Benign Neoplasms, Hyperplasias and Pigmentary Disorders - Exam 2 Flashcards
How are seborrheic keratosis commonly described?
There can be few or hundreds of these raised, “stuck-on”-appearing papules and plaques with well-defined borders
aka can also look crusty
Where on the body are seborrheic keratosis commonly found?
benign neoplasms of the epidermis that typically appear on the chest and the back
very common
What am I? How are they inherited?
seborrheic keratosis
autosomal dominat
What is the relationship between SKs and age? What do they typically start out as? What happens when SKs get irritated?
SKs tend to increase in incidence and number with increasing age
They may start out as a flat wrinkled plaque with a “postage stamp” appearance
with irritation or trauma: they may become pruritic or painful with associated redness or bleeding
A ____ is an 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
What is dermatosis papulose nigra?
papular seborrheic keratoses (most often seen as dark brown 1-3 mm papules) on the face of individuals with darker skin phototypes
What does a relatively rapid onset of numerous SKs indicate?
may be a cutaneous sign of internal malignancy.
**What is the sign of Leser-Trelat?
**Multiple eruptive SKs in association with a visceral cancer
**adenocarcinoma of the gastrointestinal tract
Waxy, “stuck-on,” verrucous-appearing papules or plaques
Color is variable and may range from skin-colored, pink, light brown, yellow-brown, and brownish-black to black.
Pigmentation may be variable within a single lesion
Scratching the surface usually shows a scaling, rough appearance
well-circumscribed
What am I?
seborrheic keratosis
What is the technical term for a skin tag? Where are the MC locations?
acrochordon
most commonly around the neck or in the axillae
How can the classic “stuck-on” appearance of an SK be best appreciated? What does it look like if you removed the coarse, waxy scale? Will SKs continue to keep growing?
transilluminate them
show a raw, moist base
NO! grow rapidly and reach a static size without further growth.
Ridges, fissures, white pinpoint milia-like cysts, and comedo-like openings, all better visualized with non-polarized dermoscopy of _____ skin lesion.
Seborrheic keratosis
In seborrheic keratosis: the ridges and fissures together form a ____ pattern. Describe the vascular pattern. Will SKs have sharp borders?
cerebriform
The vasculature pattern most commonly demonstrated is looped, or hairpin, vessels
YES! borders are sharply demarcated
How are Seborrheic Keratosis dx?
clinical but can bx if concerned for malignancy
Sharply demarcated proliferation of monotonous epidermal keratinocytes.
Flat, exophytic or endophytic.
Small keratin-filled cysts (ie, horn cysts) present within the tumor
This is a histopathology report of _____.
Is there any cancerous potential?
Seborrheic Keratosis
no cancerous potential
What is the pt education associated with seborrheic keratosis?
Patient reassurance regarding the chronic and benign nature of these lesions is key
only need additional follow up if multiple erupt -> concern for cancer
What are the therapy options for SKs in patients who choose to tx them?
Cryosurgery
Curettage and cautery
Chemical peels for small and superficial ones
laser therapy
shave excision can be used for larger lesions
What causes melasma? Where is the MC body location?
Acquired light or dark brown pigmentation that occurs in exposed areas by the sun
MC on the face (malar and frontal areas)
What are the risk factors for melasma? Who is the MC pt?
Pregnancy (“mask”)
Genetics
Idiopathic
Sun exposure
Ingested contraception
Medications (diphenylhydantoin)
females in hot climates
What is the tx for melasma?
Tri-Luma QHS for 6-8 weeks and need to apply GOOD sunscreen
laser
What are the components of Tri-Luma? When is it used?
Fluocinolone 0.01%
Hydroquinone 4%
Tretinoin 0.05%
tx for melasma
What are the 3 pt education points for melasma?
Avoidance of sun
Sunscreen >30 spf re-apply q 80 min
Remove estrogen exposure
What sunscreen ingredients provide the best coverage?
Titanium dioxide and zinc oxide (best coverage)
What am I? What is the underlying cause?
solar lentigo
“sun spots”
Localized proliferation of melanocytes resulting from acute or chronic exposure to sunlight
How big are the normal solar lentigo? What is the MC age? What skin type?
1-3 cm
Onset = >40 years old
caucasians: skin type 1 and 2
Light yellow, light brown, or dark brown (variegated)
Round, oval, with slightly irregular borders and ill defined
on sun exposed sites
What am I?
What is the tx?
Solar Lentigo
tx:
light cryo or laser therapy
Skin colored, brown, round or oval
Pedunctulated papiloma
What am I?
What size?
What is the MC patient?
Acrochordon (skin tag)
Usually constricted at the base >1mm – 10mm
MC in middle aged and elderly obese females in the intertriginous areas
What are some common locations for acrochordon? What 2 other conditions are also seen with it?
