Skin Lesions Flashcards
What is the appearance of strawberry naevi/haemangioma?
Typically oval, scarlet shaped
Well defined borders
Surface may be smooth or lobulated
When do strawberry naevi tend to appear?
2-3w after birth
They are not present at birth
Do strawberry naevi tend to expand and get bigger?
Yes - reach ultimate size within 3-6m of delivery
Due to vascular nature, also seem to increase in size when child crying/straining
Where is the most common place for strawberry naevi to appear?
Head and neck
If there are three or more strawberry naevi what should be considered?
Whole body MRI to rule out internal strawberry naevi
In which groups of children are strawberry naevi most common?
Premature babies
Girls
What is the aetiology of strawberry naevi?
Benign, developmental vascular tumours of unknown origin
How are strawberry naevi managed?
Nearly all lesions undergo spontaneous involution
Plastic surgery to remove loose skin/fibro-fatty deposits around prev. site of lesion sometimes req.
If lesion –> airway obstruction, tracheostomy will be req.
If causing feeding/visual obstruction, intra-lesional steroids or propranolol therapy may slow proliferation
What is the proper name for a port wine stain?
Naevus flammeus
When are port wine stains present from?
Birth
What is the appearance of port wine stains?
Light pink –> dark red/purple
Usually involving the face
Well defined edge
When do port wine stains disappear?
They do not reduce with age and remain unchanged in size
In 8-15% of cases port wine stains are associated with what?
Underlying brain and eye abnormalities.
What is the aetiology of port wine stains?
Congenital lesion of unknown aetiology.
How are port wine stains managed?
Covered with cosmetic camouflage
Laser treatment for those who are self conscious (often this is v. painful)
What are other names for a salmon patch?
Naevus simplex, stork bite, angles kiss
What are salmon patches composed of?
Distended and persisting fetal dermal capillaries
What is the appearance of a salmon patch?
Irregular, dull, pinkish red, macular areas often featuring fine, linear telangiectasia
Where are salmon patches most common?
Nape of the neck
also - upper eyelids, forehead, tip of nose
What emphasises the appearance of a salmon patch?
When the child cries/exerts themselves
How long does it take salmon patches to disappear?
Usually about 1m
What is the aetiology of salmon patches?
Localised capillary telangiectatic lesion of unknown aetiology
What is the treatment of a salmon patch?
None req., may consider laser if persists
What features comprise Klippel-Trenaunay syndrome?
Severe AV malformations of the limbs, bone hypertrophy and port-wine stain
What features comprise Sturge-weber syndrome?
Trigeminal distribution port wine stains + capillary haemangiomas in the brain
What investigations can you do for suspected deeper AV malformations?
MRI
How might you treat some of the deeper AV malformations?
Might be able to do embolisation
What is the appearance of chondrodermatitis nodularis chronica helicis?
Small, inflamed, hard, very painful nodules in the upper ear (around helix)
Tend to form scale over them and recur
How should you investigate chondrodermatitis nodularis chronica helicis?
Biopsy to rule out malignancy
What is the aetiology of chondrodermatitis nodularis chronica helicis?
Repeated pressure to upper ear most likely cause
Actinic damage, cold, frost bite and repeated physical injury may be implicated
How should you manage chondrodermatitis nodularis chronica helicis?
Non-surgical first: topical antibiotics (if lesion infected), topical corticosteroids, cryotherapy, laser therapy, curettage, electrocauterization, intralesional collagen injections, corticosteroid injections, relieving pressure on ear
Surgery - wedge resection or larger complicated reconstructive techniques
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What is a dermatofibroma?
Nodular dermal proliferation
What is the appearance of a dermatofibroma?
Firm, elevated or flat, hyperchromic, tender nodule which dimples when overlying dermis is squeezed
Why might a dermatofibroma form a yellow-brown colour?
Due to iron and melanin deposition
Where are dermatofibromas most commonly found?
The limbs
What is the proposed aetiology for dermatofibromas?
An abnormal response to dermal injury, e.g. insect bites
How do you treat dermatofibromas?
No treatment req.
Intralesional steroids have been shown to initiate regression
How do you differentiate keloid scarring from hypertrophic scarring?
Keloid extends beyond the margin of the surgical scar
Define a keloid scar
Well demarcated area of fibroid tissue overgrowth that extends beyond the original defect
Are keloid scars painful?
Can be very hypersensitive or tender
What are risk factors for developing a keloid scar?
+ve FH
Black, Hispanic or Asian
Acromegalics, post-thyroidectomy
What is the aetiology of keloid scars?
