Northland DHB SKIN Northland DHB SKIN SERVICESERVICE

Plastics updatePlastics update

Northland DHB SKIN Northland DHB SKIN SERVICESERVICE

Plastics updatePlastics update

Peter Allen, plastics moss

David J M Crabb FRACS (GEN), FRACS (plastic)

Peter Allen, plastics moss

David J M Crabb FRACS (GEN), FRACS (plastic)

Nested within general surgery

Primary triage Peter Allen

Secondary triage D. Crabb

supported by Clinic staff, Pathway coordinator

General surgery, Gypsy service network, combined clinics with Opthalmology

and TBA with ENT.

Nested within general surgery

Primary triage Peter Allen

Secondary triage D. Crabb

supported by Clinic staff, Pathway coordinator

General surgery, Gypsy service network, combined clinics with Opthalmology

and TBA with ENT.

The DHB SKIN SERVICE

Plastic section

The DHB SKIN SERVICE

Plastic section

Introduction non surgical treatment

of skin cancer

Introduction non surgical treatment

of skin cancer

categorizes the clinical picture at glance

includes full spectrum of progression

useful tool to decide approach

helpful to decide surgery/topical

combined with photo, biopsy ,growth rate

categorizes the clinical picture at glance

includes full spectrum of progression

useful tool to decide approach

helpful to decide surgery/topical

combined with photo, biopsy ,growth rate

The Hutt DHB Plastics visual scale

Non Melanomatous lesions

The Hutt DHB Plastics visual scale

Non Melanomatous lesions

The clinical Picture The clinical Picture

Is mixed

Presenting lesion

with background of many others

Deciding which are surgical?

Which are non surgical?

2

Is mixed

Presenting lesion

with background of many others

Deciding which are surgical?

Which are non surgical?

2

The borderline The borderline

digital palpation

Thickened lesion implies dermal invasion

Ulceration

Failure to respond

Beware the Morphoeic BCC

exception, scarring feels flat

Biopsy, biopsy, biopsy

digital palpation

Thickened lesion implies dermal invasion

Ulceration

Failure to respond

Beware the Morphoeic BCC

exception, scarring feels flat

Biopsy, biopsy, biopsy

Problem can be staged

Progression and evolvement is non linear

Problem can be staged

Progression and evolvement is non linear

Ephemeral solar keratosis, comes and goes

in various places

Ephemeral solar keratosis, comes and goes

in various places

Persisting solar keratosis, waxes and wanes

in same place

Persisting solar keratosis, waxes and wanes

in same place

progresses to established lesion, such as superficial

BCC but may be SCC or more aggressive lesion

progresses to established lesion, such as superficial

BCC but may be SCC or more aggressive lesion

Background photo-ageingBackground photo-ageing

Irradiation damage UV+UVB Irradiation damage UV+UVB

Total life time dose in exposed areas, about 100,000hrs

graduated change over life course

Accelerates in older age

Made worse by suppressed or impaired immunity

Related to genetics of skin type and evolutionary biology

Total life time dose in exposed areas, about 100,000hrs

graduated change over life course

Accelerates in older age

Made worse by suppressed or impaired immunity

Related to genetics of skin type and evolutionary biology

Biological Anthropology Biological Anthropology

all Humans migrating from Africa were black, 65,000 yrs

Migration behind melting ice sheets required adaptation to lower northern light levels

skin becomes whiter/lighter and thinner

Allows penetration of available light for Vit D synthesis

Nature very precisely calibrates the skin, thickness and color

Optimised for Vit D production without collateral damage

all Humans migrating from Africa were black, 65,000 yrs

Migration behind melting ice sheets required adaptation to lower northern light levels

skin becomes whiter/lighter and thinner

Allows penetration of available light for Vit D synthesis

Nature very precisely calibrates the skin, thickness and color

Optimised for Vit D production without collateral damage

36 degree latitude is same as southern spain or northern morocco

36 degree latitude is same as southern spain or northern morocco

stem cells in dermal base have 5 different enzymes to repair fragmented

nucleic acids

stem cells in dermal base have 5 different enzymes to repair fragmented

nucleic acidsDendritic cells that mediate immunity have large target nuclei,

vulnerable

Dendritic cells that mediate immunity have large target nuclei,

vulnerable

Treatment Principles RequireTreatment Principles Require

reduced irradiation into dermis equivalent to (pureblood) maori skinreduced irradiation into dermis equivalent to (pureblood) maori skin

repair/restoration assistance to dendritic and stem cell

population

repair/restoration assistance to dendritic and stem cell

population

assisted apoptosis of abnormal cell populationassisted apoptosis of abnormal cell population