MC in intertriginous areas
Axillae
Inframammary
Groin
Neck
Eyelids
Seen in Acanthosis Nigricans and Metabolic Syndrome
What 2 things cause an increase in acrochordon? What is the tx?
increase in time and during pregnancy
tx:
Snipping
Electrodesiccation
Cryo -> need to freeze both sides of the stalk
______ is a a collection of keratin and lipid rich debris in an epithelial sac within the dermis. What are the 2 etiologies?
Epidermal Inclusion Cyst
- plugged pilosebaceous units
- traumatic implantation of epidermal cells into deeper tissues
What is the MC pt type for epidermal inclusion cyst?
males between 30 and 50 years old
What am I? What will the pt complain of? What areas of the body are involved?
Epidermal Inclusion Cyst
Asymptomatic unless inflamed or infected
MC on face, trunk, neck, scrotum
flesh colored, round, firm nodules
+/- central pore/punctum
contents is malodorous
“rancid cheese”
What am I?
How do you dx?
Epidermal Inclusion Cyst
can be a clinical dx if textbook presentation
C&S if infected
When would you need to do imaging or FNA in an epidermal inclusion cyst?
if atypical location (breast, bone)
What is the tx for an epidermal inclusion cyst?
no treatment unless cosmetic concern
then I&D +/- abx
or
surgical excision
What are the 3 types of surgical excision for an epidermal inclusion cyst? What is the goal? When should it be performed?
punch, minimal incision or elliptical excision technique
goal: complete removal of cyst sac
when the cyst is NOT inflammed
When should you consult general surgery for an epidermal inclusion cyst? Will the cyst remain constant or change?
when the cyst is in an atypical location
asymptomatic cysts may wax and wane with periods of inflammation
Do epidermal inclusion cyst have the potential to become malignant?
rarely but yes, watch for rapid growth, friability, bleeding
______ is a benign collection of fat cells inside thin fibrous capsule. What is the age of onset?
Lipoma
Onset MC between 40-60 y/o
What is the MC soft tissue tumor? Where are the MC locations?
lipoma
trunk, UE
soft, painless, slow growing, subcutaneous nodules
1-10 cm in size
rubbery
on the trunk and UE
What am I?
How do you dx?
What is the tx?
lipoma
clinical dx
surgical excision
What am I?
Where are the MC locations?
What age range?
venous lake
face, lips and ears
> 50 years old
_____ is a dark blue violaceous, asymptomatic, soft papule resulting from a dilated venule. How many do you typically see at a time? How long do they last?
venous lake
Lesions are few in number and remain for years
What is the underlying cause of a venous lake?
Dilated cavity is lined with a single layer of flattened endothelial cells filled with red blood cells and surrounded by thin wall of fibrous tissue
How will the venous lake change when compressed? How will it appear with diascopy?
When you press down on a venous lake, you’ll see the bluish-purple color lighten or disappear as the blood drains out, and the lesion will flatten or become less noticeable
^same way to say lighten with diascopy
What are the tx options for a venous lake? Do you have to tx them?
Cosmetic reasons only:
Electrosurgery
Laser
Surgical excision
______ pruritic, raised, well-circumscribed areas of erythema and edema
urticaria
What is the pathogenesis of urticaria? What is the underlined phrase?
mast cells and basophils release vasoactive substances (histamine, leukotriene C4, prostaglandins) resulting in extravasation of fluid into the dermis
What are the 5 different types of urticaria?
type I allergic IgE response
complement-mediated
physical mediated
autoimmune
idiopathic
What type of urticaria? foods, meds, insect bite/sting, latex, contact allergen
type I allergic IgE response
What type of urticaria? infectious, serum sickness, transfusion reaction
complement-mediated,
What type of urticaria? pressure urticaria, cold urticaria, cholinergic urticaria
physical mediated
What type of urticaria? SLE, RA, thyroid autoimmune d/o
autoimmune
What are the 2 different timeframes for urticaria?
acute: less than 6 weeks: think infection or allergy
chronic: recurrent, most days of the week, > 6 wks: think physical or autoimmune
raised, erythematous-pink-skin colored wheals with central pallor
shape and size change rapidly
+/- dermatographism
What am I?
**When should the lesions resolve?
urticaria
**resolves within 24 hours
What is the management for acute urticaria?
emergency department eval
triple regimen therapy: H1 + H2 + steroid is often recommended
loratadine(Claritin)
desloratadine(Clarinex)
fexofenadine(Allegra)
cetirizine(Zyrtec)
Second gen. antihistamines (first line):
What are the first line agents in the H1 antihistamine drug class?
diphenhydramine (Benadryl)
hydroxyzine (Vistaril)
What are the 2nd line agents in the H1 antihistamines?
first gen antihistamines- H1
cimetidine(Tagamet)
famotidine(Pepcid)
ranitidine(Zantac)
What are the medications in the H2- antihistamine drug class?
