JC81 (Surgery) - Skin ulcers Flashcards
Constituents and layers of skin epidermis
Epidermis • Stratified squamous epithelium o Stratum corneum (keratin layer) o Stratum granulosum o Stratum spinosum o Stratum basale
- Langerhans cells as antigen presenting cells
- Melanocytes
Constituents and layers of skin dermis
• Collagen and elastin fibers
• Adnexal structures
o Pilosebaceous unit
o Eccrine glands
o Apocrine glands
• Histiocytes and mast cells
o Antigen presenting cells
o Component of reticuloendothelial system
• Arterioles/ Venules/ Lymphatics
Constituents and layers of subcutis
- Adipose tissues
* Arterioles/ Venules/ Lymphatics
List lesions derived from epidermis
- Benign
- Premalignant
- Malignant
Benign: Skin tags/ papilloma Warts Senile seborrheic keratosis Keratoacanthoma
Pre-malignant:
Solar keratosis
Bowen’s disease (SCC in-situ)
Malignant:
SCC
BCC
Melanocytes: Benign pigmented naevi, Malignant melanoma
List lesions derived from dermis and skin appendages
Dermis: Acrochordon (skin tag) Pyogenic granuloma Histocytoma Keloids Kaposi's sarcoma Dermatofibrosarcoma protuberans
Skin appendages:
Epidermal/ sebaceous cysts
Dermoid cysts
Skin appendage tumors
List lesions derived from hypodermis and deep subcutis
Lipoma, Liposarcoma Neurofibroma, Neurosarcoma Neurofibromatosis Schwannoma Ganglion cyst
List vascular lesions from subcutis of skin
List neural lesions from subcutis of skin
Vascular:
Campbell de Morgan spots/ Cherry angioma
Spider naevi
Angioma
Nerves:
Glioma
Neuroma
Schwannoma
Describe lesion
Bulla/ Blisters
Circumscribed collection of free fluid below epidermis
Describe lesion
Macule
Circular, flat discoloration under 1cm in diameter
Well-circumscribed
Describe lesion
Nodule
Circular, Elevated lesion
Solid
May involve subcutis
>1cm in diameter
Describe lesion
Patch
Circumscribed, Flat discoloration
>1cm in diameter
Describe lesion
Papule
Superficial
Solid
Elevated and circumscribed lesion
<0.5cm in diameter
Describe lesion
Plaque
Superficial
Elevated, Solid, Flat lesion
Circumscribed
>1cm diameter
Describe lesion
Pustule
Pus-containing vesicles
• Yellowish and whitish
• Collection of polymorphs
Describe lesion
Vesicle
Circular, collection of free fluid <1cm in diameter
Differentiate petechiae, purpura and ecchymosis
Subcutaneous bleeding
Extravasation of red blood cell
Red and non-blanchable
Petechiae = 1-2mm Purpura = >3mm Ecchymosis = >1cm
Causes of scales, crust, keloid, ulcer
Scales
Accumulation of excess keratin
Crust
Dried serum and exudate
Keloid
Hypertrophic scarring
Ulcer
Circumscribed loss of tissue
Describe lesion and name
Cell of origin
Cause
Papilloma
Description:
- skin colored lesions
- Irregular keratinized
- smooth raised plaque to papilliferous pedunculated polyp
- Simple overgrowth of all layers of skin with a central vascular core
Describe lesions
Cause
Tx
Corns and callouses
Cause: Chronic trauma/ irritation causes thickening of stratum corneum
Corn - smaller, well-demarcated, square-shouldered
Callous - Larger, diffuse, slope shouldered
Tx: Surgical removal, Keratolytic agent (salicylic acid)
List 3 common cystic lesions
Epidermoid/ sebaceous cyst
Implantation dermoid
Dermoid cyst
Describe lesion Cause Content of lesion Associated condition if multiple Tx
Epidermoid cyst/ Sebaceous cyst
- Retention cyst due to obstruction of the sebaceous duct
- True cyst with epithelial lining from hair follicles
- Spherical and attached to skin with Punctum
Contains cheesy keratin material
Multiple cysts: Gardner’s syndrome (FAP associated with extracolonic manifestation)
Tx - surgical excision
Describe lesion
Cause
Implantation dermoid
Epidermal cyst
- epidermal fragment driven into dermis by penetrating injury
- History of trauma or scarring
Describe lesions
Top: Milia
