Second 24 hrs,Albumin 0.3‐0.5 ml/kg/% + D5 (or half NS in children) to maintain urine

* Parkland Memorial Hospital is in Dallas, Texas, USA

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Colloids

Demling ‐ restoration of plasma proteins not effective until 8 hrs postburn

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Special Considerations

Paediatric patient –requires more fluidscolloids frequently required

Inhalation injury –fluid requirements

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Monitoring criteria

Urine output of:30‐50 ml/h in adults 1 ml/kg/h in children 

No metabolic acidosisLucid mind (if not sedated) 

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Frequent reassessment essentialPulse and BP not necessarily indicative of volume status

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Urine too little/much?

Modify iv rate if ≥ 2 consecutive hrs

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Invasive monitoring

where:

Delay in resuscitationCardiac/ renal impairmentSevere inhalational injury 

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Resuscitation formulas

guidelines starting points for the 'average'

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Successful resuscitation?

Resuscitation fluids needed to maintain adequate urine

Maintenance fluid volume 

(normal maintenance + evaporative loss)

When:

=

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Fluid Creep

Supra‐Baxter resuscitation!

Greenhalgh DG. Burn resuscitation: the results of the ISBI/ABA survey. Burns 2010; 36:176‐182

55% is over resuscitationMost ‘cheat’ with colloid‘more is not better’

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Why not over‐resuscitate?

oedemahypoproteinaemiatissue hypoxiatissue pressurerisk of compartment syndromescardio‐respiratory demand

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Diuretics

No place except:No UO despite fluidsMyo‐ or haemo‐globinuria: UO 75‐100ml/hr, 12.5gm Mannitol/l fluids, NaHCO3

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Cardiotropics

Peripheral vasoconstriction on the zone of stasisDobutamine

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Nutritional Support

Hypermetabolicwound healingheat losssepsis

Against protein breakdownhealinginfection

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Suicide by setting fire Stopped by passers‐by50% deep burns Reached hospital 2 hrs later

Scenario 1

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Scenario 1

Body wt = 60 kgTBSA = 50%Parkland:  4 x 50 x 60 = 12,000mlHalf to be given the first 8 hrs = 6,000ml2 hrs already goneFluid to be given the next 6 hrs = 6,000mlFluid for the first hr = 14000 / 6 = 3000ml

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Myoglobinuria

Keep urine 75‐100 ml/hrMannitol 12.5 g/l i.v. fluids NaHCO3 to keep urine pH >6.5

e.g. 8.4% 50ml ivi

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Burn Wound – Depth Assessment

Depth of Burn Colour Capillaryrefill

Blisters Sensation

Superficial Red + ‐ +Superficial dermal

Pink + + +Deep dermal Fixed 

staining ‐ +/‐ +Full thickness White/

Dark ‐ ‐ ‐

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Area of the burn ‐ TBSA

Rule of ninesadults only

Lund & Browder Chartgrowing patients

Patients’ closed palmas 1% TBSApatchy injuries

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Decompression ‐ Escharotomy

Circumferential injuries can cause constricting effects

Chest: Ventilatory restrictionIncreasing airways pressure

Limbs:Cold extremitiesDisproportionate deep Pain and also on passive movementTender or indurated muscle compartmentParaesthesia or loss of sensationAbsence of peripheral pulses

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Needs high index of suspicion Compartmental pressure >30mmHg

Rx:Escharotomy – bedside, NA, sterile field, to fat, avoiding nerves/ vs, across jts, beyond 3o area. NB. HaemostasisFasciotomy is indicated when the pressure of individual muscle compartments are also raised.

