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Approach to Various Skin Lesions

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Tx of choice: skin tag
shave biopsy or removal
Tx of choice: actinic keratosis
shave removal, cautery/curettement (ED&C), cryotherapy
Tx of choice: cherry angioma
ED&C
Tx of choice: Bowen's disease (SCC in situ)
fusiform excision; <1cm: ED&C or cryotherapy
Tx of choice: BCC
ED&C
-cure rate 95-98%
Tx of choice: SCC
fusiform excision
Tx of choice: dermatofibroma
shave removal, fusiform excision
Tx of choice: cherry angioma
ED&C
Tx of choice: keratoacanthoma
fusiform excision, ED&C
Tx of choice: lentigo
cryotherapy
Tx of choice: lentigo maligna
fusiform excision
Tx of choice: melanoma
fusiform excision
Tx of choice: milia
curettement alone
Tx of choice: molluscum contagiousum
curettement alone
Tx of choice: nevi (atypical)
shave removal, fusiform excision
Tx of choice: pyogenic granuloma
ED&C
Tx of choice: sebaceous hyperplasia
ED&C
Tx of choice: seborrheic keratosis
shave removal, cryotherapy
Tx of choice: warts
ED&C, cryotherapy
Tx of choice: planar warts
curettement alone
Tx of choice: plantar warts
cryotherapy
Benefits of placing multiple lesions in single formalin container
1. covers legal aspects
2. conserves costs
Which excised lesions should be sent to patho for definitive Dx
ALL
Angioma (Hemangioma)
1. small: ball electrode to cauterize lightly
->2mm: local
-Wipe away tissue and repeat til no vessel is seen
2. Cryotherapy or sclerotherapy also works
3. Superficial shave excision or curettement followed by light cautery of base best for large angiomas
Acrochordon (skin tag): most direct & simple approach
1. elevate tag with pickups & excise w/ sharp tissue scissors at level of surrounding skin
-use local for broad base
-hemostasis: Monsel's solution (ferric subsulfate) or aluminum chloride
Skin tag: small
ball electrode
-lightly & quickly cauterize
-wipe away
Skin tag: cryosurgery
1. difficult to limit freeze to only tag
2. use styrofoam cup method & pickups to grasp tag
-tag necroses off
-freeze twice in same visit
Actinic Keratosis: def
sun-induced, premalignant lesions
Actinic Keratosis: single lesion Tx
shave, cauterize, or cryo (most common)
Actinic Keratosis: multiple lesion Tx
1. Tx w/ 5-fluorouracil (5-fu), masoprocol (Actinex) cream, imiquimod (Aldara) cream, or photdynamic therapy w/ Levulan w/ light therapy (blue IPL)
2. Lesions that do not heal= surgical sampling for histology
-SCC
Risk actinic keratosis will progress to SCC
1. Early lesions: <1%
2. Persistent hypertophic lesions: 10-20%
5FU & macropol: SE
erythma & tenderness
5FU & macropol Tx
1. face: bid x3-4 weeks
2. arms: tid-qid
Basal cell carcinoma (BCC) characteristics
1. small, centrally located ulcerated depressions
2. raised, pearly borders (nodular cystic type)
Sclerosing (morpheaform) BCC manifestation
1. flat lesion w/ nondescript borders
2. nonhealing ulcerations w/ no elevation
3. may be pigmented
-confused w/ SKs, nevi or melanomas
4. erythematous & bleed easy
-mimic pyogenic granuloma
Superficial BCC manifestion
1. on back
2. flat & scaley
-look like SCC, actinic keratosis, eczema or tinea
BCC causative factors
sun exposure, chronic irritation, HPV
BCC biopsy
1. almost any area can be sampled
2. ulcerated: sample nonulcerated portion
-ulcer may only show necrotic changes (not enough depth)
3. Normal skin from margin not needed
BCC facts
1. No one dies from BCC unless there is long-term neglect
2. Don't mets (usually)
