COMMON BENIGN SKIN LESIONS IN ADULTS BARRY LADIZINSKI

COMMON BENIGN SKIN LESIONS IN ADULTS BARRY LADIZINSKI CATHERINE FLORIO PIPAS DARTMOUTH MEDICAL SCHOOL

ASSESSING SKIN LESIONS IN FAMILY PRACTICE “Benign skin tumors are commonly seen by family physicians. The ability to properly diagnose and treat common benign tumors and to distinguish them from malignant lesions is a vital skill for all family physicians. Any lesions for which the diagnosis is uncertain, based on the history and gross examination, should be biopsied for histopathologic examination to rule out malignancy. ” Am Fam Physician 2003; 67: 729 -38.

ACROCHORDON http: //www. visualdxhealth. com/adult/acrochordon. Skin. Tag. htm

DESCRIPTION & HISTORY • AKA SKIN TAG, CUTANEOUS PAPILLOMA, SOFT FIBROMA • COMMON, BENIGN, FLESHCOLORED PAPULE • UNCOMMON BEFORE AGE 30, VERY COMMON THEREAFTER • FOUND IN 25% OF ADULTS, INCREASE WITH AGE • F>M, OBESITY, DIABETES, PREGNANCY, INTESINAL POLYPOSIS SYNDROMES http: //www. visualdxhealth. com/adult/acrochordon. Skin. Tag. htm

SKIN FINDINGS & LABORATORY • SOFT, PINK, 1 -10 MM PAPULE, PEDUNCULATED ON A THIN STALK • MOST COMMON LOCATIONS: AXILLA, NECK, EYELIDS, INTERTRIGINOUS AREAS (INFRAMAMMARY & INGUINAL CREASES) • DUE TO LOCATION, IRRITATED BY SKIN, JEWELRY, CLOTHING http: //www. visualdxhealth. com/adult/acrochordon. Skin. Tag. htm • BIOPSY: HYPERPLASTIC EPIDERMIS, THIN SQUAMOUS EPITHELIUM AROUND A FIBROVASCULAR CORE

PROGNOSIS & TREATMENT • PERSIST INDEFINITELY • THROMBOSIS & TENDERNESS WITH TORSION • NO MALIGNANT THREAT • NO TREATMENT REQUIRED • REMOVED FOR COSMESIS, DISCOMFORT, BLEEDING • SCISSOR-SNIP EXCISION AT BASE OF STALK • ELECTROCAUTERY OR CRYOTHERAPY FOR SMALL LESIONS, ANESTHESIA OPTIONAL • RECURRENCES COMMON http: //www. visualdxhealth. com/adult/acrochordon. Skin. Tag. htm

SEBORRHEIC KERATOSIS http: //www. visualdxhealth. com/adult/seborrheic. Keratosis. htm

DESCRIPTION & HISTORY • AKA SENILE WART, SEBORRHEIC WART, BASAL CELL PAPILLOMA • FLESH-COLORED TO BLACK, RAISED PAPULE • UNCOMMON BEFORE AGE 30, VERY COMMON THEREAFTER, MOST PEOPLE DEVELOP ONE • F=M, AUTOSOMAL DOMINANT INHERITANCE http: //www. visualdxhealth. com/adult/seborrheic. Keratosis. htm • LESER-TRELAT SIGN: SUDDEN ERUPTION OF MULTIPLE PRURITIC LESIONS INDICATING INTERNAL (STOMACH, COLON, BREAST) MALIGNANCY

SKIN FINDINGS & LABORATORY • SIZE AND APPEARANCE VARY, USUALLY MULTIPLE LESIONS • FLAT OR RAISED, WAXY, 2 MM 3 CM, WELL-DEMARCATED, “STUCK ON” APPEARANCE • MOST COMMONS LOCATIONS: TRUNK, FACE, EXTREMITIES • BIOPSY: HYPERKERATOSIS, PAPILLOMATOSIS, INCREASED BASAL CELLS WITH KERATIN (HORN) CYSTS http: //www. mrcophth. com/pathology/skin/seborrheickeratosisqq. jpg • DIFFERENTIAL DIAGNOSIS: ROUGHER SURFACE & USUALLY DARKER THAN MELANOMAS