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Burn Sepsis

Major cause of mortalityCauses –

barrier,  immunity, necrotic tissue, invasive monitoring, cross infection

Wound Bx

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REHABILITATION

FunctionalCosmeticPsychosocial

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Reconstruction

AlopeciaEyebrowsEyelidsFacial skinCommissuresNeckLimb joint contracturesHand deformitiesChronic woundsUgly scars

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Skin Lesions

Dr. David SY WongConsultant (Plastic Surgery)

Sebaceous Cyst

• A cyst that traps sebum produced from sebaceous glands

• Causes a roundish lump in the skin often characterised by a central dimple

• Contains keratin which is tooth-paste like• May undergo infection

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Epidermoid Cyst

• A type of sebaceous cyst that forms from cells of the epidermis and traps keratin

• Often found on the face, neck, chest and uppper back

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Pilar cyst

• A type of sebaceous cyst that forms from cells in the bottom of hair follicles

• Also called trichilemmal cyst or wen• Often found on the scalp

Inclusion Cyst

• A keratinous cyst found anywhere particularly the fingers and toes

• From trauma resulting in the subcutaneous implantation of epidermal cells

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Dermoid Cyst

• A congenital subcutaneous cyst that forms from inclusion of skin elements during embryonic fusion of developing parts

• Often found on the lateral eyebrow areas or the nose

Lipoma

• The commonest subcutaneous soft tissue tumour

• Consists of benign aggregates of normal slowly growing adipocytes

• Soft, transilluminates, slip sign• Multiple in Dercum’s disease

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Skin Tag

• Harmless small flesh-coloured or brown growths that hang off the skin

• Usually on the neck, sometimes armpits, groin, or under the breasts

• = Acrochordons• Commoner in older people • Likely where skin rubs against skin or

clothing

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Keratoses

• Seborrhoeic keratosis (SK) is a benign, hyperplastic epidermal lesion

• Greasy in appearance • Found in where sebaceous glands abound

(ie, face, shoulder, chest, back). • Common in middle-aged and elderly • Dark-colored, waxy raised papules with a

"stuck-on" appearance• Actinic/ Senile variants

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Keratoacanthoma

• = molluscum sebaceum • A nodular skin lesion that grows rapidly

over 2 - 6 weeks, froms a central keratin plug and then ulcerates with a crater for several months to heal leaving a puckered scar

• In exposed areas and elderlies• Must be differentiated from SCC

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Sebaceous naevus of Jadassohn

• A congenital nevus appearing as a yellowish waxy, hairless plaque(s) on the head and neck

• Enlarges with body growth and becomesmore warty with time

• Due to overgrown epidermis and skin elements

• Tumors may arise over time which may bemalignant

• Treatment is complete surgical excision

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Wart

• Cauliflower growth caused by HP1V• Contagious• Types: vulgaris, plana, filiform, genital,

mosaic, plantar• Treatment: salicylic acid, AgNO3, cautery,

cryotherapy, excision, laser

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Cutaneous Horn

• A clinical presentation of a rough, firm, white-yellow horny, often curved, plug or outgrowth of epidermal origin

• Causes: wart, seborrhoeic keratosis or actinic keratosis, 15% will arise from an underlying squamous cell carcinoma (SCC)

• Histology should be obtained

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Fibroma

• A benign tumor composed of fibrous connective tissue forming a firm tiny lump on the skin

• May have an abundance of additional tissue, e.g. neurofibroma, angiofibroma

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Neurofibroma

• A tumor of nerve fiber • Occasionally solitary, more frequently as

part of neurofibromatosis:– an autosomal dominant genetic disorder by an

mutation or inheritance• Type 1 (von Recklinghausen's disease) - CALM• Type 2 – 8th cranial nerve tumours, meningioma,

schwannomas

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Trichoepithelioma

• A tumour derived from the hair follicle • Appears as a solitary firm flesh-coloured

nodule, usually on the face, to be distinguished from BCC

• Multiple trichoepitheliomas may occur as an autosomal dominant condition

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Pilomatrixoma

• A benign asymptomatic skin tumor from the hair matrix

• As a slow-growing, skin-coloured or purplish bony hard mass on the skin ofthe head and neck area

• Often seen in young children• Sometimes familial• May show calcification on X-ray• Malignant transformation is rare

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Keloid

• Claw-like firm growths on the skin with or without prior trauma extending outside the original confines and continues to grow despite periods of apparent quiescence.