-failure to Tx= recurrence, which may need referral or more aggressive Tx
3. Difficult to Tx
-higher recurrence rates in nasolabial folds & preauricular areas
-intercanthal area difficult r/t tear duct involvement
4. Lesion < 5-6mm in any location= excellent response to any Tx
5. Involve upper portions of skin
6. Radiation
-rarely used
-reserved located in lid margin & large lesions on elderly
-not recommended for sclerotic/morpheaform types around tear ducts d/t scar tissue & younger pt d/t long-term sequelae from radiation
BCC: ED&C Technique
1. Local
2. Scoop out lesion w/ large reusable dermal curette & scrape base until gritty feeling & send to patho
-disposable too sharp
3. Fulgurate or cauterize enrie base w/ ball electrode
-destroy remaining cells & control bleeding
4. Repeat x2
-do not penetrate too deeply & pass through entire dermis, if it happens small window of fatty tissue will be visible in bottom of wound= formal excision indicated (tumor most likely went deep into SQ tissue)
5. Cover w/ topical astringent, ABX ointment & dressing
-follow moist healing process= good cosmetic
BCC: ED&C Aftercare
1. gently wash area 3-4x/day (soap & H2O)
-prevent eschar from forming
2. use ABX ointment (or petroleum gel) 6-8x/d
-keeps area moist
-aids in reepithelialization
3. Keep open unless it is under clothing
4. Cover at night
BCC: Lesions that require complete excision
1. younger pt
2. larger sized (>1cm)
3. aggressive location (nasolabial folds, preauricular areas eyelids)
4. sclerosing-type BCC
5. recurrent lesions
6. Ill defined margins
BCC: Complete excision instructions
1. Removed 3-4mm of normal skin around all edges
2. Mark edges to aid in histological eval
BCC: Advantages of ED&C over cryo
1. necrotic lesion can be felt w/ curette
-surgeon knows how far & deep to proceed w/ scraping
BCC: Other Tx
1. Laser therapy: ablate lesion
2. Topical 5FU & imiquimod: Tx superficial BCC
3. Cryotherapy: lesions <1cm
-freeze/thaw/freeze
-cure rates: 98%
BCC: F/U
3 mo
What percent of pt. develop new BCCs w/in 3 years
30%
BCC: Chemosurgery Indications
1. recurrent, morpheaform-type
2. very large lesions
3. larger lesion in high-risk sites
Squamous Cell Carcinoma (SCC): appearance
-diffuse, nonhealing, crusted lesion
-multifocal or from sun damage
-margins not clear
SCC: location
base of actinic keratosis or cutaneous lesion
SCC vs. BCC
-more aggressive
-can mets
SCC: Bx
-include portions of central area
-deep punch into SQ preferred
-deep saucer-type shave is adequate
-rule out SCC
SCC: Early or small lesions Tx
-cautery & curettement, cryotherapy
-Tx of actinic changes & post-treatment residual lesions (after 6-8 wks): 5-FU or masoprocol creams & cryotherapy
SCC: excision
-removed at least 5mm of normal tissue to be sure all margins are clear
SCC in situ (Bowen's disease)
-severely dysplastic, not yet invaded beyond epidermis
-Tx similar to SCC, excision rarely needed
SCC: reeval
3-6 mo.
-eval lymph nodes draining the area
Dermatofibroma: location
anterior surface of lower leg
Dermatofibroma: etiology
-unknown
-fibrous Rx to trauma, viral infection, insect bite
Dermatofibroma: confused with
-verrucae or nevi
-BCC (confirm w/ sample)
Do dermatofibromas turn into CA
NO
Dermatofibromas Tx
1. Observe (once Dx is confirmed)
2. Excise if complete removal desired (deep seated)
3. Cryotherapy (generally resistant)
4. Shave flat (most judicious)
Cutaneous horn Tx:
-Deep saucer-type shave & cautery; send to patho
-Type of actinic keratosis
-Caution to r/o early SCC at base
Keratoacanthoma: Def.
