Category: Work and accident related injuries

SKIN CANCER: CAUSATION, DETECTION, TREATMENT AND PREVENTION

CAUSATION

Skin cancer can arise via the action of genetic and environmental factors and the interaction of these determinants.

Genetic factors are a very important determinant of the predisposition to develop skin cancer and in many situations, can be the main operative factor.

Environmental factors alone or in combination with genetic factors account for a large proportion of observed skin carcinomata

Generally, the most important environmental factor is exposure to radiation that usually involves sun exposure that can be recreational, work related or often both.

Therapeutic use of ultraviolet light and exposure to x rays can induce skin carcinomata.

Exposure to some chemicals such as arsenic and petroleum by products found in some work environments can be carcinogenic.

Occasionally, skin carcinomata can arise at the sites of previous physical trauma, in scarred areas or from low grade skin irritation seen in some inflammatory skin conditions.

Individuals that have a compromised immune system either produced by illness or immunosuppressive drugs are at a heightened risk of developing malignant and premalignant skin lesions. A compromised immune system can compound the risk posed by other causative factors outlined above.

DETECTION

The primary method of detection of skin carcinomata is by visual inspection by a suitably qualified medical practitioner. However, awareness by an individual of a skin lesion that is suspicious or “not quite right” is often an initiating event that leads to a medical consultation. Despite individuals’ reticence to self-diagnose, their perception of abnormality may be well founded and should not be ignored.

Over recent times the availability of online images of abnormal skin lesions has enhanced the community’s awareness of the presentation of abnormal skin lesions. This facility can also sometimes provoke unnecessary anxiety.

Medical diagnostic software to detect abnormal moles has been developed to aid in the diagnosis of abnormal skin lesions, however this aid has not yet reached the level of reliability to be solely relied upon in diagnosis.

Smartphone attachments and apps are now available to diagnose abnormal skin lesions but are significantly inferior to medical grade computer assisted diagnostic tools.

A handheld magnifying instrument (called a dermatoscope) is a useful adjunct to naked eye diagnosis by trained medical personnel.

The mainstay of diagnosis is by pathological histological examination after a skin biopsy or excision specimen has been obtained. This procedure allows for an exact pathological diagnosis to be made and in the case of skin cancer can often allow for a more accurate prognosis.

TREATMENT

Skin cancers and premalignant skin lesions can be treated using several methods

The most definitive method of treating these lesions is by surgical excision however less aggressive lesions can be treated by other surgical and medical modalities

Other surgical techniques include shaving, curetting, electro-desiccation and cryotherapy

Medical treatments can include topical and oral anticancer medications, phototherapy and x ray therapy.

It is not uncommon for combinations of these treatments to be used

PROTECTION

The best protection against developing skin cancers and pre-malignant skin lesions is protection from avoidable environmental influences.

In the case of ultraviolet radiation this includes covering via clothing and the use of sunscreens and avoiding recreational or occupational sun or tanning parlour exposure.

Care also needs to be exercised to avoid industrial carcinogens. These are usually well documented

Recently several oral and topical chemo preventive measure have been identified that can decrease the onset of some malignant and pre-malignant skin lesions. These include some derivatives of Vitamin A, B and D

SCARRING,ASSESSMENT AND TREATMENT

Scarring of skin produces physical, psychological and social consequences.

Deep scarring skin changes can produce major deformities, restriction of movement and function and are caused by loss, distortion or displacement of tissue.

Deep skin changes usually involve the deep fascia, subcutaneous fat and the deep collagenous dermis

Correction of deep scarring may require the use of plastic surgery techniques, whereby tissue is replaced or reduced by various techniques. Deformative scarring may be corrected by several release techniques.