• Commoner on the chest, shoulders, back and earlobes

• Sometimes familial• Associated with intense itchiness and pain• Commoner in pigmented races

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• Consists of fibrous tissue which is mainly collagen type 3 slowly replaced by type 1

• May be associated with pits collecting dirt and precipitating infection

• Should never be excised without adjuvant treatment

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Folliculitis

• Infection of hair follicles• Staph aureus, Pseudo aeruginosa• When severe with pus collection, is

referred to as furuncle (or boil)

Abscess

• A collection of pus associated with signs of inflammation which may point and discharge onto the overlying skin

• From attempt of body to localise the injury• Treatment: Incision in a cruciate manner

to open up all loculi, drainage with debridement, and packing of the wound to expect second intention healing. Send abscess wall for section and pus for C/ST.

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Carbuncle

• An area of acute skin infection with a collection of microabscesses multiloculatedin honeycomb cavities with numerous openings draining onto the overlying skin

• Staph aureus, Strep pyogenes• Commonest on the nape of the neck• Screen for diabetes• Requires aggressive excision and

debridement with antibiotics

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Cellulitis

• Spreading inflammation of subcutaneous connective tissue by bacteria after skin trauma

• Presents as a red and tender swollen area around a wound which may not be evident

• More commonly affecting the limbs• Facial involvement = Erysipelas• Submandibular space = Ludwig’s angina• Particularly associated with Streptococcus

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Erysipelas

• A bacterial infection classically affecting the face but also may affect the legs often associated with local lymphatic blockage and particularly by Group A Streptococcus

• Presenting as a tender red swollen patch with a raised border sometimes with blisters and fever

• Diagnosis is by clinical appearance• Treatment is by antibiotics

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Pyogenic Granuloma

• Infected granulation tissue after minor injury often by Staph and usually presents as a small lump of raspberry like mass which grows rapidly and bleeds readily on touch

• Association seen with pregnancy as epulis• Treatment can be expectancy, cautery,

cryotherapy, or excision

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Necrotizing Fasciitis

• A rapidly progressive quickly lethal synergistic polymicrobial infection (often an aerobic with an anaerobic) of the deep fascia with concomitant death of the overlying skin and subcutaneous tissues

• Patient becomes acutely septic with fever and chills rapidly developing shock and careful examination reveals a patch of advancing violaceous hot and severely tender skin which may be necrotic in areas

• Called Fournier gangrene when predominantly affecting the genito-perineal region

• High index of suspicion and prompt aggressive debridement +/- second look essential together with antibiotics

• Resultant extensive wounds often require skin grafting or flaps

• Screen for diabetes

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Pyoderma Gangrenosum

• A condition with tissue destruction resulting in deep extensive necrotic limb or trunk ulcers often associated with autoimmune derangements, arthritidesand blood malignancies

• Often from a site of minor injury, e.g. insect bite, needle prick, rapidly enlarging and painful with a purple colouredundermined edge

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• Diagnosis is clinical by exclusion• Treatment is primarily by steroids and

immunosuppressives, debridement should be conservative

Acnes vulgaris

• A disorder of pilosebaceous follicles characterised by comedones and inflammatory papules, pustules, ornodules affecting skin where they aredensest.

• The patient may be distressed by disfiguring scars and pain, as well as psychologically.

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• Genetic factor and androgens are important. Follicular epidermal hyperproliferation and plugging causes retention of sebum which is produced in excess. Propionibacterium acnes, a commensal, promotes inflammation

• Hydrogen peroxide, retinoids, antibiotics (topical or systemic) and oral contraceptive pills (in females) have been found useful. Avoidance of junk foods is believed helpful.

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Sebaceous Hyperplasia

• This is due to enlarged sebaceous glands presenting as small yellow bumps up to 3 mm

• More in the elderly or immunosuppressed• Treatment is conservative. Light cautery,

or laser may help. When severe, oral isotretinoin may be useful.

Hidradenitis suppurativa

• A chronic indolent infection affecting where apocrine glands abound, e.g. armpits, groins, with aggregates of subcutaneous abscesses, discharging sinuses and cellulitis

• Thought to be due to plugging of apocrineglands

• Surgical excision under antibiotics is usually needed

• Resultant defects may be recnstruction

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Naevus of Ota

• A bluish disfiguring discoloration affecting one side of the face usually Va or Vb more common in females, sometimes with scleral involvement

• Due to entrapment of melanocytes in the upper dermis

• Cutaneous component remarkably response to QS-laser.