- Small 1-2mm epidermal cysts on face
Bottom: Pilar cyst
- Trichilemmal cyst, slow-grwoing firm cyst on scalp
Name lesion
Multiple epidermal cysts
> > Steatocystoma multiplex
Describe and name lesion
Cause
2 main etiologies and physical difference
Tx
Dermoid cyst / Sequestration dermoid
Cause: formed by epidermal cells being sequestrated beneath skin
Etiologies:
- Congenital: inclusion of embryonic epithelium at sites of embryonic fusion (midline of scalp, external angle of eye, lower mandible)
- Acquired: Epithelium driven beneath skin by puncture wound leads to formation of cystic lesions
Congenital - soft and may transluminate
Acquired - hard and firm
Tx: Surgical excision
List 3 Keratotic lesion
Seborrheic keratosis
Actinic keratosis
Keratoacanthoma
Describe and name lesion
Demographics
Cell of origin
Diagnostic features
Tx options
Seborrheic keratosis/ Basal cell papilloma/ Senile warts
- Brown-black, Raised plateau of hypertrophic greasy skin,
- well-demarcated, plaque-like papules, Waxy with papuliferous surface
Demographic: elderly >70
Cell of origin: Benign overgrowth of the basal layer of epidermis
Dx features:
- Can be picked off using blunt forceps
- Leser-Trelat sign: acanthosis nigricans + skin tags + senile warts appear with GI/ lung cancer
Tx: o Cryotherapy* o Curettage/ shave excision o Electrodesiccation o CO2 laser ablation
Describe lesion
Areas of skin affected
Tx
Actinic keratosis/ Solar keratosis/ Senile keratosis
- UV-exposed skin
- Dry, scalpy, crusty surface with erythematous base
- Early lesions are flat papules
- Hyperkeratosis and acanthosis with malignant potention
Tx:
- Excision
- Currettage
- Cryosurgery
- 5-FU cream
Describe and name lesion
Typical area of involvement
Growth pattern
Tx
Keratoacanthoma/ Molluscum sebaceum
- Dome/ nodular, flesh-colored nodule
- Central crater filled with keratin plug
Area: Common on the face but can occur anywhere with sebaceous glands/ hair-bearing sun-exposed skin
Growth: rapid growth for few weeks, then static and involution
Tx: Excisional biopsy (exclude SCC) and Surgical excision
Naevi
Cause
3 types
Developmental abnormality with hyperplasia of incompletely differentiated tissue elements
Types:
- Melanocytic naevus (Moles)
- Strawberry naevus (Infantile haemangioma)
- Sebaceous naevus
Describe lesion
4 subtypes based on age of presentation
Melanocytic naevi
Junctional: in children, flat, dark pigmentation
Compound: Young adult, raised, varied pigmentation
Intradermal: old age, dome-shaped, flesh-colored
Congenital: large, dark, raised, thick, hairy
Risk factors of melanocytic naevi malignant transformation
Dysplastic naevus with diameter >2mm Family history of skin cancer Previous skin cancer Giant congenital melanocytic naevus (whole trunk black) Age >50
Ddx melanocytic naevi
Melanoma
BCC
Seborrheic keratosis
Describe lesion
Compare sporadic vs familial subtypes
Dysplastic naevi
- Irregular border
- Speckled pigmentations
Sporadic: a/w caucasians with fair skin with excessive sunlight exposure and freckles
Familial: Dysplastic naevus syndrome, high risk of malignant transformation
Describe and name lesion
Cell of origin
Cause
Tx
Dermatofibroma (histiocytoma, sclerosing angioma)
- Site: Most commonly located in lower extremities
- Size: Usually nodules 0.3 – 1.0 cm but giant lesions > 3 cm have also been described
- Color: Hyperpigmented
- Consistency: Firm
- Associated symptoms: Pruritus
- Classically dimple when pitched
Cause: History of trauma/ insect bites causing proliferation of fibroblasts, fibrosis and iron pigmentation
Tx:
o Surgical excision
o Cryotherapy with liquid nitrogen
Describe lesion
Histological features
Tx
Dermatofibrosarcoma protuberans (DFSP)
Painless, indurated plaque with irregular nodules
Diffuse, skin-colored
