Six dermatologists discuss how to identify common but important skin conditions in patients presenting for aesthetic procedures
Since the lockdown began in March 2020 to help curb the spread of COVID-19, we have seen a noticeable rise in patients presenting to aesthetic clinics. Save Face, a national register of accredited practitioners, has seen a 40% increase in traffic to its website, with the public researching aesthetic treatments and going on to source local practitioners.
One of the most common reasons patients present to clinics are concerns around the physical signs of ageing on the skin. Practitioners then, are in a prime position to spot more serious skin concerns, and advise and refer them accordingly, sometimes catching them earlier than they might otherwise have. In this article, six dermatologists discuss common skin concerns and how to recognise and diagnose them.
Characteristics: Appearance of an open sore that does not heal, a reddish or irritated area, a shiny bump or nodule, a small pink growth or a scar-like area.
Can be confused with: Sebaceous gland hyperplasia, psoriasis, dermatitis, eczema, lichenoid keratosis, other skin cancers like melanoma, and precancers like actinic keratosis.
BCC is the most common skin malignancy in the UK, with more than 100,000 cases per year.1 BCC is seen more with advancing age, though the condition is observed increasingly in those in their late 20s and 30s.2 Those with fair skin, a tendency to burn in the sun, and a history of excessive sun exposure are more at risk. The lag period between sun exposure and developing BCC can be several decades, so a recent history of sun exposure is not relevant. BCC is usually a condition affecting white ethnic populations though 0.4% of lesions are reported to have occurred in mixed race individuals and those from Indian, African and Chinese backgrounds2 so it is important to be aware of this diagnosis even in skin of colour.
Virtually every aesthetic practitioner is likely to encounter BCC in their career. In diagnosing a BCC, the history of a new or growing lesion that intermittently scabs or bleeds is very helpful. Any aesthetic practitioner should also be familiar with the range of appearances of a BCC and various free online atlases are easily accessible.3 While BCC does not cause mortality, it is important for practitioners to recognise BCCs as early treatment can significantly reduce morbidity. Mistreatment can delay diagnosis and increase morbidity. Unlike inflammatory lesions, a BCC is persistent and never comes and goes. A BCC grows slowly with time, doubling every six to 12 months.4 Early lesions are symptomless. Eventually, lesions ulcerate, bleed, and form a scab. Ulceration and scabbing may occur in cycles, and the lesion appears to apparently ‘heal’ in the intervening periods when the scab clears – only to break down again a few weeks or months later. This can give a false sense that the lesion has improved. The three main types of BCC have distinct clinical appearances: superficial BCCs, nodular BCCs and morphoeic BCCs.
Superficial BCCs: present as a circular eczema like patch and develop a rolled, raised edge that can be seen with a side light. Unlike eczema, a superficial BCC is usually a non-itchy single patch impervious to moisturisers or steroid creams. Superficial BCC can also mimic fungal rashes and psoriasis, and very occasionally pink seborrheic keratoses can also look like a superficial BCC.5,6
Nodular BCCs: are translucent papules which become nodules as they grow. A rolled edge develops if the centre ulcerates. Linear and arborising telangiectasias are seen under the dermatoscope, sometimes looking like benign moles, particularly skin-coloured mature moles. Nodular BCC can also look like benign cysts or a fibrous papule, a benign red or skin coloured dome like spot that most commonly occurs on the nose.5,6
Morphoeic BCCs: are much more subtle and can look like an ivory white area of skin thickening, much like a scar or localised area of morphoea. The presence of a ‘scar’ without the history of trauma or surgery ought to raise suspicion that the lesion could be a BCC. Induration is a helpful sign in detecting BCCs, especially for nodular and morphoeic BCC, where the skin surrounding a lesion feels thickened when it is palpated or pinched. Induration occurs as roots from the BCC are extending beyond a lesion.5,6
Sebaceous gland hyperplasia can also look like a nodular BCC. Sebaceous gland hyperplasia are common on the forehead and cheeks of middle-aged people. They can usually be diagnosed with a dermatoscope where a yellow spot is seen, that has multiple yellow globules and a central crater. Telangiectasias usually do not branch much and do not cross the centre.7 Mature moles, also known as intradermal naevi, and fibrous papules, which are both benign lesions, can also be confused with nodular BCC. In patients with a history of BCC, it is important to note that inflamed spots due to acne or rosacea will usually clear within six to eight weeks, whereas BCC will persist.