• Screen for eye complications

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Melancytic Naevus

• = mole, a collection of normal melanocyticcells in the skin

• A giant melanocytic naevus is a congenital large sized melanocytic naevuson the body:– Size: varied criteria, e.g. > patient’s palm– Risk of malignancy especially first 2 decades– Cosmetic concern

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Cafe au lait Macule

• A flat patch of well-circumscribed, hyperpigmented brown lesion on the skin of the face or body

• Occasionally syndromic, e.g. neurofibromatosis type 1

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Becker naevus

• A congenital or acquired epidermal naevus• Due to overgrowth of the epidermis,

melanocytes and hair follicles • Usually develops during childhood or

adolescence on the shoulders or upper trunk

• May be responsive to laser

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Lentigines

• = (pleural of lentigo) are small brownishspots with a clearly-defined edge due to melanocytic proliferation in the basement membrane

• Unrelated to sun exposure • Often seen in young children

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Freckles

• (= ephelis) are flat brownish patches on the face

• Caused by an increased amount of melanin in a normal number of melanocytes.

• Typically increase in number and darkness with sunlight exposure

• More common in fair skin

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Melasma

• Tan-coloured well demarcated patches especially on the cheeks of middle-aged women

• Likely to be related to female hormones and sun exposure

• Laser is only effective if melanin deposition is epidermal. Hydroquinone, tretinoin and peel may help.

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Syringoma

• This is a skin-colored or yellowish firm rounded bump, 1-3 mm in diameter, occurring in clusters on the eyelids especially of middle aged females

• Caused by sweat duct proliferation or tumors

• Of cosmetic significance only

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Xanthelasma

• Yellow plaques most commonly on the inner canthus of the eyelids, more often the upper, often somewhat symmetrical and may progress

• May be associated with elevated plasma lipids and hyperlipidaemia

• May be treated with excision, laser, chemical cautery or cryotherapy but recurrence is common

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PWS

• A birthmark which is a vascular anomalyof dilated cutaneus capillaries giving a reddish to purplish discoloration to the skin, often flat but grows in size with child and darkens and may form nodules in later life

• May be syndromal , e.g. Sturge–Weber,Klippel–Trénaunay–Weber

• Laser may help in some

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Venous lake

• Dark blue-to-violaceous compressible papules on the lips or ears in elderlies

• Caused by dilation of venules• Laser or excision can be useful

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Rosasea

• A chronic and indolent condition characterized by facial erythema and flushing associated with various stimulations

• Aetiology often unknown• Laser treatment may help

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Malignant lesions

SCC

• Cutaneous scc is cancer of the more superficial lying keratinocytes of squamous epithelium

• The tumour grows initially as a nodule but soon ulcerates with raised everted edges

• Predilection for sun exposed areas• Tendency to disseminate• A Marjolin's ulcer is scc arising in

previously traumatized, chronically inflamed or scarred skin

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• Mohs surgery is removal of tumour edges in small bits for frozen section control to obtain clear margins in order to reduce the size of the resultant defect for lesions on the face

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BCC

• A malignant skin tumour that rarely metastasizes but can cause significant local destruction if left

• Arises from cells in the basal layer of the epidermis

• The commonest skin cancer• Presents in 5 forms: nodular, infiltrative,

micronodular, morpheaform, superifical

• Papules with central depression, Pearly, Ulceration, Pigmented, Rolled border, Telangiectases

• Growth is usually very slow• Predilection for sun exposed areas• Mohs surgery also applicable

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Melanoma

• A malignant tumour of melanocytes• Presents as a dark skin lesion• 5 clinical types: Lentigo maligna, acral,

superifical spreading, nodular, mucosal• Rare in Orientals but more common in

Caucasians especially living near the Equator.

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• Suggestive clinical features: asymmetrical, border irregularity, multiple colours, diameter bigger than 6mm, enlarging/ elevated.