PROGNOSIS & TREATMENT • PERSIST, GROW SLOWLY • OFTEN AYSMPTOMATIC • NO TREATMENT REQUIRED • REMOVED FOR COSMESIS, DISCOMFORT, IRRITATION • CRYOTHERAPY FOR FLAT LESIONS, CURETTAGE WITH ANESTHESIA FOR THICKER LESIONS http: //www. visualdxhealth. com/adult/seborrheic. Keratosis. htm • EXCISIONAL BIOPSY FOR LESIONS SUSPICIOUS OF MELANOMA

EPIDERMOID CYST http: //meded. ucsd. edu/clinicalimg/skin_eic. htm

DESCRIPTION & HISTORY • • http: //www. visualdxhealth. com/adult/epidermoid. Cyst. Sebaceous. Cyst. htm AKA EPIDERMAL INCLUSION CYST SEBACEOUS CYST IS A MISNOMER AS SEBACEOUS GLANDS ARE NOT PART OF THESE CYSTS FIRM, ROUND, SOMEWHAT MOBILE, KERATIN-FILLED MOST COMMON TYPE OF KERATINOUS CYST 2 ND MOST COMMON TYPE IS PILAR (WEN) CYST, FOUND ON SCALP M>F, ARISE AFTER PUBERTY GARDNER’S SYNDROME: AUTOSOMAL DOMINANT, MULTIPLE CYSTS ON FACE & BACK, COLONIC POLYPOSIS, OSTEOMAS

SKIN FINDINGS & LABORATORY http: //www. visualdxhealth. com/adult/epidermoid. Cyst. Sebaceous. Cyst. htm • HARD, DOME-SHAPED, PALE, 0. 5 -5 CM NODULE • MOST COMMON LOCATIONS: BACK, FACE, HAIR-BEARING AREAS (ARISE FROM SQUAMOUS EPITHELIUM OF FOLLICLE) • SOMEWHAT MOBILE, BUT CONNECTED TO SKIN THROUGH SMALL PUNCTUM, APPEARING AS A COMEDONE (BLACKHEAD), REPRESENTING HAIR FOLLICLE FROM WHICH CYST DEVELOPED • BIOPSY: CYST CAVITY FILLED WITH KERATIN & LINED BY SQUAMOUS EPITHELIUM

PROGNOSIS & TREATMENT http: //www. visualdxhealth. com/adult epidermoid. Cyst. Sebaceous. Cyst. htm • PERSIST, GROW SLOWLY • NO MALIGNANT THREAT • PRONE TO TRAUMA & RUPTURE • INFLAMED CYSTS ARE RED, HOT & TENDER • STRONG INFLAMMATORY RESPONSE WILL PREVENT RECURRENCE • USUALLY INFLAMMATION SUBSIDES, CYST RECURS & SCAR FORMS • ASYMPTOMATIC CYSTS DO NOT REQUIRE TREATMENT • REMOVED FOR COSMESIS, PAIN, RECURRENT INFECTION • INCISED WITH ANESTHESIA

DERMATOFIBROMA http: //missinglink. ucsf. edu/lm/Dermatology. Glossary/dermatofibroma. html

DESCRIPTION & HISTORY • AKA FIBROUS HISTIOCYTOMA • FIRM, DERMAL PAPULE • F>M, ETIOLOGY UNKNOWN, MAY BE BENIGN NEOPLASIA OR RESPONSE TO INJURY (REACTIVE HYPERPLASIA) • CONFUSED WITH INSECT BITE DUE TO INITIAL ITCHING http: //www. visualdxhealth. com/adult/dermatofibroma. htm • MULTIPLE LESIONS (>15) ASSOCIATED WITH AUTOIMMUNE DISORDERS OR IMMUNOSUPPRESSION

SKIN FINDINGS & LABORATORY http: //www. visualdxhealth. com/adult/dermatofibroma. htm • FIRM, RAISED, PINK TO BROWN, 3 -10 MM PAPULES, NODULES OR PLAQUES • DOME-SHAPED, FEELS LIKE A BUTTON ON PALPATION • FITZPATRICK’S SIGN: LESION DIMPLES WHEN PINCHED • MOST COMMON LOCATIONS: ANTERIOR SURFACE OF LOWER LEGS, EXTREMITIES • BIOPSY: UNENCAPSULATED PROLIFERATION OF SPINDLESHAPED CELLS • DIFFERENTIAL DIAGNOSIS: EXCESS HEMOSIDERIN MAY TURN LESION BLACK SUGGESTING NODULAR MELANOMA OR PIGMENTED DERMATOFIBROSARCOMA PROTUBERANS