common, benign epithelial tumor found in elderly pt
Keratoacanthoma: etiology
viral
Keratoacanthoma: Differential Dx
1. SCC
-SCC variant: can NOT be differentiated histologically
-many patho reports will say "can not r/u SCC"
-Tx similar to SCC
2. BCC
Keratoacanthoma: Dx
history of rapid growth
Keratoacanthoma: development
1. Starts as dome-shaped papule that enlarges rapidly
2. Fully developed tumor: round, dome-shaped mass w/ central keratin-filled crater (1-2cm)
3. May stop growing after 6 weeks, & slowly regress over 12 months
Keratoacanthoma: location
dorsum of hands, ears & neck
Keratoacanthoma vs. BCC
during curettement, they are more sclerotics & fibrous
Keratoacanthoma: Tx
1. Cryotherapy (small lesions)
2. Deep saucer-type shave
3. ED&C x3
4. conventional excision w/ 3-5 mm free margins
Seborrheic Keratoses: Def
1. benign, hyperkeratinized superficial epidermal lesions
2. occur commonly w/ aging
3. Size: 2mm-3cm
4. No malignant potential
Seborrheic Keratoses: Appearance
looks like it can be lifted off w/ fingernail
-often rubbed off w/ towel (recur)
Seborrheic Keratoses: DD
BCC, SCC, nevi, verrucous lesions
Seborrheic Keratosis: Pathology report
verruciform keratosis
Seborrheic Keratosis: Tx
1. radiofrequency (electrosurgery) shave
-anesthesia used
2. shave excision w/ mild curetting of base
-hemostasis: Monsel's solution or aluminum chloride
3. Cryotherapy (most common)
-liquid nitrogen w/ spray thermos (quickest)
-blister may form or lesion will fall off
-be absolutely sure of Dx
What to consider if if may SKs occur all at once
internal malignancy (Leser-Trelat sign)
SK: Medicare does not cover removal for unless:
markedly irritated or pruritic, bleeding, rapidly growing, or Dx is uncertain
Lentigo (liver spots): Def
common, brownish or tan macules
-increased # during childhood & adult life & occasionally fade spontaneously
Lentigo: Locations
Sun-exposed areas of face, shoulders, arms & hands
-senior freckles
Lentigo: Bx
Irregular borders or dark pigmentation
-r/o lentigo maligna melanoma
Lentigo: Tx of choice
Cryotherapy
Lentigo: Other Tx
1. Bleaching & depigmentation
-has to be used for life
2. Superficial ablation w/ laser
3. Radiofrequency
4. trichloroacetic acid
5. IPL (latest, most effective; expensive)
Lentigo Maligna (Melanoma in situ): Def
1. sun-associated precursor of lentigo maligna melanoma (invasive CA)
2. can grow to several cm
3. face
4. slow-growing macules w/ irregular borders & pigmentation
Lentigo Maligna vs Lentigo
-lentigos are smaller, homogenous color & appear mainly on dorsa of hands & forearms
Lifetime risk factor for lentigo transforming tinto LM
4.7%
Lentigo Maligna: Tx
1. Bx (unless absolutely sure of Dx)
2. Complete surgical excision
Lipomas: Presentation
-Palpable lesion under skin
-nontender, move freely & have soft, irregular consistency
Lipomas: DD
sebaceous cyst
-cysts have pores, more tense
Lipoma: Removal indicaitons
1.rapidly growing or changing lesions should be removed
-r/o liposarcoma
-usually don't progress to malignancy
2. areas of pressure
3. cause pain or discomfort
-areas on lower legs have have high chance of malignant degeneration
Lipoma: Removal <3cm
1. Inject 1mL lido w/ epi
2. 1-2cm incision through dermis in line w/ skin lines
-sterile prep & draping NOT needed
3. use homostates or curved scissor to dissect from surrounding adhering tissue
-pressure on base will extrude the lipoma
-may be encapsulated
4. remove any loosely adhering fatty tissue in cavity
-close w/ steristrips or tissue glue & pressure dressing
Lipoma: Removal >3cm
Formal excision w/ sterile technique & sutures
Melanoma: major caveat
depth of lesion is very important in determining appropriate definitive Tx
Melanoma: ABCDEFG
-clinical features of malignant melanoma
A: Asymmetry
B: Border irregularity
C: Color Variegation
D: Diameter >6cm
E: Elevation above skin surface
F: Feeling different (pruritus); Family Hx
G: Growth or Change
Melanoma: Bx & removal
1. Don't shave if melanoma is likely or suspected
-depth is important
2. choose area that is most nodular or atypical (darkest, inflamed, irregular)
-mostly nevi
3. Strong suspicion: punch Bx
NIH guidelines
lesion that invade <1mm, 1-cm clear excisional margins around lesion are adequate
-extensive work-up NOT indicated for minimal depth lesions
Molluscum Contagiosum: Def
-small, 2-3mm, papular, wartlike excrescence with central umbilication
-painless & rarely cause pruritis
-appear as crop of multiple lesion in young children, or later in adolescents & young adults as they become sexually active
-viral
Molluscum Contagiosum: Tx
1. Expectant observation
-spontaneously resolve (3-18 mo.)
