Skin Lesion Flashcards
A 70 year old man has a basal cell carcinoma affecting his temple. Following excision and histopathological assessment, which of the factors outlined below has the greatest bearing on prognosis?
Pathological subtype Completeness of excision Lymphocytic infiltrate Lymphovascular invasion Mitotic index
Completeness of excision
Incompletely excised BCC have upwards of 30% recurrence rates. Systemic spread with these lesions is rare and it is usually local recurrence that is the main problem.
A 22 year old man presents with an infected sebaceous cyst. The cyst itself is swollen, discharging pus and has some surrounding erythema. What is the most appropriate treatment?
Excision of the cyst of closure of the defect with interrupted 3/0 silk
Excision of the cyst and closure of the defect with subcuticular 4/0 undyed nylon
Incision and drainage with excision of the cyst wall and packing of the defect
Incision and drainage with conservation of the cyst wall and packing of the defect
Administration of oral co-amoxiclav and definitive surgery once the infection has cleared
Incision and drainage with excision of the cyst wall and packing of the defect
The correct treatment for an infected sebaceous cyst is incision and drainage with removal of the cyst wall. Conservation of the cyst wall will invariably lead to recurrence. Under no circumstances should an infected wound like this be primarily closed. The administration of antibiotics without drainage of sepsis is futile.
An 83 year old lady presents with multiple patches of pigmented irregular, superficial lesions over the torso. They do not bleed but have become increasingly itchy. What is the best course of action?
Shave biopsy Excisional biopsy Trucut biopsy Incisional biopsy Wide surgical excision
Shave biopsy
This is most likely to be seborrhoeic warts. These are usually superficially sited and are best managed with shave biopsy and cautery.
A 70 year old lady presents with a number of skin lesions that she describes as unsightly. On examination she has a number of raised lesions with a greasy surface located over her trunk. Apart from having a greasy surface the lesions also seem to have scattered keratin plugs located within them. What is the most likely diagnosis?
Keratoacanthoma Pilar cysts Dermatofibroma Seborrhoeic keratosis Epidermoid cyst
Seborrhoeic keratosis
Seborrhoeic keratosis may have a number of appearances. However, the scaly, thick, greasy surface with scattered keratin plugs makes this the most likely diagnosis.
A 34 year old gardener presents with a lesion affecting the dorsum of his right hand. It has been present for the past 10 days and occurred after he had been pruning rose bushes. On examination, he has a raised ulcerated lesion which bleeds easily on contact. What is the diagnosis?
Keratoacanthoma Pyogenic granuloma Basal cell carcinoma Squamous cell carcinoma Amelanotic melanoma
Pyogenic granuloma
Trauma is a common precipitant of pyogenic granuloma and contact bleeding and ulceration are common.
A 68 year old farmer presents with a skin lesion on his forehead. It has been present for the past 6 months and has grown slightly in size during that time. On examination, he has an ulcerated lesion with pearly white raised edges that measures 2cm in diameter. What is the most likely diagnosis?
Keratoacanthoma Squamous cell carcinoma Pyogenic granuloma Basal cell carcinoma Bowens disease
Basal cell carcinoma
The raised pearly edges in an ulcerated lesion at a sun exposed site makes BCC most likely.
A 65 year old man presents with a 5cm ulcerated area over his medial malleolus. It has been present for many years and the nurses have complained that it is not healing with simple bandages. What is the best course of action?
Perform a core biopsy Perform a punch biopsy Arrange a split thickness skin graft Undertake an incisional biopsy Arrange for wide surgical excision and skin grafting
Perform a punch biopsy
A 21 year old lady presents with a nodule on the posterior aspect of her right calf. It has been present at the site for the past 6 months and occurred at the site of a previous insect bite. Although the nodule appears small, on palpation it appears to be nearly twice the size it appears on examination. The overlying skin is faintly pigmented. What is the most likely cause?
Pilar cyst Dermatofibroma Spitz naevus Seborrhoeic wart Basal cell carcinoma
Dermatofibroma
Dermatofibromas may be pigmented and are often larger than they appear. They frequently occur at sites of previous trauma.
