Skin Lesions

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Skin Lesions

• Amr Y Arkoubi MD, FRCSC
• Plastic and Reconstructive Surgery
• King Fahad Medical City

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Classification

• Benign lesions
• Premalignant lesions
• Malignant lesions

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1. Benign Lesions

• Verruca Vulgaris
• Nevi
• Seborrheic Keratosis
• Cysts
• Lipoma
• Fibromata
• Vascular lesions
• Miscellaneous

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Verruca Vulgaris

• AKA Warts
• Viral Etiology (HPV)
• Confined to the epithelium
• Management
• May disappear spontaneously
• Cauterization, Cryotherapy or Laser
• Surgical ???

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Nevi

• AKA moles
• Classification
• Junctional
• Compound
• Intradermal (dermal)
• No or low risk of malignant transformation

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Seborrheic keratosis

• AKA age spots
• Common on trunk and face of elderly
• stuck on, elevated, brown, greasy
• Treatment
• Excise if diagnosis uncertain
• curettage, electrodessication, cryotherapy or
  surgery

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Cysts

• Epidermoid
• AKA sebaceous cysts
• Excise with overlying skin if attached
• If inflamed incise and drain with subsequent
  excision
• Dermoid
• Congenital lesions occurring midline or lateral
  eyelid (embryonic fusion lines)
• Treat by excision

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Lipoma

• Subcutaneous, fluctuant fatty lesions
• Not adherent to overlying skin
• Excise if symptomatic
• Malignant variant present (liposarcoma)

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Fibromata

• Fibroma
• Subcutaneous solid encapsulated lesions
• Excise for definitive diagnosis
• Neurofibroma
• Intradermal, with overlying pigmentary changes
• Excise if symptomatic
• Dermatofibroma
• Nodular intracutaneous lesion with pigmentary
  changes
• Treatment is excision

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Vascular lesions

• Hemangiomas
• Vascular malformations

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Hemangiomas

• Most common benign vascular tumor
• Appear at or shortly after birth, proliferates
  for several months, then regresses over years
• Treatment is generally active non-intervention

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Vascular Malformations

• Capillary, venous, arterial, lymphatic or a
  combination
• Present at birth, grow with patient and do not
  regress
• Treatment includes laser therapy, embolization,
  sclerotherapy and surgery

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Capillary malformation
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Lymphatic malformation
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Combined malformation
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Miscellaneous lesions
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Xanthelasma

• Small deposits of lipid-laden histiocytes
• Most common is eyelids
• Sometimes associated with systemic disorders
  (hyperlipidemia)
• Treat by excision or Laser

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Rhinophyma

• Severe acne rosacea of the nose
• Overgrowth of sebaceous gland
• Large bulbous nose results
• Treatment is surgical planing (shaving)

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Keloids

• Over abundance of collagen deposition (scar
  fibrous connective tissue)
• Common on earlobes and upper trunk
• Higher incidence in dark-skinned races
• No single method of treatment is uniformly
  successful

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2. Premalignant Lesions

• BCC precursors
• Nevus sebaceous
• SCC precursors
• SCC in situ
• Actinic Keratosis
• Cutaneous horn
• Malignant Melanoma precursors
• Lentigo maligna
• Dysplastic Nevus
• Congenital Hairy Nevus

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Nevus Sebaceous

• Nevus Sebaceous of Jaddasohn
• Common on face and scalp
• Yellowish orange plaque like
• 15-20 transformation to BCC

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SCC in situ

• AKA Bowens disease
• Scaly brown, tan or pink patch
• Non-invasive but may develop into invasive SCC
• Treatment is excision

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Actinic Keratosis

• Crusted inflamed lesion
• Frequent on sun exposed areas (lips, and ears)
• Risk factors
• Westerns population
• Immune diff.
• May transform to SCC
• Treatment is excision

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Cutaneous horn

• Similar in etiology to Actinic keratosis
• Hyperkeratosis
• Thick, conical growth on face and sun exposed
  areas
• Parakeratosis at the base
• Treatment is excision of the lesion at the base

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Lentigo Maligna

• AKA Hutchinsons freckle
• Atypical melanocytes in atrophic skin
• Flat, smooth, varied shades of brown with
  irregular borders
• Slow growing
• 20-30 MM transformation
• Treatment is excision

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Dysplastic nevus

• Irregular borders
• Variegated in color
• Intra epidermal melanocytic dysplasia
• Often familial
• Risk of transformation to MM

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Dysplastic nevus

• Management
• A Asymmetry (shape, surface)
• B Border irregularity
• C Color Variegation (brown to black)
• D Diameter gt6mm
• Excision and histological examination of all
  suspicious pigmented lesions