PROGNOSIS & TREATMENT http: //www. visualdxhealth. com/adult/dermatofibroma. htm • PERSIST, REMAIN STABLE IN SIZE & APPEARANCE • OFTEN AYSMPTOMATIC, BUT ITCHING & TENDERNESS COMMON • LEG LESIONS SUBJECT TO TRAUMA FROM SHAVING, FRICTION FROM BOOTS • NO TREATMENT REQUIRED • REMOVED FOR COSMESIS, DISCOMFORT • EXCISIONAL BIOPSY COMPLETELY REMOVES LESION BUT RESULTS IN SCAR FORMATION • CRYOTHERAPY HAS LESS SCARRING, BUT MAY NOT COMPLETELY REMOVE LESION

PYOGENIC GRANULOMA http: //www. visualdxhealth. com/adult/pyogenic. Granuloma. htm

DESCRIPTION & HISTORY http: //www. visualdxhealth. com/adult/pyogenic. Granuloma. htm • AKA GRANULOMA TELANGIECTATICUM • FRIABLE, VASCULAR PAPULE • NAME IS MISLEADING, THESE ARE VASCULAR LESIONS THAT ARE NOT PURULENT, BUT IT WAS ONCE ASSUMED INFECTION WAS THE CAUSE • M=F, CHILDREN & YOUNG ADULTS, DECREASE WITH AGE, REACTIVE RESPONSE TO INJURY • EPULIS GRAVIDARUM: OCCUR ON GINGIVA IN PREGNANT WOMAN, REGRESS AFTER BIRTH

SKIN FINDINGS & LABORATORY http: //www. siumed. edu/~dking 2/intro/skinbiop/images/GT 1. jpg Image copyright 2009 by David G. King, used with permission. • YELLOW TO RED, DOMESHAPED, 3 -10 MM PAPULE • MOST COMMON LOCATIONS: HEAD & NECK, BUT CAN OCCUR ANYWHERE • BEGINS AS A SMALL PAPULE & GROWS RAPIDLY FORMING A STALK OR “COLLARETTE” • BIOPSY: PROLIFERATING ENDOTHELIAL CELLS & FIBROBLASTS WITH MIXED INFLAMMATORY INFILTRATE • DIFFERENTIAL DIAGNOSIS: BACILLARY ANGIOMATOSIS & KAPOSI’S SARCOMA IN HIV PATIENTS WITH MULTIPLE LESIONS, ANGIOSARCOMA IN OLDER WHITE MALES

PROGNOSIS & TREATMENT • PERSIST INDEFINITELY • FRIABLE, TENDER, BLEED EASILY WITH TRAUMA • SOME INVOLUTE SPONTANEOUSLY, MOST PATIENTS SEEK TREATMENT DUE TO BLEEDING • EXCISION WITH AGGRESSIVE ELECTRODESICCATION & CURETTAGE TO CONTROL BLEEDING AND ENSURE TOTAL DESTRUCTION • CRATERIFORM SCAR AFTER TREATMENT • MULTIPLE SATELLITE LESIONS MAY DEVELOP AFTER TREATMENT • RECURRENCES COMMON http: //www. visualdxhealth. com/adult/pyogenic. Granuloma. htm

CHERRY ANGIOMA http: //missinglink. ucsf. edu/lm/Dermatology. Glossary/cherry_angioma. html

DESCRIPTION & HISTORY http: //www. visualdxhealth. com/adult/cherry. Hemangioma. htm • AKA CAMPBELL DE MORGAN’S SPOT • BENIGN, ACQUIRED VASCULAR NEOPLASM • M=F, UNCOMMON BEFORE 30, NEARLY ALL ADULTS THEREAFTER, INCREASE IN NUMBER & SIZE WITH AGE • ETIOLOGY UNKNOWN, ASSOCIATED WITH PREGNANCY, INCREASED PROLACTIN LEVEL, EXPOSURE TO BUTOXYETHANOL & MUSTARD GAS • LESER-TRELAT SIGN: SUDDEN ERUPTION OF MULTIPLE LESIONS ASSOCIATED WITH INTERNAL MALIGNANCY