treat the whole problemtreat the whole problem

Treatment Treatment

A screening cream with equivalent protection to Maori skin

addition of anti oxidants into cream to assist self repair by damaged cells to

assist

Stem cells for cell replacement and Dendtritic cell for cell monitoring/tagging

A screening cream with equivalent protection to Maori skin

addition of anti oxidants into cream to assist self repair by damaged cells to

assist

Stem cells for cell replacement and Dendtritic cell for cell monitoring/tagging

Clears ephemeral solar keratoses

dampens cellular background activity

Assists Dendritic cell role in Apoptosis

When combined with seasonal therapeutic creams (Effudix/Aldara) will

dramatically reduce frequent flyers

Clears ephemeral solar keratoses

dampens cellular background activity

Assists Dendritic cell role in Apoptosis

When combined with seasonal therapeutic creams (Effudix/Aldara) will

dramatically reduce frequent flyers

Result Result

seasonal Treatment

My practice

seasonal Treatment

My practice

winter 5 flurouracil to treat background ephemeral and

some persisting solar keratoses, 3 pulsed cycles

winter 5 flurouracil to treat background ephemeral and

some persisting solar keratoses, 3 pulsed cycles

Atumn check repose, identify non responders, surgical propositions

Summer then escalate Aldara / cryotherapy

Atumn check repose, identify non responders, surgical propositions

Summer then escalate Aldara / cryotherapy

winter back to 5FU if neededwinter back to 5FU if needed

spring check up prior to

aldara/screening cream, surgical

propositions

spring check up prior to

aldara/screening cream, surgical

propositions

Seasonal topical treatment cycle

Winter

Seasonal topical treatment cycle

WinterWinter topical, 5 Fluorouracil given in pulsed mode 3 to 4 cycles

With Hydrocortisone 1% in rest periods

Ideal for the multiple persisting solar keratotic background activity

Winter topical, 5 Fluorouracil given in pulsed mode 3 to 4 cycles

With Hydrocortisone 1% in rest periods

Ideal for the multiple persisting solar keratotic background activity

Hutt stage 1 and above will be present in all lesions as a

background to the presenting lesion

Hutt stage 1 and above will be present in all lesions as a

background to the presenting lesion

Patient is often motivated to act on prevention after

surgical episode

Patient is often motivated to act on prevention after

surgical episode

11

Seasonal topical treatment cycle

Atumn

Seasonal topical treatment cycle

AtumnPersisting solar keratosis if it is non responsive to

5FU

(suitable Hutt 1 and 2, not all may respond)

will need Aldara or cryotherapy

Persisting solar keratosis if it is non responsive to

5FU

(suitable Hutt 1 and 2, not all may respond)

will need Aldara or cryotherapy

Aldara ideal for early lesions including Hutt 3

superficial BCC

Suitable for up to 6 lesions, otherwise systemic effect

5 weeks, 5 days and then stop, pm application

combined with Am screening cream

Aldara ideal for early lesions including Hutt 3

superficial BCC

Suitable for up to 6 lesions, otherwise systemic effect

5 weeks, 5 days and then stop, pm application

combined with Am screening cream

Seasonal topical treatment cycle

summer

Seasonal topical treatment cycle

summer

Superficial BCC with little infiltration should

respond To Aldara but may not

Adjacant Hutt 1 and 2 will go with Effudix

Superficial BCC with little infiltration should

respond To Aldara but may not

Adjacant Hutt 1 and 2 will go with EffudixCryotherapy about the same effectiveness to Aldara

Good for scalp and non facial area

often more convienant than topical ie shorter

White scar on face

If not effective first time unlikely second will do

Surgery for non responders

Cryotherapy about the same effectiveness to Aldara

Good for scalp and non facial area

often more convienant than topical ie shorter

White scar on face

If not effective first time unlikely second will do

Surgery for non responders

33

Surgical reconstructive treatmentSurgical reconstructive treatmentAll incomplete removals come forward to frozen

section

all prior surgery and scar must be removed

F/S control for all margins and then immediate or

delayed reconstruction

Same for significant primary tumours involving

sensitive structures in the face

Perineurial invasion on SCC treated as Melanoma

All incomplete removals come forward to frozen

section

all prior surgery and scar must be removed

F/S control for all margins and then immediate or

delayed reconstruction

Same for significant primary tumours involving

sensitive structures in the face

Perineurial invasion on SCC treated as Melanoma

Reconstructive surgery is often but not always stagedReconstructive surgery is often but not always staged

Avoiding the unescessary escalationAvoiding the unescessary escalation

Fat grafting for subcutaeous contour regeneration

additional toolbox in staged reconstruction

Fat grafting for subcutaeous contour regeneration

additional toolbox in staged reconstruction

two flap nose and

cheek extensive

BCC

frozen section

clearance

two flap nose and

cheek extensive

BCC

frozen section

clearance

fat grafting compensates for

loss of cheek sub cutaneous

volume

fat grafting compensates for

loss of cheek sub cutaneous

volume

Recontruction often multi staged with large

step escalation

Recontruction often multi staged with large

step escalation

small lesions can be much

larger on Frozen Section

small lesions can be much

larger on Frozen Sectionlarge defects with lining often need tissue

expansion

large defects with lining often need tissue

expansion

where do we start

first consult

where do we start

first consultbody check

background activity

history of lesions/prior surgery/recurrence

get your fingers on it

surgical propositions first

Screening cream with anti oxidant will calm and treat S/K

Aldara for 6 worst non surgical ones/repeat

Cryotherapy about equivalent to Aldara but white mark

Effudix given early if needed or delayed to winter

body check

background activity

history of lesions/prior surgery/recurrence

get your fingers on it

surgical propositions first

Screening cream with anti oxidant will calm and treat S/K

Aldara for 6 worst non surgical ones/repeat

Cryotherapy about equivalent to Aldara but white mark

Effudix given early if needed or delayed to winter

summary, treat the entire problemsummary, treat the entire problem

Early lesions need management

train the patient to self manage

A stitch in time saves 9

biopsy is a wonderful operation

if you cant get it all don't try it might need a really big hole

Multiple biopsies give useful information

If in doubt always skin graft as local tissue is precious

Early lesions need management

train the patient to self manage

A stitch in time saves 9

biopsy is a wonderful operation

if you cant get it all don't try it might need a really big hole

Multiple biopsies give useful information

If in doubt always skin graft as local tissue is precious

Thank you for your attention

Best of luck its a big problem

Thank you for your attention

Best of luck its a big problem