Any practitioner treating moles, seborrheic keratoses, skin tags and cysts with destructive methods for cosmetic reasons, such as advanced electrolysis or laser shouldn’t hesitate to refer to a dermatologist if the lesions do not look absolutely typical. Only treat benign lesions with destructive methods if you are clinically sure of the diagnosis, and if there is any doubt refer.
Dr Sajjad Rajpar is a consultant dermatologist, laser specialist and Mohs surgeon at Belgravia Dermatology and Midland Skin Clinic.
Characteristics: Erythematous, scaly skin lesions, can involve nails and joints, is associated with several comorbidities, including cardiovascular disease and has significant psychosocial morbidity.
Can be confused with: Seborrheic dermatitis, fungal skin infection, fungal nail infection, secondary syphilis.
Psoriasis is a chronic inflammatory multisystem disorder which predominantly affects the skin but can be associated with nail and joint involvement and an increased risk of cardiovascular disease affecting 2% of the population. Age of onset occurs in two peaks: 20-30 years of age and 50-60 years of age. Men and women are affected equally.8 Due to the potential negative impact on patients’ mental health,9-13 aesthetic practitioners may well be consulted and correct diagnosis and onward referral to appropriate specialists is essential. The aetiology of psoriasis is multifactorial. It occurs due to a combination of genetic, immunological and environmental factors. Known exacerbating factors for psoriasis include stress, skin trauma, obesity, alcohol, medications, and sudden withdrawal of systemic steroids.8
There are several different types of psoriasis, amongst others:8,13
The prevalence of psoriatic arthritis increases with age and appears to be higher amongst patients with more severe psoriasis and those with nail involvement. Nail involvement is very common and includes pitting, distal onycholysis (separation of the nail from the nail bed), oil spots and subungual and proximal hyperkeratosis (thickened skin). There may also be proximal nail fold inflammation with loss of the cuticle. Fingernails are more likely to be affected than toenails.
Management of psoriasis should include a review of associated lifestyle factors and triggers. The choice of treatment depends on disease severity, treatment history and level of compliance.11
Appropriate first-line treatment for patients with limited psoriasis is centred on emollients in combination with active topical treatments.10 Emollients help soften scale, relieve itch, and reduce discomfort. The choice of emollient should be directed by patient preference and should be prescribed in large quantities. Active topical treatments include topical steroids, topical vitamin D3 analogues, salicylic acid and coal tar preparations. Topical corticosteroids should be used in caution due to risk of adverse effects such as skin thinning, purpura and secondary skin infection.10
For patients with more extensive disease, phototherapy, oral retinoids, methotrexate and biologics12,13 are all recommended as systemic treatments. A referral to secondary care will be required to discuss systemic therapy.
Dr Mia Steyn is a final year dermatology registrar and Dr Rakesh Anand and Dr Emma Craythorne are both consultant dermatologists, all at St John’s Institute of Dermatology, Guy’s and St Thomas’ Hospital.
Characteristics: Asymmetry, rough edges, mottled colouring with shades of brown, black grey, red or white, a diameter greater than 6mm.
Can be confused with: Benign moles, seborrheic keratosis, solar lentigines.
The incidence of melanoma in the Caucasian population in the UK is doubling every 10 years and occurs in roughly 10 per 100,000 people per year.14 Approximately 10% of all cutaneous malignant melanomas are familial where two or more first degree relatives have a melanoma.14 Intermittent exposure of fair skinned individuals to intense sunlight is thought to be the main cause of the steadily increasing incidence of melanoma.
Early diagnosis of melanoma is critical and there is evidence that melanoma publicity campaigns, regular self-examination and education of healthcare works have reduced mortality. This incidence remains very low amongst darkly pigmented populations of African, Asian and Hispanic origin; however, one can still get melanoma in unusual sites such as the nail bed or the sole of the feet and can be associated with a worse prognosis as often recognised late.14,15
Aesthetic practitioners come from a range of backgrounds and do not always deal with melanoma or skin cancer. However, their patient will be seeing them with a desire to improve their skin and it is not uncommon for a patient to ask about a mole they may be considering removing cosmetically. Equally, a practitioner may notice an unusual mole that the patient has not paid attention to, and it is important to know what to do if this occurs.