Genes + environmental factors
How do you manage keloid scars?
Avoid unessential trauma in those who are predisposed to keloid scarring
What is the xanthelasma?
Sharply demarcated yellowish deposit of fat underneath the skin, usually on or above the eyelids
Define seborrheic keratosis
Benign proliferation of epidermis keratinocytes
What is the appearance of a seborrheic keratosis?
Raised, yellow-brown/black lesions, greasy and usually multiple
Have a ‘stuck on’ appearance
Usually of little concern to patient but may cause itching
What is the aetiology of seborrheic keratosis linked to?
Familial trait
Multiple erruptions of them can be linked to inflammatory dermatosis, severe sunburn or may be a manifestation of visceral malignancy (GI cancer usually)
Most are idiopathic
How can you manage seborrheic keratosis?
No treatment req.
Dermal shaving
Currettage
Cryotherapy
What is a blue naevus?
Area of blue or black dermal pigmentation produced by aberrant collections of pigment producing but benign melanocytes
Usually non-tender
When do blue naevi most commonly appear?
During puberty
What is the treatment of blue naevi?
None required
May be excised if patient wants it
What are combined naevi?
Melanocytic naevi formed by the overgrowth of melanocytic cells in the epidermis and dermis
What do combined naevi appear like?
Raised, variegated lesions, with sandy and blue/black pigmentation
Irregular borders
How do you manage combined naevi?
Don’t req. treatment
Biopsy if suspicious looking
What are the appearance of compound naevi?
Small, uniformly brown, as they mature become darker and raised
Where is there an increased risk of a compound naevus undergoing malignant transformation?
Great number of them
Positive family history of malignant melanoma
What is the aetiology of compound naevi?
Benign proliferation of melanocytes of unknown cause
What is the management of compound naevi?
None
Biopsy if unsure of diagnosis
Define halo naevus
Melanocytic naevus surrounded by a depigmented halo of otherwise normal skin
When do halo naevi occur?
When pre-existing melanocytic naevus develops a ring or halo of depigmentation around it
How long do halo naevi take to disappear?
Usually central melanocytic naevus gradually regresses but may take several years for the pigmented area to regain normal skin colour
What is the aetiology of halo naevi?
Unknown
?anti-melanoma Ab
?lymphocytic infiltration of halo
What is the treatment of halo naevi?
Usually none
Biopsy if unsure about diagnosis
When do intra-dermal naevi from?
When junctional melanocytes stop proliferating and the overlying skin returns to normal
What do intradermal naevi appear like?
Raised, non-pigmented nodules
May have terminal hair, visible capillaries
May also appear as flesh coloured, wrinkly sacs on flexor surfaces
What is the aetiology of intradermal naevi?
Overgrowth of cells in the dermis of unknown aetiology
How do you treat intradermal naevi?
None req.
Excised for cosmetic reasons
Biopsy if unsure of diagnosis
What is a junctional naevus?
Cellular naevus with junctional activity present on histology
What is the appearance of a junctional naevus?
Slightly raised/flat
Usually roughly symmetrical, pigmented lesion
Tan-brown, speckling of pigment
Usually these turn into compound naevi
What is the aetiology of a junctional naevus?
Benign proliferation of melanocytes of unknown aetiology
What is the other name for spitz naevus?
Juvenile melanoma (distinctive pathological features that make them v. difficult to distinguish from malignant melanoma)
What is the appearance of a spitz naevus?
Rounded, blanching, pigmented lesions and surrounding halo
Overlying epidermis is fragile and can bleed/crust following minor trauma
What is the treatment of a spitz naevus?
Excision with 1-2mm margin of normal skin - sent to histology (v. difficult for pathologist to know difference between spitz naevus and malignant melanoma without knowing age and clinical appearance)
What are the features of a common wart?
Multiple, raised, hyperkeratotic
Very painful
Where do warts occur?
In areas of recent trauma
In which group of patients are warts even more common?
Immunosupressed patients (also more resistant to treatment)
What is the aetiology of the common wart?
Benign cutaneous tumours caused by human papilloma virus
How do you treat common warts?
Usually resolve spontaneously
Salicyclic acid paints, cryotherapy
What are the appearance of molluscum contagiousum?
Shiny, pearly white umbilicated papules which grow slowly over 6-12w
Often multiple due to virus disseminating from original lesion
What can occur in the lesions of molluscum contagiousum?
May become inflamed, secondarily infected or eczematised
What is the aetiology of molluscum contagiousum?
Infection with pox virus (molluscum contagiousum virus - usually MCV-1 genome)
How do you treat molluscum contagiousum?