• Suspicious features in a mole changing malignant: recent growth in size, satellite lesions, irregular/ change in pigmentation, ulceration, irregular outline, ulceration/ bleeding, itching/ pain, LN

• Dx: excisional biopsy• Treatment: complete surgical excision

with an adequate margin can be curative in early cancer.

• Prognosis: tumour depth (Breslow), T-stage, ulceration, lymph node metastasis.

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• Sentinel LN biopsy is the use of cutaneouslymphoscintigraphy to identify regional lymphatic basins at risk for metastasis from truncal or head/neck primary melanomas that have ambiguous drainage patterns to determine whether lymph node dissection is indicated in early stage melanomas

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Bowen’s Disease

• An epidermall in-situ form of SCC, also known as Erythroplasia of Queyrat if occurring on the glans or prepuce

• Presents as a persistent very slowly growing, well demarcated erythematousplaque with an irregular border andsurface scaling mimicking eczema

• Predilection in elderly females• Excision is an option in treatment

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EMPD

• Extramammary Paget’s disease is a rare, slow-growing, intraepithelial adenocarcinoma more usually affecting the apocrine gland-bearing areas, e.g. genitals, perineum and axilla.

• Presents as a patch of itchy eczematous rash often ignored for some time in an elderly

• Apart from location, morphologically and histologically identical to PD of the nipple

• Associated with internal malignancies, e.g. gastrointestinal, urologic, gynaecologic, which should be screened

• Usually treated by wide surgical excision with frozen section margin control or radiotherapy, reconstruction may be required

• Tendency to recur• Potential to develop invasive CA

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Merkel cell CA

• Am extremely rare but aggressive skin cancer that develops from cells of neuroendocrine origin. They are most often found on the head, neck, and arms but can start anywhere.

• Believed to be related to Merkel cell polyomavirus (MCPyV) in susceptible people.

• Usually presents as a firm red skin nodule• Dx is often made upon biopsy

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• Predilection to spread to lymph nodes and internal organs.

• Treatment: wide local excision + regional node dissection if early

• Tendency to recur

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DFSP

• A rare sarcoma of the dermis of low to intermediate malignancy

• Presents as a very slow growing firm lump in the skin of a middle aged person especially on the torso

• Dx is by core tissue biopsy • Wide local excision is the treatment of

choice in early disease

• Tendency to recur locally or distantly • Prognosis is much worse when

dissemination occurs

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Cutaneous Angiosarcoma

• A rare very aggressive cancer of endothelial cells that line vessel walls

• Presents as violaceous flat patches of recent onset in the skin, especially the scalp and face, resembling bruises, typically in an elderly

• Diagnosis is often delayed• Readily metastasizes

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• Readily recurs after treatment• Prognosis is very poor• Very wide excision with reconstruction is

the treatment in early cases

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Dysplastic naevus

• = atypical mole• often larger than ordinary moles, with

irregular and indistinct borders, unevencolour, and may be raised

• increased risk for melanoma, especially when multiple

• Inherited dysplastic nevus syndrome is autosomal dominant and, if from a melanoma kindred, is associated with a very high risk of melanoma

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Cylindroma

• A dermal appendage tumour characterized by cylinders of hyalinized or mucinousstroma separating by nests of epithelial cells

• Commonly occurs as a nodule on the scalp, and when multiple, may coalesce to form the turban tumour

• May turn malignant as slow-growingtumours which tend to spread locally via the nerves

Sebaceous CA

• A rare but aggressive cancer from the glands in the skin and very commonly affects the eyelids

• Presents as a yelloish nodule in the lid and may be accompanied by conjunctivitis

• Dx is by biopsy• Spreads readily• Complete excision is the treatment if

possible, Mohs micrographic surgery may be applied

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Secondaries

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Clinical Diagnosis

• Physical characteristics• Patient demographics• Symptoms• Location• Growth pattern• Systemic disorder

Workup

• Biopsy– Indications:

• Malignancy• Doubtful diagnosis

– Method:• Excisional• Incisional/ Shave/ Punch

• Regional/ Systemic evaluation

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Treatment Approaches

• Curettage• Electrocautery• Cryosurgery• Excision• Laser

Histology

• All excised specimens must be sent for histological examination

• Doubt about diagnosis means biopsy and histology are mandatory