Histology: cord/ nests of cells invade into adjacent soft tissue
Tx: Wide excisional margin +/- RT
Describe and name lesion
- Cell of origin
- Presentation
- Special signs
- Tx
Neurofibroma
Origin: neuromesenchymal origin including Schwann cells, perineurial cells, fibroblasts and mast cells
Presentation: asymptomatic or Tingling sensation in nerve distribution
- Site: Any subcutaneous tissue, common in forearm
- Size: Papules or nodules < 2 cm in diameter
- Shape: Fusiform or sessile/ pedunculated with long axis lying along the length of limb
- Color: Hyperpigmented
- Number: Can be solitary but often multiple
- Composition: Firm and rubbery
Signs:
o Tinel sign = Symptoms of pain and paraesthesia can be elicited
o Button-hole sign = Applying direct pressure may make some neurofibroma seem to retract into the skin
Tx: surgical excision
Name lesion
Cause
Neurofibromatosis
AD NF-1 and NF-2 mutation
Multiple nodules with cafe au lait pigmentation
Possible malignant transformation
Acoustic neuroma
Lipoma
Content
Tx
Malignant features
Content: Matured adipocytes in fibrous capsule
Tx: Conservative, excision, liposuction
Malignant features: Pain, rapidly enlarging, skin changes, firm consistency
Compare vascular tumor vs vascular malformation in skin
- Age of onset
- Size changes
- Example
Vascular tumors
- Common tumor of infancy, but not present at birth
- Rapidly increase in size disproportionate to body size, then involution
- e.g. Strawberry naevus
Vascular malformation
- Present at birth
- Grows proportionally to body size
- Degenerate or hypertrophy (AVM)
- e.g. arteriovenous malformation, AV fistula
Name lesion
Demographic
Growth pattern
Complications
Tx options
Haemangioma/ Strawberry naevus
Growth:
• Rapid proliferation of blood vessels in the first year of life (followed by)
• Gradual regression of vascular component with replacement of fibrofatty tissues
Cx:
ulceration and permanent disfigurement
compromise vital organ function including eyes, CNS and circulatory system
Tx: Serial observation (wait for involution) Topical or intralesional corticosteroids Topical β-blockers Pulsed-dye laser (PDL) Excisional surgery
Complications of skin haemangioma
Critical compromised blood flow:
- Bleeding
- Ulceration
Mass effect: - Periorbital hemangioma: Upper eyelid affected: >> Stimulus-deprivation amblyopia >> failure to develop binocular vision >> Corneal distortion and astigmatism
- Airway hemangioma»_space; Airway obstruction
Skin examination methods
• Dermoscopy
• Diascopy
o Pressing a glass slide onto skin
• Wood’s light
o Examination of difference in pigmentation
Biochemical/ serum tests for skin diseases
• Serology
o Anti-skin antibodies (pemphigoid and pemphigus)
o ANA, anti-dsDNA, anti-ENA, anti-Jo1
o Anti-HIV
- Skin swab (bacterial/ virus)
- Skin scraping (fungus/ scabies mites)
• Skin prick test
o Type I hypersensitivity reaction
o Intradermal injection of common allergens
o Allergens in atopic dermatitis
• Skin patch test
o Type IV hypersensitivity reaction
o Allergens in contact dermatitis
Biopsy techniques for soft tissue mass
Fine needle aspiration (FNA)
Core-needle biopsy
Incisional biopsy
o Gold standard for lesion > 3 cm
Excisional biopsy
o Gold standard for lesion < 3 cm or for tumours that are probably benign
Describe lesion and name
Cause
Types
Viral warts
- Site: Common on hands or areas touched by hands including face, arms and knees
- Size: < 1 cm in diameter
- Shape: Hemispherical papule
- Color: Greyish-brown
- Surface: Rough and hyperkeratotic
- Composition: Firm
Cause: human papilloma virus (HPV) infection
Types: o Common warts (Verruca vulgaris) o Plantar warts (Verruca plantaris) o Flat warts (Verruca plana) o Periungual warts o Anogenital warts
Viral warts