Superficial scarring involves the superficial collagenous dermis and surface epidermal layer which also incorporates pigment cells and may involve superficial blood vessels, nerves, hair and sweat apparatus

Superficial dermal scarring can produce raised or keloid scars, superficial depressions, wrinkling and red vascular changes. Destruction of hair and sweat glands may occur, the latter producing dry and irritable skin. Nerve damage can result in unpleasant skin sensations and in some cases traumatic damage occurs due to lack of skin perception.

Vascular changes seen as excessive redness or obvious blood vessels can be improved using specific laser therapy

Depressive scars can be improved using various filler techniques or by stimulating the body’s repair mechanisms to produce new collagen. Topical derivatives of Vitamin A have been shown to have this property as have some dermabrasion techniques

Overactive, raised or keloid scars can be treated by surgical excision but in many cases medical treatments in the form of injected or topical cortisone preparations can be very useful

Topical silicon preparations can also produce scar diminution

Scarring can be perceived by superficial skin changes alone without deeper structures being involved

Excessive or deficient pigmentation of the skin can ensue due to over stimulation or damage to the skin’s superficial pigment cells

Excessive pigmentation can be decreased by superficially applied preparations such as vitamin A and other preparations or in some cases laser treatment

Deficient pigmentation can be improved by ultraviolet light techniques and in some cases by pigment cell transplantation

Scarring can be particularly traumatic on the face and hands.

The psychological and social impacts of skin scarring are often a major component of injury and addressing these factors should go hand in hand in the therapeutic approach to the treatment of scarring.

When the legal fraternity need a medical opinion on skin related issues, they may seek an expert dermatologist consultant‘s perspective on a case requiring specific answers regarding a situation. I aim to provide a professional and experienced perspective to often complex medicolegal situations.

When doctors receive a medico -legal request, the specific information required is not always obvious and they may not possess the legal perspective to formulate the required response in a form that is useful to the legal practitioner.

In my medico legal reports, I am acutely aware of the needs of the requesting legal practitioner and strive to produce reports that are concise and relevant in a timely manner.

I strongly believe that all reports should be given on a strictly impartial basis.

EXAMPLES OF SKIN RELATED SITUATIONS FREQUENLY ENCOUNTED

TRAUMA AND SCARRING

• raumatic incidents producing scarring are frequently occur in motor accident and workplace incidents. Scarring produced in these situations needs careful assessment and documentation and particular attention needs to be given to the physical and emotional sequalae and impacts on the activities of daily living. These aspects are often overlooked in the impact assessments of an individual’s disability.
• Chemical irritant and allergic reactions are frequently noted in industrial situations and a similar approach to traumatic injuries needs to be adopted. These injuries often need an in-depth investigation of the causative factors as initially these may not be obvious. These investigations can include a detailed review of all chemical substances in a working and/or other environment and subsequent analysis and testing. Chemical and allergenic investigations may be needed.

MEDICAL AND WRONGS ACT MATTERS

These can often involve a careful analysis of causation and impairment. From a causation perspective, initial impressions can be both complex and deceiving. In both medical situations and work-related areas there are often multiple factors involved in causation which at first sight are both complex and confusing. A thorough investigation of an individual’s medical and environmental history is necessary to piece together a legal relationship. Sometimes such an analysis can provide surprising results.

Impairment assessment in these situations can be easily be misunderstood by the clients of lawyers. An attempt is made to clarify causative factors in reports in plain language.

TRAUMA

Physical trauma to the skin can produce a number of skin changes

Sharp trauma can produce skin lacerations with damage to deeper tissues with possible scarring, deformation and loss of function.

Superficial trauma may produce abrasions that may lead to superficial scarring with damage to hair structures, sweat glands and pigmentation. Nerve damage can also occur leading to uncomfortable sensations and loss of skin perception. The loss of skin sensation can lead to accidental trauma and further skin damage.

Blunt trauma can produce bruising and possible tissue damage in the deeper layers of the skin with subsequent bruising, scarring and possible loss of function

Chronic trauma produced by constant contact with water and detergents can precipitate irritant eczematous reactions. This is seen in hairdressers and dishwashers