Benign, Neoplasms, Hyperplasias, and Pigmentary Disorders Flashcards
- extremely common benign neoplasms of the epidermis
- MC chest and the back
- Few or hundreds of these raised, “stuck-on”-appearing papules and plaques with well-defined borders
Seborrheic Keratosis
cause of Seborrheic Keratosis?
unknown,
familial trait - autosomal dominant mode of inheritance
SKs tend to increase in incidence and number with increasing ?
age
how may SKs start of as?
a flat wrinkled plaque with a “postage stamp” appearance (flat seborrheic keratosis)
T/F: SKs are MC symptomatic
F: asymptomatic
but when irritated or traumatized, they may become pruritic or painful with associated redness or bleeding
inflamed seborrheic keratosis that presents as a pink shiny papule or plaque with an appearance that resembles that of a nodular or cystic basal cell cancer.
lichenoid keratosis
papular seborrheic keratoses (most often seen as dark brown 1-3 mm papules) on the face of individuals with darker skin phototypes.
Dermatosis papulosa nigra
Relatively rapid onset of numerous SKs
may be a cutaneous sign of ?
internal malignancy
Multiple eruptive SKs is associated with?
what is the other name for it?
- visceral cancer - MC adenocarcinoma of GI tract.
- the sign of *Leser-Trélat *
*
- Waxy, “stuck-on,” verrucous-appearing papules or plaques
- skin-colored, pink, light brown, yellow-brown, brownish-black to black.
- Pigmentation variable within a lesion.
- Scratching shows scaling, rough appearance
- Lesions are usually well-circumscribed.
- They may occur on any body site.
SKs
pedunculated 1-2 mm, furrowed, rough-surfaced polyps appear most commonly around the neck or in the axillae
MC in middle aged and elderly
skin tag - acrochordon
The stuck-on appearance of SKs can sometimes be best appreciated with ?
side-lighting - Hold a penlight or dermatoscope parallel to skin surface at edge of SK
- Ridges, fissures, white pinpoint milia-like cysts, and comedo-like openings - best with non-polarized dermoscopy
- ridges + fissures = cerebriform pattern
- looped/hairpin vessels
- sharply demarcated borders.
- Early evolving has many features similar to solar lentigines: broken, interrupted lines (fingerprinting), few comedo-like openings, and borders that are scalloped or moth-eaten.
these dermoscopy features are for what lesion?
Seborrheic Keratosis
how to dx SK?
- clinically
- Dermoscopy can help differentiating SK vs melanocytic nevi vs melanoma.
- Bx if any concern for malignancy
histopathology findings of SKs
- Sharply demarcated proliferation of monotonous epidermal keratinocytes
- Flat, exophytic or endophytic
- Small keratin-filled cysts (ie, horn cysts) present within tumor
- Occasional features
- Well-demarcated intraepidermal nests of basaloid cells (Borst-Jadassohn phenomenon) in clonal variant
- Spongiosis with squamous eddies
- Reticulated, acanthotic, or papillomatous
- Variable inflammatory cell infiltrate, may be sparse lymphocytic or lichenoid
mgmt pearls for SKs
- removed only for cosmetic reasons
- Patient reassurance
- if multiple SKs, a suspicious pigmented lesion may be overlooked.
- multiple eruptive SKs = prompt search for underlying internal malignancy, esp if patient hx or ROS is suspicious for cancer.
tx options for SKs
- Cryosurgery (MC) - dyspigmentation
- Curettage and cautery
- Chemical peels (eg, trichloroacetic acid) - for small and superficial SKs
- Laser therapy (pulsed CO2, alexandrite, and ER:YAG)
- Shave excision - for larger lesions
- Acquired light or dark brown pigmentation that occurs in exposed areas by the sun
- MC Face
Melasma
RF for Melasma
- Pregnancy (“mask”)
- Genetics
- Idiopathic
- Sun exposure
- Ingested contraception
- Medications (diphenylhydantoin)
*
- Macular
- Hyperpigmented skin
- Sharply defined
- Usually uniform
- MC on malar and frontal areas of face
- F>M; Hot climates
dx?
w/u?
tx?
- melasma
- clinical; Woods lamp not needed - Shows epidermal pigment enhancement
- Tri-Luma QHS (fluocinolone 0.01%, hydroquinone 4%, tretinoin 0.05%); laser
- avoid sun, SPF +30 (Titanium dioxide and zinc oxide, remove estrogen exposure
- Localized proliferation of melanocytes resulting from acute or chronic exposure to sunlight
- 1-3 cm
- Onset: >40 y/o
Solar Lentigo
Solar Lentigos are MC in who?