Other pigmented lesions can be confused with melanoma. Many patients over the age of 50 may have superficial scaly pigmented lesions called seborrheic keratoses. Others may have uniformly pigmented lesions on the face known as solar lentigines which are harmless but a marker of photoageing. Dermoscopy can be helpful in differentiating these, but this requires training in its use.16
The appearance of a pigmented lesion is important. It may be there is an unusual shape to a lesion, or there may be a variation in colour that immediately is obvious. A practitioner should then ask the patient whether there has there been a change in shape, size or colour? Is there a family history of skin cancer?
Sun and UV exposure should be a key question in any consultation as photoageing is a major factor in the ageing face. Excessive use of sun beds, frequency of sunny holidays, occupation which may be related to the outdoors, or having lived or worked abroad should be explored.
Does the individual have other moles that are not immediately obvious or are not regularly seen, such as on the back? We, as aesthetic practitioners, are in an excellent position to discuss the monitoring of moles with patients. If a practitioner notices an abnormal mole I would recommend referring the patient to their GP, who would consider a referral via the two-week rule skin cancer pathway.
The key element with melanoma is early diagnosis and treatment. If one can identify a melanoma with a depth of less than 0.75mm, the 10-year survival rate is greater than 95%, whereas if the depth is greater than 4mm, the percentage 10-year survival falls to approximately 50%. This emphasises the importance and impact of delayed or missed diagnosis.17
Aesthetic practitioners are in the ideal position to provide advice about using adequate sun protection methods, which not only help with photoageing, but can reduce the cumulative sun exposure and risk of sunburn, and thereby the risk of melanoma. It is not an exaggeration that by simply being observant and aware of the above issues as part of your role as an aesthetic practitioner, you may save someone’s life.
Dr Daron Seukeran is a consultant dermatologist at James Cook University Hospital Teesside and group medical director at sk:n
Characteristics: Receding hairline, small red lumps, loss of eyebrows.
Can be confused with: traction alopecia, normal hairline, androgenic alopecia, alopecia areata.
Frontal fibrosing alopecia (FFA) is a type of permanent hair loss that affects predominantly the frontal hairline. It develops because of inflammation and destruction of the hair follicles but it is unclear why this particular area is affected more often than other areas. It may be insidious and progress without any symptoms but occasionally the skin may be itchy and painful. The hairline recedes slowly with or without redness and flaking and the skin will become pale and thinner. Occasionally other areas of the body may lose hair as well and small skin-coloured lumps may develop on the face.18-20 Recognising FFA regardless of the treatment the patient has come in for is important as early treatment prevents further permanent hair loss. Thorough history and clinical examination usually suffice to suspect the diagnosis, as well as surmising if a woman is of perimenopausal age. Often patients may not be aware that their hairline is receding early, and treatment delays usually lead to significant negative cosmetic outcome. FFA is usually diagnosed with clinical examination and often with the help of a dermatoscope. The best way to confirm the diagnosis is by taking a small sample (biopsy) from the edge of an active area to be examined.
Once the diagnosis is confirmed there are a variety of treatments that may stop the progression of the condition and the hair loss. The treatments may be topical: steroid creams and non-steroidal creams, injections, and tablets. Short courses of steroid tablets, hydroxychloroquine, a type of antibiotics or some hormonal treatments have been reported as effective. Unfortunately, there are no cures for FFA and the hair that has been lost will not grow back.
Hair transplantation is an option after several years of inactivity of the condition, but the overall survival of the transplanted hair follicles is usually low even in the setting of burnt-out disease. Some patients with more extensive hair loss will prefer to wear wigs. Without treatment, the receding of the hairline progresses with about 2mm to 2cm per year, but the condition usually stabilises after several years.18
Dr Kristina Semkova is a consultant dermatologist at the St John’s Institute of Dermatology Guy’s and St Thomas’ Hospital.
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