2. Curettement w/ small disposable (sharp) dermal curette or cryotherapy (Tx of choice)
-can use topical local
Neurofibromas: Description
1. soft, nodular lesion
2. appear as minimally pigmented nevi
Neurofibromas: pathognomonic sign
Shave excision reveals: soft, jelly-like material at base
Neurofibromas: Tx
1. curette soft tissue & base cauterized
-significant cavity, moist healing technique
2. Don't have to remove unless symptomatic or Dx needed
3. large lesions: excision w/ suture closure
4. free margins 1 mm
Pyogenic Granulomas: Description
1. small, rapidly growing nodular, friable, vascular lesions often bleed when touched
Pyogenic Granulomas: locations
sites of trauma or previous surgery
Pyogenic Granulomas: Tx (best)
curettement & cauterize base
-will recur if any tissue remains
-some use complete excision
Pyogenic Granulomas: DD
BCC
Acquired Nevi (Moles): Description
1. benign, malnocytic nevia
2. absent at birth
-first appear in early childhood
3. become more numerous until middle age
Acquired Nevi: Location
sun-exposed areas (sun induced growth)
Acquired Nevi: Devolopment
1. Junctional nevi
-earliest
-nevus cells at junction b/t dermis & epidermis
2. Compound nevi
-late adolescent
-nevus cells in both dermis & epidermis
-may develop hair
3. Intradermal nevi
-regression
-late adulthood
-non-pigment (pink, flesh colored)
Acquired Nevi: Benign s/s
smooth, distinct, symmetric borders
-monitor pt. w/ large # d/t higher risk for melanoma development
Acquired Nevi: Removal
1. Raised or pedunculated benign nevi
-excise w/ shave removal
-no suspicion for melanoma
2. Melanoma possibility
-full-thickness Bx before removal
-complete excision
Acquired Nevi: Basis for Tx
depth
Acquired Nevi: Recurrence
1. Superficial: rarely recur
-often raised
2. Deeper compound: often do unless full depth is excised
-often flat
Halo nevus
acquired nevus; develops a white halo around it
-sign immune system is activated against the mole & it will soon disappear
-only change that does not need Bx
Dysplastic Nevi: Def
(atypical moles)
-acquired nevi that come dysplastic (precancerous over time)
-larger than common acquired nevi (>5mm)
-irregular margins
-variable pigmentation
-irregular surface contours
Dysplastic nevi: Tx
1. Full excision of suspect lesion
-d/t melanoma risk
2. Shave excisions
-deep & saucer shaped- ensure entire depth is removed
3. Radiofrequency smoothing & moist healing
-minimizes scarring
4. Can have so many that you can't excise all of them
-follow closely & their family
-sun protection
Tx for patho report of "positive margins"
1. Remove more tissue
2. Shave or frank excision w/ suture depends on exact patho
Congenital Nevi: Approach based on 3 factors
1. size
2. color
3. family Hx
Congenital Nevi: Characteristics
1. larger than 20cm extend over large portions of body -grow proportionally w/ anatomic site
-irregular surface
-contain coarse hairs
Congenital Nevi: management
1. controversial
-excision difficult & deforming
Congenital Nevi: Life time risk for CA development
5-20%
-? early removal & grafting
-?close monitoring
-melanoma may develop at any site in the lesion= Bx of irregular portion might not reveal malignancy
-?vigorous curettement in 1st weeks of life (?best alt.)
Congenital Nevi: Tx (1.5-20cm)
excise
-shave not adequate (deep lesions)
Congenital Nevi: Tx (<1.5cm)
-easiest to excise
-lowest malignant potential
-remove from areas difficult to observe (scalp, but)
Congenital Nevi: Color
1. Light moles:
-<likely to degenerate into CA
-later (after 20 years)
-allow early detection of changes
2. Dark, almost black:
-more likely to transform to melanoma
-earlier (teenage)
-more difficult to monitor
--removal appropriate
Congenital Nevi: Latest recommendations
Observe, unless changes are noted
Paronychia: Def
-infection of distal phalanx along proximal & lateral edges of nail
Paronychia: S/S
-local infection: red, tender, swolen
Paronychia: Mild Tx
soaks & topical ABX
Paronychia: Significant Tx
-may develop abscesses
1. I&D once area of loculated area of purulence can be ID
-digital block depends on size
-may need packing to keep from reoccumulating
2. Topical ABX
3. Systemic ABX: marked cellulitis, immunocompromised
Chronic Paronychia: secondary to:
Fungal infection
Rashes (Exanthems, Dermatoses): Bx indication
-usually not helpful
1. clarification of DD (inflammatory dermatoses)
2. r/o cutaneous neoplasm
Rash: Multiple site- Bx Guidelines
1. Choose area w/ primary inflammatory changes, but are free from secondary changes (crusting, fissuring, erosion, ulceration, & infection)
2. Choose area where scar will not be obvious & hypertrophic scar not a problem
Rash: Macule- Bx Guidleines
1. Fresh lesion w/ abnormal color