SKIN FINDINGS & LABORATORY • ROUND, NONBLANCHING, CHERRY RED TO MAROON, VASCULAR, 0. 5 -5 MM PAPULE • SCATTERED RANDOMLY, FEW TO HUNDREDS OF LESIONS • MOST COMMON LOCATIONS: TRUNK, HEAD, NECK, EXTREMITIES • BIOPSY: SHARPLY DEFINED PROLIFERATION OF DILATED CAPILLARIES AND POSTCAPILLARY VENULES • DIFFERENTIAL DIAGNOSIS: TELANGIECTASIAS MORE PAPULAR & BLANCH EASILY, PYOGENIC GRANULOMA MORE FRIABLE & TENDER, BACILLARY ANGIOMATOSIS IN HIV PATIENTS http: //www. geocities. com/sampyroy 2000/cherryheman. jpg

PROGNOSIS & TREATMENT • PERSIST, GROW SLOWLY • ASYMPTOMATIC, TRAUMA MAY CAUSE BLEEDING • NO TREATMENT REQUIRED • REMOVED FOR COSMESIS • LASER SURGERY OR ELECTRODESICCATION FOR TYPICAL LESIONS, EXCISION FOR LARGER LESIONS http: //www. visualdxhealth. com/adult/cherry. Hemangioma. htm • CRYOTHERAPY NOT EFFECTIVE

LIPOMA http: //medicine. ucsd. edu/Clinicalimg/skin-lipoma. jpg

DESCRIPTION & HISTORY • MOST COMMON SOFTTISSUE TUMOR, ANNUAL INCIDENCE: 1 PER 1000 • BENIGN, DERIVED FROM ADIPOCYTES • FIRM NODULE, RUBBERY CONSISTENCY • USUALLY SOLITARY (80%) • M>F, ETIOLOGY UNCLEAR, POSSIBLY DUE TO TRAUMA OR CHROMOSOME 12 REARRANGEMENT http: //missinglink. ucsf. edu/lm/Dermatology. Glossary/lipoma. html

SKIN FINDINGS & LABORATORY • SLOW-GROWING, FATTY TUMOR, <5 CM(80%)– 20 CM • MOST COMMON LOCATIONS: BACK, SHOULDERS, NECK, AXILLA, BUT CAN DEVELOP IN ANY ORGAN IN THE BODY • BIOPSY: MATURE ADIPOCYTES ARRANGED IN LOBULES, ENCLOSED BY THIN FIBROUS CAPSULE http: //www. microscopyu. com/galleries/pathology/images/lipoma/lipo ma 10 x 02 large. jpg • DIFFERENTIAL DIAGNOSIS: EPIDERMOID CYST HAS CENTRAL PUNCTUM & SURROUNDING INDURATION, LIPOSARCOMAS ARE >5 CM, DEEP & LOCATED ON THIGH

PROGNOSIS & TREATMENT http: //www. histopathology-india. net/Lipoma. htm • PERSIST INDEFINITELY • NO MALIGNANT THREAT, DO NOT UNDERGO SARCOMATOUS CHANGE • OFTEN AYSMPTOMATIC, BUT LARGE TUMORS CAN BE PAINFUL DUE TO NERVE COMPRESSION • USUALLY DO NOT INFILTRATE SURROUNDING TISSUE • NO TREATMENT REQUIRED • REMOVED FOR COSMESIS, COMPRESSION OF SURROUNDING STRUCTURES • EXCISION WITH ANESTHESIA

APPROACH TO SKIN LESIONS IN FAMILY PRACTICE • “Treatment includes excision, cryotherapy, curettage with or without electrodesiccation, and is based on the type of tumor and its location. ” • “Generally, excision is the treatment of choice for lipomas, dermatofibromas, pyogenic granulomas, and epidermoid cysts. ” • “Cherry angiomas are often treated with laser therapy and electrodesiccation. ” • “Common treatments for acrochordons and seborrheic keratoses are cryotherapy and shave excision. ” Am Fam Physician 2003; 67: 729 -38.

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