____ MOA stabilize mast cell membrane, inhibits further histamine release
steroids
prednisone
What is the management of chronic urticaria?
antihistamines prn
refer to dermatology for further evaluation/management
identify and avoid cause
_____ is a rapidly developing vascular lesion usually following minor trauma. How common is it?
pyogenic granuloma
very common to have 1
Smooth
+/- crusts
+/- erosions
Bright red
Dusky red
Violaceous
Brown-black papule
Erodes
Vascular bleeds spontaneously
What am I?
What is the rx?
pyogenic granuloma
sx excision
Electrodesiccation and Curettage
What am I?
What can it be mistaken for?
Pyogenic Granuloma
amelanotic nodular melanoma
____ is the MC tumor in babies. What is it composed of? What is it NOT?
amelanotic nodular melanoma
endothelil hyperplasia
NOT a vascular malformation
When does a hemangioma start to form? MC in males or females? Where are the 2 MC locations?
Starts 2-4 weeks of age
more common in females
MC on head and neck
What are the 4 types of hemangiomas?
simple
deep
multiple
congenital
When does a simple hemangioma resolve?
Resolve on own by year 5-10
What is a deep hemangioma?
Lower dermis and subq fat / bluish w/ telangiectasias
What size are multiple hemangiomas typically?
Small <2mm papules (entire body)
What is a congenital hemangioma?
Present at birth
Purplish/telangiectasia/large veins
**Why are deep and multiple hemangiomas a problem? What diagnostic tests should you order?
OBSTRUCT VITAL FUNCTIONS!!!
VISION
LARYNX
NOSE
MOUTH
MRI TO EVAL
DOPPLER AND ARTERIOGRAPHY TO SEE BLOOD FLOW
What is the tx for hemangioma? What is the first line tx?
Propranolol first line
refer to cardiology to monitor
prednisone 2-3mg daily for 6-12 weeks
can also do laser surgical options, topical timolol
______ is a depigmenting disorder characterized by a patchy absence of melanocytes. What is the underlying cause?
vitiligo
a depigmenting disorder characterized by a patchy absence of melanocytes
What is the onset of vitiligo? What races does it affect?
½ of all cases begins between 10-30 years of age
affects all races!! but reported and treated more frequently in races of darker skin complexion
__% of vitiligo patients have a first degree relative with vitiligo. How is it transmitted?
> 30
likely a polygenic transmission
What are the 3 theories about the mechanism of destruction of melanocytes in vitiligo?
autoimmune
neurogenic
self-destruction
pathogenesis of vitiligo: _______ Selected melanocytes are destroyed by certain lymphocytes that have been activated for unknown reasons.
autoimmune
pathogenesis of vitiligo: _______ Interaction of the melanocytes and nerve cells
neurogenic
pathogenesis of vitiligo: _______ Melanocytes are destroyed by toxic substances formed as part of normal melanin biosynthesis
self-destruction
individual “chalk” white macules with sharp margins
Painless and without pruritus
Often seen first in sun-exposed areas
What am I?
How large are the macules?
vitiligo
5 mm to 5 cm or larger
What is the Koebner phenomenon?
May report new vitiligo macules in areas of recent trauma
in vitiligo, may see loss of color to _____, _____, and _____ overlying areas of depigmented skin
mucosal membranes, retina or hair
What are the 4 presentation types of vitiligo? Which one is MC?
generalized**- MC
segmental
localized
Vitiligo Universalis
Type of vitiligo presentation: ______ Symmetrical with widespread distribution.
“Lip-tip” pattern involves skin around mouth, fingers and toes, as well as nipples and genitalia
generalized- MC
Type of vitiligo presentation: ______ 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
segmental
Type of vitiligo presentation: ______ Focal to only 1-3 macules in a single sight
localized
Type of vitiligo presentation: ______ Confluence of macules resulting in only a few pigmented areas.
Vitiligo Universalis
aka mostly depigmented
What type of vitiligo is one sided and common in younger pts?
segmental
How do you dx vitiligo? What will a skin bx show?
clinical dx
normal skin with lack of melanocytes
What is the pt education for vitiligo?
NO CURE!!
⅓ of patients may report a few areas of spontaneous repigmentation
sunburn precautions!! SPF >30 recommended
What are some tx options for vitiligo?
Topical Glucocorticoids: Intermittent application of high potency steroid for single or few macules, but if no response in 2 months, discontinue
Topical Photochemotherapy: topical 8-methoxypsoralen (8-MOP) and UVA
If no response, when should a pt stop applying high potency steroids for vitiligo?
but if no response in 2 months, discontinue
What are the 2 components of systemic photochemotherapy in vitiligo? When is it used?
Oral 8-MOP and UVA therapy
Treatment for 1 year with poor results for “lip-tip” distribution. Genitals shielded and not treated
What is the tx of choice for vitiligo in kiddos older than 6?
Narrow-band UVB
______ is also done in the management of refractory vitiligo and involves small skin grafts taken from normally pigmented skin
Minigrafting
