16: 68-year-old man with skin lesion Flashcards
Primary and Secondary Skin Lesions
Primary skin lesions are uncomplicated lesions that represent initial pathologic change, uninfluenced by secondary alterations such as infection, trauma, or therapy.
Secondary skin lesions are changes that occur as consequences of progression of the disease, scratching, or infection of the primary lesions.
Primary Skin Lesions
Macule: A macule is a change in the color of the skin. It is flat, and if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. It is less than 1 cm in diameter. Some authors use 5 mm for size criterion. Sometimes “macule” is used for flat lesion of any size.
Patch: A patch is a macule greater than 1 cm in diameter.
Papule: A papule is a solid raised lesion that has distinct borders and is less than 1 cm in diameter.
Plaque: A plaque is a solid, raised, flat-topped lesion greater than 1 cm in diameter. It is analogous to the geological formation, the plateau.
Nodule: A nodule is a raised solid lesion and may be in the epidermis, dermis or subcutaneous tissue.
Tumor: A tumor is a solid mass of the skin or subcutaneous tissue; it is larger than a nodule.
Vesicle: A vesicle is a raised lesion less than 1 cm in diameter and is filled with clear fluid.
Bulla: A bulla is a circumscribed fluid filled lesion that is greater than 1 cm in diameter.
Pustule: A pustule is a circumscribed elevated lesion that contains pus.
Wheal: A wheal is an area of elevated edema in the upper epidermis.
Skin Cancer Screening Recommendations
The annual skin cancer screening by full body skin examination by health care provider is an I recommendation by USPSTF. I recommendation means that current evidence is insufficient to assess the balance of benefits and harms of a primary care clinician performing a whole body skin examination or a patient doing a skin self- examination for the early detection of skin cancers.
However, the American Cancer Society recommends appropriate cancer screening by a physician, including a skin examination, during a periodic health examination. The American Academy of Dermatology promotes free skin examinations by volunteer dermatologists for the general population through the Academy’s Melanoma/Skin Cancer Screening Program. It also encourages regular self-examinations by individuals.
In the context of apparently conflicting recommendations by different organizations and when there is no sufficient evidence for the benefit or harm of certain recommendations, (like USPSTF I recommendation), the best policy may be to discuss the recommendation with patients and ask their preference. Physicians, however, should be able to discuss the possible outcomes of the patient’s choice.
Risk factors for nonmelanoma skin cancers include:
- 80% of lifetime sun exposure is obtained before 18 years of age (single greatest risk factor)
- Episodic sun exposure “probably does not increase risk”
- White race
- Celtic ancestry
- Fair complexions
- People who burn easily
- People who tan poorly and freckle
- Red, blonde or light brown hair
- Increasing age
- Use of coal-tar products
- Tobacco use
- Psoralen use (PUVA therapy)
- No significant Family History
- Male»_space;> female
- Whites near equator (UV exposure)
- Outdoor work
- Chronic osteomyelitis sinus tracts
- Burn scars
- Chronic skin ulcers
- Xeroderma pigmentosum
- Human papillomavirus infection
- Previous skin cancer of any type gives 36-52% 5-year risk of second skin cancer
Risk factors for melanoma skin cancer include:
- White race
- Celtic ancestry
- Fair complexions
- People who burn easily
- People who tan poorly and freckle
- Red, blonde or light brown hair
- Early adulthood and later in life
- Cumulative sun exposure “probably does not increase risk”
- “Intense, intermittent exposure and blistering sunburns in childhood and adolescence are associated with
increased risk” - Radiation exposure
- Melanoma in 1st or 2nd degree relative
- Familial atypical mole-melanoma syndrome (FAMMS)
- Male > female (slight)
- Whites near equator (UV exposure)
- Indoor work
- Higher incidence in those with more education and/or income
- Nonfamilial dysplastic nevi
- Large number of benign pigmented nevi
- Giant pigmented congenital nevi
- Nondysplastic nevi (markers for risk, not precursor lesions)
- Xeroderma pigmentosum
- Immunosuppression
- Previous nonmelanoma skin cancer
- Other malignancies
- Previous melanoma
A consent form should contain:
the name of the procedure the diagnosis the risks of the procedure the benefits of the procedure the alternative to the procedure that was proposed
Patient Education for Protection Against Sun Damage
The key to preventing a skin cancer is to stay out of the sun and not to use a sunlamp. If you are going to be in the sun, you should wear clothes made from tightly woven cloth so the sun’s rays can’t get to your skin. You should also stay in the shade when you can. Wear a wide-brimmed hat to protect your face, neck, and ears.
Remember that clouds and water won’t protect you from the sun’s rays. The sun’s rays can also reflect off water, snow, and white sand.
If you can’t stay out of the sun or wear the right kind of clothing, you should use sunscreen to protect your skin. But don’t think that you are completely safe from the sun just because you are wearing sunscreen.
Use sunscreen with a sun protection factor (SPF) of 15 or more. Put the sunscreen everywhere the sun’s rays might touch you, including your ears, the back of your neck, and bald areas on your scalp. Put more on every two to three hours and after sweating or swimming.
Prostatitis Syndrome Symptoms
Prostatitis syndromes tend to occur in young and middle aged men. The symptoms of prostatitis include pain (in the perineum, lower abdomen, testicles and penis, and with ejaculation), bladder irritation, bladder outlet obstruction, and sometimes blood in the semen.
