The diagnosis, differential diagnosis, and management of common skin lesions are crucial aspects of general practice, particularly in the context of Australian healthcare where skin conditions are common due to various factors including high levels of sun exposure.
Diagnosis
- Clinical History and Examination: The first step in diagnosing a skin lesion involves a thorough clinical history and physical examination. Important aspects of the history include the duration and evolution of the lesion, associated symptoms (like itching or bleeding), and any relevant personal or family history of skin diseases or cancers.
- Visual Assessment: Skin lesions are primarily diagnosed based on their appearance. Characteristics such as size, shape, color, texture, and any associated secondary changes (like scaling or ulceration) are noted.
- Use of Dermatoscopy: This tool enhances the visualization of skin lesions, particularly for pigmented lesions, and is helpful in differentiating benign from malignant lesions.
- Biopsy: If a lesion is suspicious, a biopsy may be necessary for definitive diagnosis. This could be a shave, punch, or excisional biopsy depending on the lesion’s characteristics.
Differential Diagnosis
- Benign Lesions:
- Seborrheic Keratosis: Warty, stuck-on appearance, commonly in older adults.
- Nevi (Moles): Uniform color and borders, common in all age groups.
- Skin Tags: Small, soft, pedunculated lesions typically in skin folds.
- Actinic Keratosis: Scaly, erythematous patches in sun-exposed areas, a precursor to squamous cell carcinoma.
- Malignant Lesions:
- Basal Cell Carcinoma (BCC): Pearly nodules, often with telangiectasia, mainly on sun-exposed areas.
- Squamous Cell Carcinoma (SCC): Hyperkeratotic, scaly lesion, can ulcerate, more aggressive than BCC.
- Melanoma: ABCDE – asymmetry, border irregularity, color variation, diameter >6mm and evolving are key features.
- Inflammatory Lesions:
- Psoriasis: Well-defined erythematous plaques with silvery scale.
- Eczema: Itchy, red, scaly patches, often in flexural areas.
Management
- Benign Lesions:
- Often no treatment is required except for cosmetic reasons or if the lesion is symptomatic.
- Simple procedures like cryotherapy, curettage, or excision can be used.
- Pre-Cancerous Lesions (e.g., Actinic Keratosis):
- Topical agents (5-fluorouracil, imiquimod).
- Cryotherapy.
- Regular monitoring.
- Malignant Lesions:
- BCC/SCC: Surgical excision with clear margins is the mainstay of treatment. Mohs micrographic surgery can be used for lesions in cosmetically sensitive areas or for recurrent tumors.
- Melanoma: Wide local excision, sentinel lymph node biopsy might be indicated. Advanced cases may require systemic therapies.
- Referral to a dermatologist, plastic surgeon or oncologist may be necessary for management of malignant lesions.
- Inflammatory Lesions:
- Psoriasis: Topical steroids, vitamin D analogs, phototherapy for more extensive disease, systemic agents for severe cases.
- Eczema: Moisturizers, topical steroids, avoiding triggers.
Prevention and Monitoring
- Regular skin checks, especially for individuals with high sun exposure, history of skin cancers, or familial predisposition.
- Sun protection measures including the use of sunscreen, protective clothing, and avoiding peak sun hours.
- Patient education about self-monitoring of skin lesions and when to seek medical advice.
Referral
- Suspected malignant lesions should be referred to a dermatologist.
- Complex or uncertain cases may also benefit from specialist referral.
Follow-up
- Regular follow-up is important, especially for individuals with a history of skin cancers or those with pre-cancerous lesions, to monitor for any changes or development of new lesions.
This approach ensures a comprehensive evaluation and management plan for skin lesions in the general practice setting, aligning with the guidelines of good medical practice.