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Congenital hairy nevus

• Dermatomal distribution
• Small, Moderate to Giant in size
• Potential for malignant transformation ? MM

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3. Malignant Lesions

• Basal Cell Carcinoma
• Squamous Cell carcinoma
• Malignant Melanoma
• Others
• Merkel cell tumor
• Dematofibrosarcoma protuberans
• Sarcomas

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Basal Cell Carcinoma

• Most common skin cancer
• Seen on face or other sun-exposed areas
• slow growing (years), locally invasive
• Types
• Nodular
• Superficial
• Pigmented
• Sclerosing (morpheaform)
• All types may show ulceration

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Basal Cell Carcinoma

• never metastasize (rarely metastasizes if
  ever)
• Treatment
• surgical excision with free margins
• Margins 3-5 mm (5-10 risk of recurrence)
• Mohs micrographic surgery (5 risk of recurrence)
• Aldara
• Radiation
• Electrodessication
• Curretage
• Cryotherapy

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Basal Cell Carcinoma
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Squamous Cell Carcinoma

• Second most common skin tumor
• Rapidly growing (months)
• Nodular or ulcerated with distinct borders
• Risk factors
• Sun exposure
• Radiation
• Chronic non-healing wounds (margolins ulcer)
• Immune suppression

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Squamous Cell Carcinoma

• Can metastasize to regional lymph nodes (10)
• Treatment
• Surgical excision with adequate margins (5-10 mm)
• Histologic frozen sections or Mohs Micrographic
  surgery required

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Squamous Cell Carcinoma
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Squamous Cell Carcinoma
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Squamous Cell Carcinoma
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Keratoacanthoma

• Rapid growing, nodular, umbilicated and well
  circumscribed
• Presents in sun exposed areas
• Confirm with biopsy
• Usually called SCC by pathologist
• May involute on its own
• May in fact be malignant

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Malignant Melanoma

• 3rd most common skin cancer
• Will metastasize
• Treatment is primarily surgical with some
  adjuvant therapy
• Radiation
• Chemotherapy
• Interferon alpha

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Malignant Melanoma Types

1. Superficial spreading melanoma (70)
2. Nodular melanoma (15)
3. Lentigo maligna melanoma (10)
4. Acral lentiginous melanoma (5)

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1. Superficial Spreading melanoma

• Flat to slightly elevated
• May have variety of colors
• Lesion spreads horizontally initially

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2. Nodular melanoma

• Blue / black in color
• Maybe unpigmented (amelanotic)
• Grows vertically with surface ulceration
• Poor prognosis

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3. Lentigo maligna melanoma

• Develops in Hutchinsons freckle
• Appears as elevated nodule
• Better prognosis

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4. Acral lentiginous melanoma

• On mucous membranes, palms, soles and subungual
• Maybe amelanotic in black africans
• Worse prognosis

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Prognosis

• key factors
• Location
• Depth
• Ulceration
• Lymph Nodes

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Depth (histological grading)

• Breslow Classification
• Measures depth of invasion from the granular
  layer of the epidermis
• Considered most reliable indicator
• Less than 1mm (mets close to 0)
• 1-2 mm (mets 10-20)
• 2-4 mm (mets up to 50)
• More than 4 mm (mets 66)

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Depth (histological grading)

• Level 1- mets extremely rare
• Level 2 mets 2-5
• Level 3 mets upto 20
• Level 4 mets upto 40
• Level 5 mets upto 70

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Ulceration

• May be histological
• Significant drop in prognosis

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Lymph nodes

• Micro mets
• Macro mets
• Number of mets
• Note visceral mets are much worse

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Treatment

• Surgical resection
• Complete excisional biopsy is necessary to
  determine depth
• Most important is excision of primary lesion by
  wide excision
• In situ ? 0.5 cm margins
• lt 1mm ? 1 cm margins
• 1-4 mm ? 2 cm margins
• gt 4 mm ? 2-3 cm margins

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Treatment

• Lymph node biopsy
• Sentinel lymph node biopsy is used to determine
  regional mets
• Total lymph node dissection is indicated if
• Lymph nodes palpable
• Sentinel nodes positive

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SLN

• 2 stage
• 1. nuclear medicine injection Tc99 with mapping
  at 1 hour interval
• Can be done day before surgery
• 2. Vital blue dye injection immediately pre-op
• Intradermal injection
• Clip afferent and efferent lymphatics
• True sentinal node is hot and blue
• Hot residual field count lt10 of node count
• Blue dye uptake into node

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SLN
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Treatment

• Adjuvant therapy
• Extremity perfusion for selected cases
• Radiotherapy
• Chemotherapy
• Immunotherapy
• All have not been proven curative but may have a
  palliative role

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Questions?