- Area of body affected by HPV type 1, 6 and 11
- Predisposing conditions
o HPV Type 1 commonly infects the soles of feet causing plantar warts
o HPB Type 6 and 11 commonly infects the anogenital region causing anogenital warts
Predisposing conditions include eczema (atopic dermatitis) and immunodeficiency (AIDS/ organ transplantation)
Viral warts
Treatment
Choices of treatment
o Topical salicylic acid* (exfoliates affected epidermis and stimulate local immunity)
o Cryotherapy with liquid nitrogen*
o Surgical excision
Describe and name lesion
Typical areas of involvement
Ddx
Etiologies
Tx
Acrochordon (skin tag)
- sites of friction particularly the neck, axilla, inframammary and inguinal region
- MUST be differentiated from neurofibroma
Etiologies:
- DM and obesity
- Crohn’s disease (perianal skin tags)
Tx:
o Excision under LA
o Cryosurgery with liquid nitrogen
o Electrodessication
Describe and name lesion
Areas of involvement
Ix and Tx
Pyogenic granuloma
- Benign vascular tumour of the skin or mucous membranes
- Pyogenic: Surface is often infected and ulcerated
- Granuloma: Capillary loops grow vigorously and forms a protruding mass of tissue
- Rapidly growing lump which bleeds easily and discharges serous and purulent fluid
Site: Common on body parts liable to injury such as hands and face
Ix: Excisional biopsy
Tx: Surgical excision, Curettage/ shave excision, Cryotherapy, Injection sclerotherapy, Electrocauterization
Describe and name lesion
Cell of origin
Common areas of involvement
Tx
Ganglion cyst
Origin: Fluid-filled swelling overlying a joint or tendon sheath
Benign lesions usu. painless, but may lead to pain, weakness and loss of function
Site: Near joint capsules and tendon sheaths
o Dorsal side of the wrist (70%) (most common)
o Volar side of the wrist over scaphotrapezoid joint (20%)
Tx:
- Conservative with either observation or non-surgical treatment such as aspiration
- Surgical removal with excision
5 types of ulcer edges with examples
- Sloping - Ischemic venous ulcer/ Healing ulcer/ Traumatic ulcer
- Punched-out - Ischemic ulcer/ Deep trophic ulcer/ Syphilitic ulcer
- Undermined edge - destroys subcutis quicker than spread - Tuberculous ulcers
- Rolled edge - central necrosis with fast periphery growth - BCC
- Everted edge - Fast growing infiltrating cellular disease - Squamous cell carcinoma/ Ulcerated adenocarcinoma
3 types of ulcer base
Granulation tissue
o Red sheet of delicate capillary loops and fibroblasts covered by a thin layer of fibrin or plasma
Dead tissue (i.e. slough)
Tumour
o Base of a squamous cell carcinoma is the malignant tissue itself
o May be slightly vascular or necrotic
Differentiate the two sets of lesions
Left: Hypertrophic scar
- Confined within boundaries of scar
- Site: Any location
- Develops quickly after injury/ scarring with involution after a year
Right: Keloid scar
- Extends beyond boundaries of scar
- Head and neck, upper check and back
- Develops for years after injury/ scarring with no involution
List types of skin vascular tumors
• Infantile hemangioma
• Congenital hemangioma
RICH = Rapidly involuting congenital hemangioma
NICH = Non-involuting congenital hemangioma
- Pyogenic granuloma
- Tufted angioma
- Kaposiform hemangioendothelioma
List types of skin vascular malformations
• Capillary malformation
o Port-wine stains
o Nevus simplex (Macular stain)
• Arteriovenous malformation
• Lymphatic malformation
o Macrocystic lymphatic malformation (Cystic hygroma)
o Microcystic lymphatic malformation (Lymphangioma circumscriptum)
• Venous malformation
Describe and name the lesion
Common affected areas
Cause
Associated conditions
Tx
Port-wine stain
• Low-flow vascular malformations of dermal capillaries and post-capillary venules
Association conditions