2. Punch Bx
Rash: Papule- Bx
removed completely
Rash: Plaque, Nodular & Suspected Neoplasms- Bx
1. Bx thickest area through full depth into SQ fat
2. fine-needle aspiration
Rash: Vesicles & Bullae: Bx
1. intact lesion
-rupturing a sac makes histology more difficult
2. sample at margin where blister roof is attached to remainder of specimen
-include normal skin (only time normal skin is helpful to make Dx- vesicular bullous disease)
Sebaceous Hyperplasia (Adenosum Sebaceum): Characterizations
1 .also called senile sebaceous gland hyperplasia
2. small growths composed of enlarged sebaceous glands
3. very small (2-5mm)
4. mimics BCC
5. lesion is deep seated
Sebaceous Hyperplasia vs. BCC
-BCC solitary lesions
-SH numerous present on forehead and temporal areas
Sebaceous Hyperplasia: Tx
removal of elevated portions of papule w/ shave, sharp curettement, or electrosurgical technique, cryotherapy (small)
-if not curetted, not completely removed
Sebaceous Hyperplasia vs. Necrotic CA
SH very dense & fibrotic
Sebaceous Hyperplasia: Bx Indications
nature uncertain
Sebaceous Cyst (epidermal cyst): Def
-round, tense, keratinizing cyst
-freely mobile & superficial
Sebaceous cysts on scalp called
trichilemmal cysts (wens, pilar cysts)
Sebaceous cyst presentation
slowly growing lesion that is SQ, smooth, & nontender
-Hx: purulent drainage or inflammation may be present
-small central punctum (pore) differentiates from lipoma
Sebaceous cyst: 3 precautions
1. Examine lesion in preauricular areas closely
-parotid tumors can present as cyst
-any question= obtain needle Bx
2. Cysts in infants are likely dermoids (fusion plane cyst)
-fistulous connections w/ deeper spaces
-most common location: lateral erd of eyebrow (easily removed)
-all others may have intracranial connections (nasal bridge, scalp, neck, postauricular areas)
-MRI to exclude contiguous tract (requires neuro consult)
-70% appear by 5 y.o.
-more worrisome if contain hair or capillary changes
3. Everything is what it is until it ain't
-only way to be sure of Dx is to remove
-DD: mestastic melanoma or other CA
Downside to watchful waiting of asymptomatic lesions
1. grow, making removal more difficult
2. infection
-once sebaceous material & smell are observed they don't need pathology
Sebaceous cyst: Tx
1. Areas w/ thin skin (face)
-anesthesia
-5-6mm incision in cysts using no.11 blade or 3-4mm sharp dermal punch
-express all contents using external pressure
-sac not produced= grasp the sac with curved hemostats or curette away any possible residual sac
-no sterile technique or sutures are indicated
-blood or infection= pt. will express it
-sac left behind & cysts reforms= formal excision w/ suture
Sebaceous cyst: risk for unsuccessful Tx
1. large (>2cm), previous infection, previous attempt at removal, deep in skin tissue
Infected Sebaceous cysts: Tx
I&D
-usually no infection, cyst has ruptured & caused inflammatory response
-formal excision is not advised (infection likely w/ sutures)
Sebaceous cyst: Technique
1. Prep w/ alcohol
2. Inject 2mL of 2% lido w/ epi over top of lesion
3. no. 11 blade- incise; removed all material
4. insert hemostats to break up up pockets; try to remove sac
5. 1/4-in. iodoform gauze into wound (leave small tail)
6. Cover w/ ointment so dressing does not stick
-change dressing 2-3x/d; change gauzee in 3 weeks
-no ABX necessary after I&D
Telangiectases
1. Small cherry hemangiomas
benign, small, red, vascular lesion
-do NOT require Tx
-bleeding or irritated= lightly cauterized & wiped off w/ gauze
-malignancy not considered
2. Spider veins
-best treated w/ sclerotherapy if on legs
-radiosurgery w/ 30-g needle for face & isolated lesions (works poorly in legs)
-can produced pain & paresthesias if untreated
-fine & dense veins (rosacea)= IPL
Warts (Verruca Vulgaris & Plantaris): recurrence rates
30% or higher
Warts: percent that will resolve spontaneously
60%
Warts: Tx
1. Vitamins enhance immune system
2. Candida antigen injections
-efficacious, cost effective, least traumatic, no scarring
Plantar warts: 1st-line Tx
Candida antigen
-except in simplest cases
Plantar warts: Other Tx
1. avoid surgical excision on bottom of feet
-scar tissue often remains painful after healing
2. soaking followed by paring of callous tissue improves efficacy to any Tx
3. Cryo: effective, no scarring
Xanthelasma
-most common form of xanthoma
-yellow-white plaque on eyelids
-Dx: clinically
-Goal of Tx: stary superficial
-Tx: light fulguration or cauterization, radiofrequency loop ablation (easier to control depth), surgical removal w/ abnormal tissue w/ curvilinear elliptical (6-0 suture), express lesion after opening w/ 18-g needle
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