- MC on sun exposed sites
- MC Caucasians - Skin Type 1 and 2
- Light yellow, light brown, or dark brown (variegated)
- Round, oval, with slightly irregular borders and ill defined
- Skin lesions strictly macular - 1-3 cm
dx? tx?
- Solar Lentigo
- Cryo, Laser
what are the sun exposed areas?
- Forehead
- Cheeks
- Nose
- Dorsa of hands
- Forearms
- Upper back
- Chest
- Shins
acrochordons are MC in who?
- females
- obese individuals
Acrochordons are MC in ___ areas
intertriginous
- Axillae
- Inframammary
- Groin
- Neck
- Eyelids
acrochordons are seen in with what other 2 conditions
- Acanthosis Nigricans
- Metabolic Syndrome
acrochordons become larger and more in number over time especially during ?
pregnancy
tx for acrochordon
- Snipping
- Electrodesiccation
- Cryo
a collection of keratin and lipid rich debris in an epithelial sac within the dermis
Epidermal Inclusion Cyst
aka: epidermal cysts, “sebaceous cysts” - avoid using term sebaceous cyst
cause of Epidermal Inclusion Cyst
- plugged pilosebaceous units
- traumatic implantation of epidermal cells into deeper tissues
Epidermal Inclusion Cyst MC in who?
- 2:1 M>F
- 4th and 5th decades (30-50 y/o)
- asx unless inflamed or infected - inflammation results from cyst wall rupture
- flesh colored, round, firm nodules - +/- central pore/punctum
- contents is malodorous - “rancid cheese”
- MC on face, trunk, neck, scrotum
Epidermal Inclusion Cyst
w/u for Epidermal Inclusion Cyst
- clinical dx
- C&S if recurrent infection
- Imaging or FNA if atypical location (breast, bone)
tx for epidermal inclusion cyst
- asx - none unless cosmetic concern
- inflamed - I&D
- infected - I&D, +/- abx therapy
- Excision: complete removal of cyst sac
- punch, minimal incision or elliptical excision
- best performed when cyst is not inflamed - Surgical consult if cyst is located in atypical location
course and prognosis of epidermal inclusion cyst
- asx cysts may wax and wane with periods of inflammation
- rarely becomes malignant - watch for rapid growth, friability, bleeding
a benign collection of fat cells inside thin fibrous capsule
MC soft tissue tumor
Lipoma
- Onset MC between 40-60 y/o
- soft, painless, slow growing, subcutaneous nodules
- 1-10 cm in size
- MC location - trunk, UE; hands, head, feet are less common
dx?
w/u?
tx?
- lipoma
- clinical; bx if painful, restricts movement, grows rapidly, firm
- surgery if painful, comesis or dx unclear
- Dark blue violaceous, asymptomatic, soft papule resulting from a dilated venule
- MC on face, lips, and ears
- MC > 50 years old
Venous Lake
cause of venous lakes?
- Etiology unknown
- potentially from Solar exposure and Genetics
Because of its dark blue or sometimes even black color, Venous lakes may be confused with ? (3)
- nodular melanoma
- pigmented bcc
- pyogenic granuloma
ways to r/o malignancy in venous lakes?
- Compressed with pressure
- Lightened with diascopy
- Dermoscopy = vascular
tx for venous lakes
Cosmetic reasons only
- Electrosurgery
- Laser
- Surgical excision
pruritic, raised, well-circumscribed areas of erythema and edema
urticaria
pathophys of urticaria
mast cells and basophils release vasoactive substances (histamine, leukotriene C4, prostaglandins) = extravasation of fluid into dermis
causes of urticaria
- type I allergic IgE response
- complement-mediated - infectious, serum sickness, transfusion rxn
- physical mediated - pressure, cold, cholingergic
- autoimmune - SLE, RA, thyroid
- idiopathic
how are urticarias categorized
- acute < 6w - infection, allergy
- chronic > 6w - physical, autoimmune
- raised, erythematous-pink-skin colored wheals with central pallor
- shape and size change rapidly - round, oval, acriform, annular, serpiginous
- individual lesion resolves < 24 h
- +/- dermatographism
- H&P should focus on underlying cause
dx?
w/u?
