29- Epidermal Nevi to SCC/Merkel Flashcards by Jenica Dela Cruz

Most common type of epidermal nevus

Keratinocytic epidermal nevi

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Most common pattern of keratinocytic epidermal nevus

Linear epidermal nevus

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Verrucous, skin colored, dirty gray or brown papules that coalesce to form serpiginous plaque

Onset at birth or within 10 years old
Follow lines of Blaschko

Keratinocytic epidermal nevus

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Most common internal manifestations in keratinocytic epidermal nevus

Skeletal

CNS

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Management of keratinocytic epidermal nevus

Can be difficult -recurs

5% 5-FU plus 0.1% tretinoin cream OD
Cryotherapy
CO2 or Er:YAG laser
Excision- small lesion

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Closely arranged, grouped often linear papules that have dilated folliculr openings with keratinous plugs that resemble comedones

Unilateral, mostly on trunk, develop from birth to 15 years old

Nevus comedonicus

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Treatment of nevus comedonicus

Uncomplicated- primarily cosmetic (pore strips, topical tretinoin)

Inflamed- oral isotretinoin 0.5mg/kg/day (most fail to respond)

Excision- limited area affected

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Erythematous papules and plaques with fine scale; characteristically pruritic

Follow lines of Blaschko, onset before 5 yo
Usually occurs only on one side

Inflammatory linear verrucous epidermal nevus (ILVEN)

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Treatment for ILVEN

Topical vitamin D
Topical anthralin

Steroids, retinoids- limited benefit

Surgical- excision, cryotherapy, laser

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Circumscribed, red, moist, shiny nodule with some crusting and peripheral scale

Usually on shin, calf, thigh
Asymptomatic, slow growing, occurs after age 40

Clear cell acanthoma

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Treatment for clear cell acanthoma

Cryotherapy, CO2 laser or excision

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Sharply demarcated papules or plaques, “stuck on appearance”

Palms and soles spared, usually on chest and back

Crumbly surface, when removed, raw moist base revealed, common in sun exposed areas

Seborrheic keratosis

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Treatment for seborrheic keratosis

Liquid nitrogen, curretage

Others: light fulguration and shave removal

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Sudden appearance of numerous seborrheic keratoses in an adult thay may be a sign of cutaneous malignancy

Rapid onset, develops at the same time as the cancer, often pruritic

Sign of Leser-Trélat

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Most common neoplasms associated with Leser-Trélat sign

Adenocarcinoma (GIT)

Other: lymphoma, breast, SCC of lung

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Minute, round, skin colored or hyperpigmented macules or papules that develop on malar/cheeks below eyes, May also involve neck, upper chest

Asymptomatic
Usually begins in adolescence
Common in black/asians

Dermatosis papulosa nigra

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Treatment for dermatosis papulosa nigra

Light curretage
Liquid nitrogen
Electrodessication

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Risk factors for developing skin cancer

Fair skinned who tan poorly
Significant chronic or intermittent sun exposure

Other: history of skin cancer
Prior radiation, PUVA, systemic immunosuppression, arsenic exposure

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Major cause of nongenital non melanoma skin cancer (NMSC) and actinic keratoses

Ultraviolet radiation (UVR)

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In situ dysplasia from sun exposure

Found on sun exposed surface- multiple, red pigmented or skin colored, flat or elevated verrucous or keratotic

Surface covered with adherent scale, rough like sandpaper, usually 3 to 1cm

Actinic keratosis

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Most common epithelial precancerous lesions

Actinic keratosis

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Actinic keratosis can be prevented by

Sunscreen

Low fat diet

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What are the six types of actinic keratosis

HABA PiLa

Hypertrophic 
Atrophic
Bowenoid
Acantholytic 
Pigmented
Lichenoid

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Treatment of actinic keratosis

Cryotherapy with liquid nitrogen
Topical chemotherapy- extensive, broad or numerous lesions

Surgical- chemical peel, laser, photodynamic therapy

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Two agents most often used in topical chemotherapy of actinic keratosis

5-FU cream - 0.5-5% OD - 0.5% x 2-3 weeks - 5% x 3-6 weeks Imiquimod -5% cream 3x a week

4 types of keratoacanthoma

Solitary Multiple Eruptive Keratoacanthoma centrifugum marginatum

``` Rapidly growing papule, dome shaped skin colored, smooth crater with central keratin plug Unique feature: rapid growth x 2-6 weeks Stationary x 2-6 weeks Spontaneous involution x 2-6 weeks ``` Occurs on sun exposed skin

Solitary keratoacanthoma

Treatment for keratoacanthoma

Excisional biopsy- <2cm - exclude SCC - excision recommended 50% involution after 3 weeks Intralesional 5-FU, bleomycin, methotrexate Low dose systemic MTX- multiple lesions

Type of keratoacanthoma that usually has a family history

Multiple (Ferguson Smith type)

Risk factors for BCC