Avoid close contact with other, do not share towels/clothes etc.
Will resolve on its own
Lesions can be spiked with liquid nitrogen, phenol or iodine
Topical cidofovir
If large enough - curettage and diathermy may be used
What are actinic keratoses?
Hyperkeratotic lesions occurring in sun-exposed adult skin
What to actinic keratoses carry a low risk of progression to?
Invasive squamous cell carcinoma (1% pa)
Describe how actinic keratoses begin and progress
Start as telangiectatic capillaries
Form a yellow/brown scale over the top
Becomes rougher, thicker and hornier over time
Where are actinic keratoses found?
SUN EXPOSED AREAS
What cause actinic keratoses?
Excessive exposure to sunlight (UV radiation)
What are risk factors for developing actinic keratoses?
Increased age Proximity to equator Fair skin (types 1/2) Outdoor activities Occupation Diet high in animal fats
What is involved in the treatment of actinic keratoses?
Advice - re. hat wearing, sun lotion, avoiding sun between 11am-3pm etc. - may regress lesions/stop new lesions forming
Cryotherapy/3% diclofenac
Topical 5FU can be used
Excision and biopsy if unsure of diagnosis
What is Bowen’s disease?
Persistent, progressive, non-elevated, red, scaley/crusted plaque with an irregular border due to an intra-epidermal carcinoma
Basically it is squamous cell carcinoma in situ
Does Bowen’s disease need to be treated?
If left untreated, it will become invasive disease
What risk factors are implicated in Bowen’s disease?
Sunlight exposure
Contact with arsenic
Increasing age
Agricultural work
How do you treat Bowen’s disease?
Excision is gold standard
Local application of 5FU and cryotherapy if small
Photodynamic therapy
What is photodynamic therapy?
Giving photosensitizing drugs and then applying a laser/high energy light on the lesion
Clinically, how are atypical moles defined?
Ill-defined/irregular borders
Irregular pigmentation
Diameter >5mm
Erythema + accentuated skin markings
How are atypical naevi categorised?
Into A, B, C or D based on personal and family involvement
A/B = 90x more likely to develop malignant melanoma
C/D = 400-500x more likely to develop melanoma
How are dysplastic naevi/atypical moles managed?
Monitored for early signs of malignant change
When are congenital hairy naevi present from?
Birth
How are congenital hairy naevi categorised?
Small - <1.5cm diam
Medium 1.5-19.5cm
Large/giant >20cm
What is the appearance of a congenital hairy naevus?
Flat, round/oval, pigmented and covered in coarse hair
Regular/irregular borders
What are patients with congenital hairy naevi at an increased risk of?
Developing malignant melanoma
How are congenital hairy naevi treated?
Surgery - staged excision, with or without grafting or skin expansion
Laser treatment may improve appearance but does not eliminate risk of malignant transformation
What are keratocanthomas?
Rapidly evolving tumours of the skin, composed of keratinising squamous cells originating in the pilosebaceous follicles
What are the appearance of keratocanthomas?
Rapidly growing (appear over a few weeks) Raised Circular Well defined margins Central ulceration
How do you treat keratocanthomas?
Spontaneously resolve
Excision/curettage may leave less of a scar than spontaneous resolution
5FU/radiotherapy may be used in those who refuse surgery
What causes keratocanthomas?
Exposure to sunlight
Contact with tar or mineral oil
What malignancies are associated with keratocanthomas?
Rarely associated with certain types of internal malignancies
What may a keratocanthomas be mistaken for?
SCC - but is much more rapidly growing!
Send off biopsy if unsure
What is lentigo maligna?
Lentiginous replacement of basal keratinocytes by atypical melanocytes with no downward invasion into the underlying dermis
What can lentigo maligna progress to?
Superficial/nodular melanoma
it is malignant melanoma in situ
What is the appearance of lentigo maligna?
Flat, often two tone, brown lesion with irregular orders
Where is lentigo maligna mostly found?
In elderly patients on sun exposed areas
How do you manage lentigo maligna?
Excision biopsy or incision biopsy if not possible
After confirmation of LM - standard excision of lesion with 5mm margin/Moh’s surgery
5FU and cryotherapy may be used but recurrence is high
What are sebaceous naevi?
Circumscribed lesions comprised predominantly of sebaceous glands
What is the appearance of sebaceous naevi?
Circumscribed plaques, yellow or tan, velvety, found on scalp, usually present from birth
Commonly present as a bald patch
What do sebaceous naevi most commonly malignantly transform to?
BCC
What is the aetiology of sebaceous naevi?