- Urticaria
- clinical, look for underlying cause
general mgmt for Urticaria
- ED eval - acute can progress to life-threatening angioedema/anaphylactic shock
- Triple Therapy: H1 (1st line) + H2 + steroid is often recommended
types of H2 antihistamines
- cimetidine(Tagamet)
- famotidine(Pepcid)
- ranitidine(Zantac)
types of 2nd gen antihistamines
- loratadine(Claritin)
- desloratadine(Clarinex)
- fexofenadine(Allegra)
- cetirizine(Zyrtec)
types of 1st gen antihistamines
- diphenhydramine (Benadryl)
- hydroxyzine (Vistaril)
MOA of oral GC
- stabilize mast cell membrane, inhibits further histamine release
- Prednisone - short term, 5 day non-tapering course
tx for chronic urticaria
- antihistamines prn
- refer to dermatology for further evaluation/management
prognosis of urticaria
- depends on identification and tx of underlying cause
- acute generally self-limiting within 24 hours
- chronic can impair quality of life
Rapidly developing vascular lesion usually following minor trauma
Very common solitary - Erodes, Vascular bleeds spontaneously
Pyogenic Granuloma
s/s of Pyogenic Granuloma
- Smooth
- +/- crusts
- +/- erosions
- Bright red
- Dusky red
- Violaceous
- Brown-black papule
tx for Pyogenic Granuloma
Surgical excision
ED&C
Pyogenic Granulomas can be misaken for ?
amelanotic nodular melanoma
3 dx of Hemangioma
Cherry angioma
Capillary hemangioma
Strawberry angioma
MC tumor in babies
vascular tumor - endothelil hyperplasia
NOT a vascular malformation
s/s of hemangiomas
- Red
- Soft
- Compressible papule nodule - 1-10cm
- Solitary
- MC on head and neck
4 types of hemangiomas
- Simple: Resolve on own by year 5-10
- Deep (aka cavernous): Lower dermis and subq fat / bluish w/ telangiectasias
- Multiple: Small < 2mm papules (entire body)
- Congenital: Present at birth; Purplish/telangiectasia/large veins
how can deep and multiple hemangiomas be problematic?
w/u?
- obstruct vital functions - vision, larynx, nose, mouth
- MRI to eval; doppler and arteriography to see blood flow
tx for hemangioma
- Propranolol 1st line
- Refer to Cardiology
- Prednisone
- Laser and surgical possible
a depigmenting disorder characterized by a patchy absence of melanocytes
results from a destruction or discontinued function of the melanocyte
Onset: (50%) 10-30 y/o
vitiligo
?% of a patients will have a first degree relative with vitiligo
> 30 %
vitiligo is likely a ___ transmission
affecting multiple gene loci responsible for immune function
polygenic
3 Theories about the mechanism of destruction of melanocytes
- Autoimmune: Selected melanocytes are destroyed by certain lymphocytes that have been activated for unknown reasons.
- Neurogenic: Interaction of the melanocytes and nerve cells.
- Self-destruction: Melanocytes are destroyed by toxic substances formed as part of normal melanin biosynthesis.
- individual “chalk” white macules with sharp margins - may see loss of color to mucosal membranes, retina or hair overlying areas of depigmented skin
- Ranging from 5 mm to 5 cm or larger
- Painless and without pruritus
- Often seen first in sun-exposed areas
- May report new macules in areas of recent trauma (Koebner phenomenon)
vitiligo
4 presentation types of vitiligo
- generalized
- segmental
- localized
- vitiligo universalis
- Symmetrical with widespread distribution.
- “Lip-tip” pattern involves skin around mouth, fingers and toes, as well as nipples and genitalia
which type of vitiligo
generalized
- Only one side or part of body in one band that do not extend beyond the initial one-sided region.
- Younger age, taking 1-2 years to progress, then stops
which type of vitiligo
segmental
Focal to only 1-3 macules in a single sight
which type of vitiligo
localized
Confluence of macules resulting in only a few pigmented areas.
which type of vitiligo
Vitiligo Universalis
w/u for vitiligo
- Clinical
- Wood’s lamp - evaluate macules on lighter skin
- Skin bx - required in cases difficult to dx; Histopathology - nml skin with lack of melanocytes
- Labs if autoimmune disorder is suspected - TSH, T4, fasting glucose, ANA, CBC for pernicious anemia, ACTH stimulation for Addison’s,
Course and Management of vitiligo
- No cure
- ⅓ of pts may report a few areas of spontaneous repigmentation
- Concern for social / psychological stress
- SPF >30
- Cosmetic cover-up - Dyes or makeup to hide the white macules; Self tanner applied to the white macules
