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COMMON BENIGN SKIN LESIONS III. I. EPIDERMAL a. Nevi (clinically difficult to differentiate) Presence of hair is not important in differentiating the types of nevi Intradermal: dome shaped o Congenital o Rests completely in the dermis o May appear during adolescence & has a tendency to grow Compound o Migrate partially into dermis Junctional: flat (usually appears during puberty) o Accumulate in epidermis CYSTS Desquamted cells (keratin) collects in the center & forms the creamy substance of the cyst Usually asymptomatic May rupture and cause local inflammation which may become infected and become an abscess (tx: incision & drainage) o The entire wall of the cyst has to be removed to prevent recurrence

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Keratosis Seborrheic o Appears in sun exposed areas o No malignant degeneration Actinic o From UV Lentigo o Due to proliferation of melanocytes in epidermis o No treatment needed EPIDERMAL APPENDAGES a. Trichoepithelioma o Benign papule usually seen in the face that appears during adolescence o Appears as multiple whitish lesions o Arises from hair follicles o If it becomes verrucoid, it may indicate malignant degeneration o Tx: Remove 1 for histology and then cauterize the rest b. Cylindroma o Present as a nodule in the axilla or in the genital area o Represents a tumor of the the apocrine gland o Benign o Known as turban tumors as they may also be seen in the scalp Eccrine Poroma o Represents a tumor of the eccrine sweat glands Sebaceous o Nevus (congenital) o Adenoma (nodular manifestation) o Hyperplasia of sebaceous glands (as seen in rhinophyma) Usually seen in middle age No malignant tendency

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Epidermal Most common type of cutaneous cyst Can occur anywhere as a single firm nodule Blockage of excretory gland that secretions are retained in the skin o When inflamed, it may grow o When inflammation is controlled, it shrinks Manifest as obstruction Presence of a punctum is pathognomonic for epidermal cyst o When comparing with lipoma, look for this punctum Tx: excision o May require antibiotics Ddx: lipoma, sebaceous cyst Inclusion Pseudocyst: not a true cyst because it has no epidermal lining Same as plain epidermal cyst except you have to have a history of trauma Epithelial cells trapped inside dermal cells Dermoid Congenital Usually found in embryonic fault lines where the bones meet o Result from trapping of the epithelium during midline closure in fetal development Commonly seen in supraorbital area o Also found in midline of face, nose, forehead, and on lateral eyebrow Not attached to skin Has epidermal components o Cyst cavity contains epidermal appendages Remove entire capsule during surgery Trichilemmal nd 2 most common F>M Characteristic strong odor

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IV. a. DERMAL Dermatofibroma Solitary nodular lesion on skin Found in subcutaneous area o Unencapsulated o Whorls of connective tissue containing fibroblasts High recurrence rate o Requires wide excision as treatment Locally invasive tumor Benign o Doesnt usually grow beyond 2cm o If >2 cm, it is a dermatofibroma protuberans (this one has malignant degeneration so excision biopsy is necessary) o Neurofibroma Multiple elevations involving the entire skin & nerve endings Comprises 25% of nerve sheath tumors Nodular with broad base Can appear as looseness of skin or elevations from skin 70% benign, 25 30% may degenerate into neurofibrosarcoma o Neurofibrosarcoma: malignant (especially if familial), remove all that produces symptoms Solitary Neurofibroma o Soft, broad base o Can produce deformity Removal of a neurofibroma causes deformity and you cannot preserve the peripheral nerves Goal of surgery: correct deformity o Cant remove entire neurofibroma but you can reconstruct Neurilemoma Arise from Schwann cells in intercostal nerves (schwannomas) Firm, well encapsulated Contained in subcutaneous Dumbbell configuration (may cause cord compression & paralysis) Does not undergo malignant degeneration Shooting pain felt upon palpation, affects nerves Feels like lipoma Compared to neurofibroma, you can still preserve the peripheral nerves during removal Movable (not adherent to skin) Microscopic:lobulated containing normal fat cells Treatment: excision with removal of entire capsule

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Hidradenitis Chronic relapsing infection of the apocrine gland o Commonly seen in the axillae Occlusion of the apocrine duct obstruction and ductal dilatation -> secondary infection Excessive scarring & sinus tract may be present Linked to a single dominant gene Exacerbation of symptoms during premenstrual period Manifests after puberty May be caused by shaving If suppuration occurs = hidradenitis suppurativa Treatment: Meticulous cleansing with antibacterial soap Topical ointment Chronic course of antibiotic I & D of localized abscess Radical excision of affected areas Electron beam radiation for severe refractory cases

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Acrochordons (skin tag) Fleshy, pedunculated masses o Difference from neurofibroma = pedunculated ito :D Haha. Axillae, trunk, eyelids Hyperplastic epidermis over a fibrous connective tissue stalk Found in areas of skin with fricition/shearing effect Usually small Always benign

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REASONS FOR REMOVAL VS RISK OF SURGERY 1. To prevent malignancy 2. To improve appearance 3. To avoid psychological sequela PRE MALIGNANT 1. Low Risk Trichoepithelioma Apocrine cylindroma (turban tumor) Intradermal nevus o May undergo malignant degeneration due to destruction of ozone layer Hypertrophic scar rd o Thats why in 3 degree burns, it is recommended that the area must be covered with a skin graft to prevent cancer due to repetitive epithelial proliferation o Keloids dont usually become malignant unless irradiated Chronic idiopathic lymphedema o Due to lymphatic obstruction

.V. MISCELLANEOUS a. Lipoma Found in soft tissues/tumor of fat cells Sebaceous cysts where ducts are obstructed Most common subcutaneous neoplasm