o Glaucoma
o Spinal dysraphism
o Soft tissues and bone overgrowth
Site: Common on the face, neck, shoulder and buttock
• Lesion on the face tends to follow the distribution of trigeminal nerve branches (CN V)
• Typically with unilateral or segmental distribution that spares the midline
Tx: Pulsed dye laser (PDL) therapy
Describe and name lesion
Cause
Sites
Macrocystic lymphatic malformation (Cystic hygroma)
- Presents at birth as a large poorly delimitated, translucent, soft mass
Lymphatic malformations (LM) are benign low-flow vascular lesions composed of dilated lymphatic channels or cysts Caused by failure of lymphatic channel fusion
Sites: commonly in cervicofacial region, axilla or lateral chest wall
List 2 types of lymphatic malformations
Macrocystic lymphatic malformation (Cystic hygroma)
• Defined as single or multiple cysts each ≥ 2 cm3
Microcystic lymphatic malformation (Lymphangioma circumscriptum)
• Defined as single or multiple cysts each < 2 cm3
Treatment of lymphatic malformations
Non-surgical treatment
• Injection sclerotherapy
• Radiofrequency ablation (RFA)
Surgical treatment
• Surgical excision
Differentiating features between angiolipoma and lipoma
Angiolipoma
- benign tumour of adipocytes typically occurring in adolescents and young adults
- Resembles lipoma but are usually painful and tender
Lipomas are not painful or tender
Positive signs of Lipoma
Surface: Smooth* or lobulated*
Mobility: Mobile in all direction*
• Slip sign*: Edge is soft, compressible and thin which might slip away from the examining fingers
Tenderness: Non-tender*
Treatment of lipoma
Local excision
• Linear excision along skin creases
• Surgical removal of fat cells and fibrous capsule
Liposuction
• May be considered in large lipoma
Complications of sebaceous cysts
Sebaceous horn
• Slow discharge of sebum from wide punctum hardens to form a conical spike
Cock’s peculiar tumour
• Infection and ulceration of cyst wall leading to an infected, open, granulating, edematous sebaceous cyst
Tx of sebaceous cysts
ALL sebaceous cysts are recommended to be excised - Prevent sebaceous cysts from being infected
Elliptical incision for sebaceous cyst to include punctum
Complete excision of cyst and contents
SCC of skin
- Common locations
- Cell of origin
- Spread modalities
Location of SCC
• Head and neck (55%)
• Dorsum of hands and forearms (18%)
• Legs (13%)
Malignant tumour arising from the epidermis forming the superficial keratinous squamous layer
Mode of spread
• Local spread: Infiltration into epidermis, dermis, adjacent tissues
• Lymphatic spread: Regional lymph nodes is the MOST common site of metastasis
• Hematogenous spread
List benign tumors of epidermal appendages
Hair follicle:
- Trichofolliculoma, Trichoepithelioma, Trichilemmoma
Sebaceous gland:
- Sebaceous adenoma
Sweat gland
- Cylindroma, Syringoma
List pre-malignant skin conditions to SCC
Bowen’s disease (SCC-in-situ)
-“Erythroplasia of Queyrat” when penis is involved
Solar keratosis (SCC-in-situ) - multiple erythematous scaly macules or papules on sites of chronic sun exposure
Marjolin’s ulcer
- long-standing benign ulcers or scars
o Commonest ulcer = Venous ulcer
o Commonest scar = Burns
Bowen’s disease
Description
Histological feature
Tx
Thick, reddish brown, scaly patch with irregular borders
Histological: Dysplastic cells confined to basal lamina
Tx: Excision, Radiotherapy, Topical 5-FU, Cryotherapy, Photodynamic therapy
Paget disease of nipple
Cell of origin
Associated disease
Ix
Tx
Mammary ducts to nipple epidermis
Erythema and eczematous lesion of nipple, frequent erosion and ulceration
Associated breast CA
Ix: Incisional biopsy
Tx: Breast CA
List 3 common malignant skin cancers
SCC
BCC
Malignant melanoma
SCC
Risk factors
Classical description
