Tony Chu - Skin Cancer2 59qa

Prevention and Management of Skin Problems Tony Chu Dermatology at Imperial College, Hammersmith Campus

Skin and Renal Transplantation  

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Renal transplantation demands systemic immunosuppression to prevent graft rejection Immunosuppression has a major impact on the skin increasing the incidence of infections, precancerous and cancerous changes in the skin Many of the skin problems related to immunosuppression can be reduced with appropriate advice and management Dermatology IC at Hammersmith

Immunosuppression and Infection 

Infections are more common in the immunosuppressed patient: Acute bacterial - folliculitis, furunculosis, abscesses, cellulitis, erysipelas Chronic infection - tuberculosis Viral infections - herpes simplex, warts Fungal - ringworm, tinea versicolor

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Most can be treated conventionally Dermatology IC at Hammersmith

Warts and the Immunosuppressed   

Warts are caused by the human papilloma virus They are commonest in childhood but a common nuisance at all times of life Human papilloma virus is now implicated in the development of cervical cancer - HPV types 16, 18, 45 and 31 parts of the viral DNA - E6 and E7 - link to specific genes in human cells, transforming them into cancer cells Dermatology IC at Hammersmith

Immunosuppression, Warts and Skin Cancer  

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Genetic model - Epidermodysplasia verruciformis Genetic immunosuppression predisposes to infection with specific wart viruses - HPV 5 and 8 Following sun exposure, the virus leads to transformation of skin cells into cancer cells and the development of squamous cell carcinomas Dermatology IC at Hammersmith

Warts in Renal Transplant Recipients    

Warts tend to develop after 4 to 5 years following transplantation Increased in sun exposed areas Many will contain EV warts virus or other oncogenic viruses Real risk of these warts developing into squamous cell carcinomas following sun exposure Dermatology IC at Hammersmith

Warts in Renal Transplant Recipients 

Management: Regular checks with a Dermatologist Treatment of all warts - usually use cryotherapy Avoid sun exposure

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One major problem is the number of warts that some recipients develop - can number in the thousands Dermatology IC at Hammersmith

Too Many Warts 

A number of our patients attend every 6 weeks and have >100 warts frozen Painful and time consuming

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Important to target all warts as you cannot predict which are potentially going to develop into skin cancers Imiquimod - cream that enhances immune systems ability to deal with viral infections used successfully in RTR without effects on the graft Dermatology IC at Hammersmith

Skin Cancer and Renal Transplant Recipients 

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In the normal population, the commonest type of skin cancer is the basal cell carcinoma ( basal cell carcinoma : squamous cell carcinoma is 10:1) In the renal transplant recipient, squamous cell carcinomas are 10X as common as basal cell carcinomas Squamous cell carcinomas are metastatic - can spread to other parts of the body - and this is increased with immunosuppression Dermatology IC at Hammersmith

Skin Cancer and Renal Transplant Recipient    

Incidence of melanoma is greatly increased in the renal transplant recipient Melanoma is the most aggressive skin cancer seen in man These may arise from pre-existing moles or come up in normal skin Melanomas are often more aggressive in the immunosuppressed Dermatology IC at Hammersmith

Skin Cancer  

The major factor in skin cancer formation is sun exposure Skin type is also important in dictating how the skin reacts to the sun Pale Celtic skin is most at risk Dark afrocaribean skin is least at risk

Dermatology IC at Hammersmith

The Sun and Man Effects on the skin are acute and chronic  Acute - protective - Skin tanning - Epidermal thickening - Sun burn 

Chronic - Photocarcinogenesis - Photoaging Dermatology IC at Hammersmith

Ultraviolet Spectrum

UVC X rays

UVB

UVA

100-280 280-210 310-400

Visible

Dermatology IC at Hammersmith

X-ray

UVB UVC UVA 100-280 280-315 315-400

Visible Light 400-700

Stratosphere - Ozone Layer

Dead Sea Level

Sea Level

Basal Cell Carcinomas    

Commonest skin cancer in Caucasian populations Major cause is sun exposure Common sites on face and trunk Not metastatic

Dermatology IC at Hammersmith

Squamous cell carcinoma      

Second most common skin cancer in Caucasian populations Caused by sun exposure - chronic sun exposure Most at risk are those with pale skin who burn in the sun Commonest on sun exposed areas Pre-cancerous lesion is the solar keratosis Metastatic potential - to regional lymph nodes, then liver, lungs etc Dermatology IC at Hammersmith

Melanoma     

Third most common skin cancer Caused by severe intermittent bouts of sun exposure Found on sun exposed and non-exposed sites Second most common cancer to affect young women High metastatic potential - local, lymph nodes, lung, liver and brain Dermatology IC at Hammersmith

Melanoma 

30% arise in a pre-existing mole Features to look out for are asymmetry of the mole, irregular shape and irregular colour

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Most commonly arise in normal skin in renal transplant patients

Dermatology IC at Hammersmith

Methods of Preventing Long Term Skin Damage    

Avoid sun Avoid midday sun Use photo-protective clothing, hats etc Use sunblocks

Dermatology IC at Hammersmith

Avoid Sun    

Almost impossible Society worships the bronzed body beautiful Even on a cloudy day, UV will get through to the earth’s surface Sunlight is tricky - it will reflect off water, sand and other structures and can get to you even in the shade Dermatology IC at Hammersmith

SEA Sand

Avoid the Mid-day Sun  

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Simple physics At mid-day the sun is directly above you and the amount of stratosphere it need to penetrate to get to you is less so more gets through Avoid sun exposure for an hour or two either side of mid-day

Dermatology IC at Hammersmith

UV Radiation path lengths for differing Solar Elevations Sun Directly Overhead

3pm

Midday

Y

Y

X

Surface

EARTH

Atmosphere

UV Protective Clothing    

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The finer the weave, the greater the protection Silk is best Nylon stockings have an SPF of about 2 Panama hats give poor protection - holes let light through Cotton cricket hat is better

Dermatology IC at Hammersmith

Sunscreens 

Reflectant

-

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Absorbent

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reflect UVB and to a lesser extent UVA absorb principally UVB into specific chemicals and reemit as insignificant quantities of heat

Dermatology IC at Hammersmith

Sun Protection Factor  

Indication of the amount of time it is safe to spend in the sun without burning ie an SPF of 10 would allow an exposure ten times greater than normal

Dermatology IC at Hammersmith

How can the Renal Transplant Recipient Avoid Skin Cancer     

Proper counselling before and after transplantation Regular use of high factor sun blocks - SPF 60, regardless weather Sun protective clothing Avoid intense sun exposure Avoid the mid-day sun Dermatology IC at Hammersmith

How can the Renal Transplant Recipient Avoid Skin Cancer   

Seek advice and treatment for any warts that come up Regular screening by Dermatology Department after 5 years post transplant Urgent advice about lumps that come up on the skin or moles that are changing

Dermatology IC at Hammersmith

How can the Renal Transplant Recipient Avoid Skin Cancer 

Effect of immunosuppressant Azathioprine and cyclosporin seem to have the same effect on the skin Likely that tacrolimus will be the same Anecdotally, one patient who was developing a squamous cell carcinoma every 6 weeks was changed to mycophenolate mofetil with no detriment to his renal function and has been free of tumours for 6 months Dermatology IC at Hammersmith