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2. Post mastectomy lymphedema o Related to recurrence of breast cancer

Moderate Risk (5 10%) Junctional nevus o Risk of malignant degeneration is the same no matter where the nevus is o Therefore, even if nevus is on the palm & sole, it has no increased risk of malignant transformation Cellular blue nevus Dysplastic nevus
Histologic findings; may be diagnosed cilnically

Neurofibromatosis o Entire body covered by neurofibroma o Remove only those producing symptoms o Von Recklinghausen disease (familial type) Cutaneous horns o Exaggerated hypertrophy of epidermis with keratinous debris Keratoacanthoma o Usually mistaken for squamous cell carcinoma due to biologic behavior (rapid growth with central umbilication) o Benign o If left alone, they may dissolve spontaneously, but most are excised because they are mistaken for Squamous Cell CA

Nevi: Risk of malignancy Acquired: higher risk Congenital: presence of melanocyte cells o Large ones have higher risk malignant degeneration Remove if: Bleeds, painful Progressively enlarges Chance in pigmentation

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High Risk (>10%) Lentigo malignant (Hutchinson Freckle) Neural nevus o Run along course of nevus o Verrucoid, not socially acceptable which is why px usually have it removed o Tx: serial excision due to high risk of malignant degeneration Giant hairy nevus o Congenital giant lesions o Trunk distribution or on chest/back o May develop malignant melanoma in 1 5% o Tx: excision Sebaceous nevus (Jadassohn) o Congenital form that becomes verrucoid as individual grows old Actinic keratosis Bowens disease o Brownish plaque o Common in Mideastern population Xeroderma pigmentosum o Autosomal defect nd o Usually die in 2 decade due to multiple skin CA o Skin is hypersensitive to solar radiation so skin develops multiple skin cancers

Modifiers of Risk (Nevi) Size: Giant > 100cm 2 2 Large: 10 100cm Small: < 10 cm Location: Posterior (more immature, usually of neural origin) Higher risk of malignant degeneration Histology: External cellular Blue nevi Neural nevi Junctional atypia 10% of melanomas usually arise from a nevus VASCULAR ANOMALIES I. Hemangiomas The only true tumor Proliferation of capillaries F > M, usually in the head and neck Usually grows during 0 12 mos of life o >12 mos, it involutes because it contains immature capillaries o Blood suppy disappears without any trace at all o Tx: observe because it can disappear until 10 y/o If present until 7 y/o, the chance that it will disappear is already small. So decision to remove is made from 7 10 y/o Spontaneous resolution: 5 y/o (50%) 6 y/o (60%) 7 y/o (70%)

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MRI: gold standard in diagnosis Indications for treatment: o Visual or airway impairment o Bleeding or ulceration o Infection o CHF o Kasabach Merri syndrome Non- invasive tx: systemic corticosteroids, intralesional corticosteroids, subcutaneous IFN alpha 2a Invasive tx: surgical excision, laser, cryotherapy, embolization Sclerosing hemangioma: manifest as verrucoid o Usually found in the extremities Granuloma due to infection o May be classified as hemangioma because of histologic appearance o Tx: excise/cauterize Senile hemangioma o Pinpoint redness o No tx needed VASCULAR MALFORMATION Structural abnormality due dysmorphogenesis Present at birth Grows concurrently No sexual predilection MANAGEMENT 1. Observation & Reassurance Because majority may spontaneously resolve 2. Sequential photographs & measurements To show progress & resolution 3. Indications for early interventions Obstruction or malalignment of visual axis (may indicate hemangioma) o In lesions of newborn, it is important to check if there is no obstruction of vision Ulceration/hemorrhage Coagulopathy due to platelet sequestration Impending airway obstruction Congenital heart failure Progressive deformation of adjacent structure 4. Specific treatment a. Mild ulceration standard wound care b. Systemic corticosteroid - < 18 mos o Only effective in babies <18 mos o Give high dose for 2 weeks c. Interferon alpha 2a d. Pulse dye laser (used in kids) o For adults, we use argon laser e. Embolization o Preliminary embolization may be done to decrease massive bleeding during surgery f. Excision WARTS 1. Verruca vulgaris (Common wart) Viral infection Auto enucleation is common 2. Flat warts Usually seen in face, neck, elbow Spontaneously disappear Because its viral, there is a high chance of autoimmunity Plantar warts Located in the sole of the foot Painful Difference from callous formation: o Callous formation is a generalized thickening of the skin o Presence of a round nodule at site of the thickening = wart Usually treated with salicylic acid Periungal Resistant to common treatment High recurrence rate Genital warts Condyloma Associated with HPV infection In the Phils, it is treated using electrocautery. Other modalities: Podopelin, Trichloroacetic acid

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Slow flow lesions Venous Capillary o Usually dont disappear spontaneously because they contain mature capillaries o In the US, laser is used to treat them. In Asians, laser cannot be used because we have dark skin. Using laser will aggravate the discoloration because we have more melanin Lymphatic (microcystic/macrocystic) o Old name: Cystic Hydroma o Enlargement of soft tissues o Removal will allow you to see honeycomb appearance of the lesion Fast flow lesions Arterial Arteriovenous congenital

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Accompanying manifestations: Skeletal distortion or hypertrophy Increased skin temperature Bruit or thrill High output cardiac failure Bleeding or ulceration Pain Tissue overgrowth Standard of care: Arteriography & superselective followed by surgical resection Other modalities: o Sclerotherapy o Compression garments o Laser thermolysis o Surgical excision embolization

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Sources: Dr. Orlinas lec Nessa D 07 notes :D