Differential diagnosis - Examine pictures of BCC, Bowen's disease, actinic keratosis and psoriasis

Dr Nigel Stollery explains how to differentiate these similar-looking superficial skin lesions.

Superficial basal cell carcinoma

Presentation

  • Superficial basal cell carcinoma (BCC) is usually a solitary lesion, which grows slowly
  • Occurs on sun-exposed areas such as the trunk and lower legs
  • No response to topical steroids or antifungals
  • There is usually no associated itch or pain

Management

  • If the diagnosis is unsure, a punch biopsy can be useful
  • Without treatment, lesions may progress to a nodular BCC
  • Topical treatments such as imiquimod or 5-fluorouracil can be used
  • Other treatments include formal excision
  • Advice on sun care is important

BOWEN'S DISEASE

Presentation

  • More than one lesion may be present in a similar area
  • More common on sun-exposed areas such as the trunk and lower legs
  • Slow increase in size is common
  • There is usually no associated itch or pain

Management

  • If the diagnosis is unsure, a punch biopsy can be useful
  • Untreated, 2-3% may progress to squamous cell carcinoma (SCC)
  • Topical treatments such as imiquimod or 5-fluorouracil can be used
  • Other treatments include formal excision or cryotherapy
  • Advice on sun care is important

PSORIASIS

Presentation

  • Widespread disease common over the extensor surfaces of elbows and knees
  • The nails and scalp may also be affected
  • Plaques associated with thick silvery-white scale and well demarcated edges
  • Five per cent of patients may also have psoriatic arthropathy
  • Other family members may be affected

Management

  • Psoriasis may respond to treatment, but relapses are common over many years
  • Currently there is no known cure for the condition
  • Treatments include emollients and vitamin D analogues, used alone and in combination with topical steroids
  • Light treatment is useful in resistant or widespread disease
  • Biologics work very well in severe disease

ACTINIC KERATOSIS

Presentation

  • Lesions occur as a result of chronic sun damage and are common on the head and hands
  • Incidence increases with age
  • Usually multiple grey, rough, scaly macules or papules, rarely greater than 1cm in diameter
  • Transition to SCC may rarely occur and should be considered in lesions that do not respond to treatment
  • The diagnosis is usually clinical, unless SCC is suspected, when a punch biopsy can be useful

Management

  • Education is essential to prevent further damage
  • Topical treatments such as 5-fluorouracil are very effective
  • New treatments include ingenol mebutate, which only requires three days of treatment
  • Cryotherapy can be useful
  • For larger, very thickened lesions, curettage and cautery can be effective

 

Dr Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Before commenting please read our rules for commenting on articles.

If you see a comment you find offensive, you can flag it as inappropriate. In the top right-hand corner of an individual comment, you will see 'flag as inappropriate'. Clicking this prompts us to review the comment. For further information see our rules for commenting on articles.

comments powered by Disqus