A 22 year old man is investigated for weight loss. A duodenal biopsy taken as part of his investigations shows total villous atrophy and lymphocytic infiltrate. He has a skin lesion that has small itchy papules. What is the most likely underlying diagnosis of the skin lesion?
Pyoderma gangrenosum Dermatitis herpetiformis Bullous pemphigoid Acanthosis nigricans Pemphigus vulgaris
Dermatitis herpetiformis
The patient has coeliac disease and this is classically associated with dermatitis herpetiformis.
Which of the skin lesions listed below are most likely to resemble a malignant melanoma?
Spitz naevus Dermatofibroma Squamous cell carcinoma Bowens disease Seborrhoeic wart
Spitz naevus
Spitz naevi can often resemble melanoma and are best excised.
A patient with Crohns disease has a purple coloured skin lesion near an ileostomy site. What is the most likely diagnosis?
Pyoderma gangrenosum Pemphigus vulgaris Metastatic Crohns disease Dermatitis herpetiformis Bullous pemphigoid
Pyoderma gangrenosum
Pyoderma gangrenosum may occur in Crohns disease. Cutaneous involvement of granulomas a.k.a metastatic crohns is recognized but very rare and much less likely and therefore not the correct answer.
A 89 year old woman presents with long standing seborrhoeic warts of her abdominal wall , they have caused troublesome itching. What is the best treatment?
Administration of topical steroids
Shave excision and cautery
Excision and primary closure
Excision and skin graft
Excision biopsy
Shave excision and cautery
These lesions are often extensive and superficial. Shave excision will suffice, material must be sent for histology.
A 30 year old man cuts the corner of his lip whilst shaving. Over the next few days a large purplish lesion appears at the site which bleeds on contact. What is the most likely diagnosis?
Pyogenic granuloma Keratoacanthoma Melanoma Squamous cell carcinoma Adenocarcinoma
Pyogenic granuloma
Pyogenic granulomas often appear at sites of trauma.
A 53 year old man presents with a nodule on his chin. He is concerned because it has grown extremely rapidly over the course of the preceding week. On examination, he has a swollen, red, dome shaped lesion with a central defect that contains a keratinous type material. What is the most likely cause?
Actinic keratosis Bowens disease Pyogenic granuloma Keratoacanthoma Squamous cell carcinoma
Keratoacanthoma
Keratoacanthomas are characterised by a rapid growth phase. This may mimic amelanotic melanoma (although such rapid growth is rare even in these lesions). The keratin core is the clue as to the true nature of the lesion.
A 29 year old man presents with a lump in his scalp. It is located approximately 4cm superior to the external occipital protuberance. It feels smooth and slightly fluctuant and has a centrally located small epithelial defect. What is the most likely underlying diagnosis?
Cocks peculiar tumour Dermoid cyst Sebaceous cyst Merkel cell tumour Seborrhoeic wart
Sebaceous cyst
Sebaceous cysts are most frequently located in the scalp and have an associated central punctum. They may become infected and develop superficial ulceration in which case they are known as ‘Cocks Peculiar Tumour’. The presence of a punctum is highly suggestive of a sebaceous cyst and are not typically found in the other lesions described.
A 58 year old lady presents with changes that are suspicious of lichen sclerosus of the perineum. What is the best course of action?
Wide excision of the area and split thickness skin grafts
Punch biopsy
Excision of area with 0.5cm margin
Excision of the area and full thickness skin grafts
Excision of the area with 2cm margin
Punch biopsy
Punch biopsies are a useful option for obtaining a full thickness tissues sample with minimal tissue disruption. In this situation, the other differential would be AIN or VIN and punch biopsies would be useful in distinguishing these.
A 28 year old female presents with a small nodule located on the back of her neck. It is excised for cosmetic reasons and the histology report states that the lesion consists of a sebum filled lesion surrounded by the outer root sheath of a hair follicle. What is the most likely cause?