May have genetic component
What is the treatment of sebaceous naevi?
Excision
If excision is not feasible, then consider dermabrasion or laser removal
Define squamous cell carcinoma
Malignant tumour arising from the keratinocytes of the epidermis
What is the first sign of a squamous cell carcinoma?
Induration of the skin
What is the appearance of a SCC?
Plaque like, ulcerated or verrucous, always firm to palpation
Irregular, erythematous border
May have raw bleeding area
What are risk factors for developing SCC?
Older age Chronic UV exposure Burns/old scars displaying new changes Chronic heat exposure (erythema ab igne) Actinic keratoses Bowen's disease Chronic granulomas, esp. long standing venous ulcers Tar exposure/Rx Certain genetic conditions
How do you diagnose SCC?
Excision biopsy + histology
What factors influence the metastatic potential of a SCC?
Anatomical site Size (>2cm 2x more likely to recur locally), lesion depth Rate of growth Aetiology Degree of histological differentiate Host immunosupression
What is the treatment of choice for SCC?
Surgical excision + follow up for possible local recurrence/nodal involvement
What are the recommended margins for the excision of SCC?
4mm+ for low risk tumours, 6mm+ for high risk tumours
What kind of surgery may be useful for recurrent SCC?
Moh’s
How should bowens disease be followed up?
Doesn’t req. follow up
How should low risk SCC be followed up after Rx?
Discharge after 6m
How should high risk SCC be followed up after Rx?
5 year follow up
What makes a SCC high risk?
>2cm diam >4mm depth Poorly differentiated Perineural involvement Immunosupressed patient Recurrent dx Secondary to chronic inflammation
What is a classic presentation of a nodular BCC?
Painless, translucent raised lesion with pearly edges and telangiectasia with central ulceration
May bleed from minimal trauma
What is considered a large nodular BCC?
=>2cm
What tends to be the best treatment for nodular BCC?
Excision
Cryotherapy or curettage + cautery may be used sometimes
Moh’s surgery should be used for high risk sites if possible
What is the typical appearance of a superficial BCC?
Pigmented and spreading superficially
May have eroded/ulcerated lesions
Multiple superficial BCC may indicate what?
Exposure to arsenic
What treatment options are available for superficial BCC?
Cryosurgery, curettage + cautery, Moh’s surgery, radiotherapy
What is the appearance of sclerotic BCC?
Smooth, deeply invasive, tend to be pale yellow with ulceration, bleeding and crusting
Lesions often extend beyond visible skin
What is the best form of treatment for sclerotic BCC?
Excision, Moh’s for high risk sites
What are multifocal BCCs?
Lesions that display many foci of malignancy
What do pigmented BCCs appear like?
Nodular BCCs that are pigmented
How does superficial spreading melanoma present?
Flat or slightly elevated pigmented lesion with variegate pigmentation and surrounding discolouration
Border is asymmetric and irregular
Lesions tend to be >7mm in diameter
What is the most common type of melanoma?
Superficial spreading melanoma
What does lentigo maligna melanoma present as before it becomes malignant?
Lentigo maligna - this occurs when the malignant lentigo maligna cells start growing vertically instead of horizontally
Changes may be indicated clinically by a (usually blue-black) nodule developing
How does nodular melanoma present?
Deeply pigmented papule or dome shaped nodule
May arise from site of previous trauma
Can grow over weeks/months
May bleed
Where does acral lentiginous melanoma occur?
Hands, feet, digital and sub-ungual areas
What does acral lentiginous melanoma look like?
Black, raised lesion
What is Breslow’s thickness?
Microscopic depth or thickness of a melanoma
What is sennitel node biopsy?
Identification and removal of first node draining an area
What % of cancers does melanoma comprise in the UK?
4%
What are the four key features of a BCC?
Pearly appearance
Rolled, raised edges
Central ulceration
Telangiectasia
What kind of biopsy should be done in suspected skin cancers?
Excision biopsy
What is a BCC on the nose known as?
Rodent ulcer
What is melanoma a cancer of?
The epidermal melanocytes
What is the ABCDE criteria for describing a potential melanoma?
Asymmetry Border - irregular Colour - non-uniform Diameter >7mm Evolution/elevation
What are the major and minor criteria for melanoma diagnosis?
Major -
Change in shape, size, colour
Minor -
Inflammation, oozing, diameter >7mm, change in sensation
What are risk factors for actinic keratoses?
Increased age Proximity to equator Fair skin (types 1 and 2) Outdoor activities/occupation Excessive exposure to sunlight Diet high in animal fats