Skin Examination
Distribution
The distribution of the skin lesions is important in diagnosing skin diseases. Many conditions have typical patterns or affect specific regions of the body. For example, psoriasis commonly affects extensor surfaces of joints, and atopic eczema impacts flexor surface of joints. Involvement of the palms and soles is seen in erythema multiforme, secondary syphilis and eczema.
Shape
Descriptions like oval, round, linear etc. can be used to describe the shape of the lesions. Annular lesions are circular with normal skin in the center. Annular macules are observed in drug eruptions, secondary syphilis and lupus erythematosus. Iris lesions are a special type of annular lesion in which an erythematous annular macule or papule develops a second ring or a purplish papule or vesicle in the center (target or bull’s eye lesion).
Arrangement
A linear arrangement of lesions may indicate a contact reaction to an exogenous substance brushing across the skin. Zosterform refers to lesions arranged along the cutaneous distribution of a spinal nerve.
Size
Some lesions are important to measure size, especially skin malignancy like squamous cell carcinoma and nevi. The squamous cell carcinoma of the skin greater than 2 cm in diameter is regarded to be in high risk for recurrence and metastasis. Nevi larger than 6 mm in diameter tend to be more malignant than the smaller nevi.
Associated symptoms
Associated symptoms, like itching, pain, or burning sensation are helpful to make a diagnosis of certain skin diseases. Eczema tends to be itchy compared to fungal skin infections. Pain is usually associated with herpes simplex or herpes zoster.
Topical Corticosteroids
Group I
Augmented betamethasone dipropionate 0.05%, Halobetasol propionate 0.05%
Psoriasis, lichen planus, severe hand eczema, and alopecia areata.
Group II
Desoximetasone, Fluocinonide 0.05%
Psoriasis, lichen planus, severe hand eczema, and alopecia areata.
Group III
Betamethasone dipropionate 0.05%, Triamcinolone acetonide 0.5% (ointment or cream)
Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.
Group IV
Floucinolone acetonide 0.025% (ointment), Triamcinolone acetonide 0.1% (ointment)
Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.
Group V
Floucinolone acetonide 0.025% (cream), Triamcinolone acetonide 0.1% (lotion) or Triamcinolone acetonide 0.025% (ointment)
Atopic dermatitis, nummular eczema, stasis dermatitis, and seborrheic dermatitis.
Group VI
Alclometasone dipropionate 0.05%, Desonide 0.05%
Dermatitis in eyelids and diaper area, mild dermatitis on face, and mild intertrigo.
Group 7
Hydrocortisone 1%, 2.5% Dermatitis in eyelids and diaper area, VII mild dermatitis on face, and mild
intertrigo.
Tinea capitis
Oral therapy is required to adequately treat tinea capitis, as they are able to penetrate the infected hair shaft where topical therapies cannot.
Griseofulvin is the first-line oral antifungal treatment approved for use. Suggested dosing is 20-25 mg/kg/day using the microsize formulation, for 6-12 weeks. Where the ultramicrosize formulation is used, a dose of 10-15 mg/kg/day is suggested, as it is more rapidly absorbed than the microsize form.
Terbinafine hydrochloide was also approved by FDA in 2007 for tinea capitis for children ages 4 years and older. The approved pediatric dose of terbinafine granule is 125 mg, 187.5 mg, or 250 mg for children weighing less than 25 kg, 25 to 35 kg, and more than 35 kg, respectively, once daily for 6 weeks.
In multiple studies, terbinafine was consistently more effective than griseofulvin against tinea capitis caused by Trichophyton tonsurans.
Tinea unguium
Though griseofulvin is approved for tinea infection of the nails, its affinity for keratin is low and long-term therapy is required. The oral therapy regimens for tinea unguium (onychomycosis)are as follows:
»terbinafine 250 mg/day for 12 weeks (toenails) or 6 weeks (fingernails only)»_space;itraconazole 200 mg twice daily as pulse therapy
one pulse: 1 week of itraconazole followed by 3 weeks without itraconazole
two pulses: fingernails
three pulses: toenails
Local Therapy
Tinea pedis, tinea manuum, tinea corporis, and tinea cruris can be treated with topical antifungal medications.
A wide variety of topical agents are available, in cream, gel, lotion, and shampoo formulations. A majority of the agents are of the ‘azole’ antifungal family (clotrimazole, miconazole, econazole, coiconazole, ticonazole, etc.). Terbinafine and naftifine represent the ‘allylamine’ family of agents. Both families of drugs are known for their high efficacy against the dermatophytes.
Cure rates of tinea corporis/tinea cruris/tinea pedis are high, with infections resolving with two to four weeks of topical therapy.
Incisional / punch biopsy
Incisional biopsy means taking out a part of the skin lesion
Punch biopsy is a specific incisional biopsy using a cylindrical dermal biopsy tool.

Disposable punches are very convenient and available from two to eight millimeters in size.
A full thickness of skin can easily be obtained with a punch biopsy.
If a lesion is less than three millimeters in size, it does not need stitches after biopsy.
Excisional biopsy
Excisional biopsy involves removing the whole lesion with a two to three millimeter margin, depending on the nature of the lesion.
Larger-sized punches may be useful for excisional punch biopsies.
Diagnostic method of choice if there is a strong suspicion of malignant melanoma.