Preferred metastasis
Tx
RF:
- Excessive UV exposure
- Carcinogens: RT, Arsenic or chromium
- Non healing wounds or unstable scars
- Congenital: xeroderma pigmentosa and Albinism
- Immunosuppression
Classical description
- Irregular ulcer with everted edge, exophytic growth
- Non-tender
Metastasis: Lymphatic preferred, haematogenous
Tx:
- topical 5-FU, RT
- Wide excision, reconstruction
- Block LN dissection
Basal cell carcinoma
Clinical subtypes
Metastatic potential
Pigmented (common in HK) Nodular/ Ulcerative Superficial Cystic Morpheaform (Sclerosing)
Rarely spread by LN or blood (c.f. SCC)
BCC
Risk factors
Non-modifiable factors
• Aging
• White ethnicity
• Family history of BCC
Modifiable factors • UV light exposure (most important) • Arsenic exposure • Ionizing radiation • Immunosuppression • Medical conditions o Gorlin’s syndrome (Basal cell nevus syndrome) o Xeroderma pigmentosum (XP)
BCC
Positive signs/ features
Common sites
Site: Most common on the face (70%)
Shape: Nodule/ Pigmented nodule/ Ulcer/ Deep eroding ulcer (rodent ulcer) *
Edge: Rolled edge. Pearly-white edge and well-defined (characteristic)*
Tenderness: Non-tender*
Attached to overlying skin*
Freely mobile over deep structures*
BCC
Treatment options
Chemotherapy • Topical 5-FU • Topical Imiquimod Photodynamic therapy Radiotherapy
Surgical treatment
• Surgical excision***
• Electrodessication and curettage (ED&C)
• Mohs micrographic surgery (MMS)
Melanoma
- Cell of origin
- Areas of involvement
- Metastatic potential
Origin: Melanocytes in basal epidermis
Areas:
- UV-exposed area
- Mucous lining, choroid of eye, meninges, soft tissue
Metastatic: LN and hematogenous
Melanoma Clinical subtypes
Superficial spreading (Most common): from pre-existing pigmented nevus
Nodular melanoma (most aggressive)
Lentigo maligna melanoma (least aggressive)
Acral lentiginous melanoma: on palms and soles
Subungal melanoma
Two prognostic system for melanoma
Breslow scale (thickness and survival)
Clark’s level of invasion (skin histological layer and survival)
Both correlate with LN metastases and survival
Thinner lesion = better prognosis
Cardinal symptoms of malignant transformation of pigmented nevus/ mole
Increase in size, shape or thickness
Changes in surface
• Loss of normal skin markings (creases) over the mole
• Becomes rough and scaly
Changes in color
• Darker as malignant melanocytes produce more melanin
Itchiness
Bleeding
• Late and slight sign
• Overlying epithelium becomes anoxic as tumour cells multiply
Evidence of local or distant spread
• Spread diffusely to surrounding skin to produce a brown halo around the primary lesion
ABCDE acronym (New York University 1985) to identify melanoma at early stage
• Asymmetry
o If a lesion is bisected then one half is not identical to the other half
• Border irregularities
• Color variegation
o Presence of multiple shades of red, blue, black, gray or white
• Diameter ≥ 6 mm
• Evolution (Enlarging/ Elevation)
o Lesion that is changing in size, shape, color or a new lesion
Melanoma
Diagnostic Ix
excisional biopsy:
Full-thickness excisional biopsy of suspicious lesions with 1 – 3 mm margin of normal skin
Sentinel lymph node biopsy (SLNB)
• Lymphatic mapping with SLNB for prognosis and staging
Melanoma
Tx
Checkpoint inhibitors* • CTLA-4 inhibitor • Anti-programmed cell death 1 (PD-1) antibodies Cytokines • Interferon-α (IFN-α) • Interleukin-2 (IL-2) Intralesional BCG therapy
Surgery:
Surgical resection with adequate margin ± BLock Lymph node dissection
Compare benign skin tumors and malignant skin tumors
- Size
- Surface
- Border
- Elevation
- LN
Benign: Stable in size No ulceration or bleed Well-demarcated border Flat No enlarged regional LN No satellite lesions
Malignant = opposite of everything