Pilar cyst Seborrheoic keratosis Dermatofibroma Atypical naevus Spitz naevus
Pilar cyst
Pilar cysts may contain foul smelling cheesy material and are surrounded by the outer part of a hair follicle. Because of their histological appearances they are more correctly termed pilar cysts than sebaceous cysts.
An 8 year old boy presented with a painless swelling on the superotemporal aspect of his orbit. It was smooth on examination, produced no visual disturbances. Following excision it was found to be lined by squamous epithelium and hair follicles. Which of the following lesions most closely matches these findings?
Dermoid cyst Desmoid tumour Lipoma Sebaceous cyst Schwannoma
Dermoid cyst
Dermoid cysts are embryological remnants and may be lined by hair and squamous epithelium (like teratomas). They are often located in the midline and may be linked to deeper structures resulting in a dumbbell shape to the lesion. Complete excision is required as they have a propensity to local recurrence if not excised.
Desmoid tumours are a different entity, they most commonly develop in ligaments and tendons. They are also referred to as aggressive fibromatosis and consist of fibroblast dense lesions (resembling scar tissue). They should be managed in a similar manner to soft tissue sarcomas.
A 23 year old lady presents with an itchy, bleeding pigmented lesion on her right thigh. What is the best course of action?
Core biopsy Punch biopsy Incisional biopsy Excision biopsy Wide excision
Excision biopsy
Avoid incisional or punch biopsy of lesions suspected to be melanoma.
This may represent a malignant melanoma. Complete excision is required to allow accurate histological assessment. If the diagnosis is confirmed then re-excision of margins may be required. Clearly if the lesion is benign then no further action is required.
Which of the following statements relating to sebaceous cysts is false?
When infected and ulcerated, are also known as Cocks peculiar tumour
Typically contain pus
Are usually associated with a central punctum
Most commonly occur on the scalp
They will typically have a cyst wall
Typically contain pus
Sebaceous cysts usually contain sebum, pus is only present in infected sebaceous cysts which should then be treated by surgical incision and drainage.
A 22 year old woman presents with a newly pigmented lesion on her right shin, it has regular borders and normal appearing dermal appendages. However, she reports a recent increase in size. What is the best course of action?
Excision biopsy Excision with 0.5cm margin Excision with 2cm margin Shave biopsy and cautery Incision biopsy
Excision biopsy
Lesions bearing normal dermal appendages and regular borders are likely to be a benign pigmented naevi. Therefore diagnostic and not radical excision is indicated. Incision biopsy should not be done
A 28 year old man undergoes an ileocaecal resection and end ileostomy for Crohn’s disease. One year later he presents with a deep painful ulcer at his stoma site. What is the most likely diagnosis?
Bullous pemphigoid Pemphigus vulgaris Pyoderma gangrenosum Squamous cell carcinoma Poorly fitting appliance
Pyoderma gangrenosum
Pyoderma gangrenosum is associated with inflammatory bowel disease (this patient had a stoma for crohns!). It is commonly found on lower limbs and described as being painful, the size of an insect bite and growing. It looks like a margherita pizza (with a red base and yellow topping!) Treatment involves steroids. It would be rare for a poorly fitting appliance to cause a deep painful ulcer.
A 73 year old man presents with a 1.5cm ulcerated basal cell carcinoma on his back. What is the best course of action?
Excision with 0.5cm margin Excision with 2cm margin Excision biopsy Incision biopsy Excision with 3cm margin
Excision with 0.5cm margin
A small lesion such as this is adequately treated by local excision. The British Association of Dermatology guidelines suggest that excision of conventional BCC (<2cm) with margins of 3-5mm have locoregional control rates of 85%. Morphoeic lesions have higher local recurrence rates.
A 72 year old man presents with a large nodule on his face. It is friable. There is no regional lymphadenopathy. He is lost to follow up and re-attends several months later. On this occasion the lesion has been noted to resolve with scarring. What is the most likely lesion?
Pyogenic granuloma Keratoacanthoma Melanoma Basal cell carcinoma Dermatitis artifacta
Keratoacanthoma
Keratoacanthomas may reach a considerable size prior to sloughing off and scarring.