``` intermittent sun exposure (+) family hx Immunosuppresion Skin types I and II Blistering sunburns in childhood ```

Most common form of BCC

Nodular BCC (50-80%)

Waxy semi translucent nodules around a central depression Edge has characteristic rolled border Bleeding on slight injury is common Ulcer occurs over time Lesions usually on face and nose

Nodular BCC

BCC that favors the trunk and distal extremities Dry psoriasiform scaly lesion, superficial flat growth, enlarge very slowly

Superficial BCC

Most common pattern of BCC seen in HIV patients

Superficial BCC

BCC that usually occurs in Latinos or Asians

Pigmented BCC

Neglected BCC that had formed an ulceration

Rodent ulcer

Though metastasis is extremely rare, this is the usual site of metastasis in BCC

Regional lymph nodes

Increases the risk of developing BCC by 10 fold

Immunosuppresion from organ transplantation

Topical therapy with 5-FU BID x 6 weeks or imiquimod 3x a week with occlusion for 6 weeks has an 80% cure rate in this type of BCC

Superficial

Surgical management of BCC

Excision- preferred due to higher cure rates Cryosurgery

Autosomal dominant disorder that presents with multiple BCC before 30 years old along with: Jaw cysts-painless swelling Pitting of palms and soles Skeletal defects

Nevoid BCC syndrome (Gorlin syndrome)

Second most common form of skin cancer

SCC

Major risk factor in the development of SCC

Chronic long term sun exposure

Immunosuppresion also enhances the risk of developing SCC Exposure to this drug is associated with greater risk

Azathioprine

SCC that develops in the genitalia may be due to

HPV 16 18 31 35

SCC usually occurs at these sites

Face | Back of hands

Important risk factors for metastasis in SCC

Thickness Others: immunosuppresion, ear location, increased horizontal size

Treatment of SCC

surgical excision

Cause of Bowen disease (SCC in situ)

HPV Arsenic Sun exposure

Erythematous, Slightly scaly and crusted, noninfiltrated patch, sharply defined May be pigmented if on genital area Invasion- devt of exophytic, endophytic or ulcerative component

Bowen’s disease (in situ SCC)

More aggressive than SCC arising in actinic keratosis

Bowen disease

BD may be misdiagnosed as

``` Psoriasis Tinea corporis Nummular eczema Seborrheic or actinic keratosis Pagets disease ```

Treatment for Bowen disease

Imiquimod 5% cream OD X16 weeks or in combination with 5% 5-FU cream BID Excision, Mohs surgery

SCC in situ of the glans penis or prepuce

Erythroplasia of Queyrat

Erythroplasia of Queyrat is caused by

High risk HPV (16,18,31,35)

Fixed, well circumscribed, erythematous moist red surface plaques on the glans penis Mostly occurs in uncircumcised men over 40

Erythroplasia of Queyrat

Treatment for erythroplasia of Queyrat

Patient’s sex partner referred for evaluation Topical: 5-FU or Imiquimod Surgical

Benign inflammatory lesion of the glans penis: red patch, erythematous moist and shiny, does not produce adenopathy Histo-plasma cell rich infiltrate Uncircumcised men affected 24-85 years old

Zoon Balanitis

Treatment for Zoon Balanitis

Topical corticosteroids With or without candidal treatment Circumcision

Unilateral sharply marginated erythematous patch or plaque in the nipple or areola May become eroded, may have axillary adenopathy 5% without evidence of CA

Paget disease of the breast

Presence of this symptom should lead to suspicion of Paget disease

Unilateral eczema of the nipple resistant to treatment

Most common location of extramammary Paget disease

Vulva

Tumor that usually occurs in elderly white men Strong evidence of sun exposure, also with PUVA and immunosuppresion Rapidly growing nontender red to violaceous nodule with shiny surface and telangiectasia

Merkel cell carcinoma

Acronym AEIOU for Merkel cell CA

``` Asymptomatic Expanding rapidly Immunosuppresion Older than 50 UVR exposed in fair skin ```

Cause of Merkel Cell CA 80% in North America and 25% in Australia

Merkel cell polyomavirus (MCPyV)

Treatment for Merkel cell carcinoma

Staging- sentinel lymph node biopsy Surgery and radiation