1
Skin tumors
The most important skin tumors
Benign tumors of epidermis
Melanocytes : acquired melanocytic nevus
Epidermal cell : seborrheic keratosis, skin tags , ± keratoacanthoma.
premalignant tumors of epidermis
Actinic keratosis, arsenic keratosis,,,,
Malignant tumors of epidermis
Basal Cell Carcinoma.
Squamous Cell Carcinoma.
Mlignant melanoma.
Paget’s Disease of the Breast.
Benign tumors of dermis
Stromal tumor as dermatofibroma
Vascular as pyogenic granuloma
Malignant tumors of dermis
Kaposi Sarcoma
Lymphoma
Dermatofibrosarcoma protuberans.
Cutaneous Metastasis.
Benign skin tumour
Acquired melanocytic nevocellular nevus(
moles)
Melanocytic nevocellular nevi are small usually (<1.0 cm), circumscribed, acquired pigmented
macules or papules composed of groups of melanocytic cells located in the epidermis, dermis, and
rarely, subcutaneous tissue. The less common in blacks or pigmented peoples, average No. in western
countries 15 moles per person, while in Iraqi persons 6 moles per person.
Duration of Lesions These lesions, which are commonly called moles, appear in early childhood and
reach a maximum in young adulthood. There is a gradual involution of lesions, and most disappear by
age 60-80.
Histological classification
can be classified according to the site of the clusters of nevus cells,
د.وسام علي عوض
2
Junctional Melanocytic nevus Cells at the dermal-epidermal junction above the basement membrane .
Compound Melanocytic nevus A combination of the histologic features of the junctional and dermal.
Dermal Melanocytic nevus Cells exclusively in the dermis.
Junctional Melanocytic
Macule, or only very slightly raised
Color; uniform tan, brown, or dark brown
Shape; round or oval with smooth, regular borders
Arrangement; scattered discrete lesions
Compound Melanocytic
Type; papules or nodules
Color; dark brown, sometimes even black; color may become mottled as progressive conversion
into dermal type.
Shape; round, dome-shaped, smooth, occasionally papillomatous or hyperkeratotic,
Dermal Melanocytic
Type; papule or Nodule
Color; skin-colored, tan, brown, or flecks of brown, often with telangiectasia
Shape; round, dome-shaped
Management of Melanocytic NCN
Indications for removal of acquired melanocytic NCN are
1. Site—lesions on the scalp, soles, all mucous membranes, anogenital area
2. Color—if color is or becomes variegated
3. Border—if irregular borders are present or develop
4. Symptoms—if lesion begins to persistently itch, hurt, or bleed
5. If criteria for malignancy are detected by dermatoscopy.
Seborrheic keratosis
The seborrheic keratosis is perhaps the most common of the benign epithelial tumors. Genetic
factor have a role, sun exposures, internal diseases. Rarely before 30 years of age.
The lesion starts as a macule, a skin-colored or light tan lesion, and in the course of time
becomes more pigmented; at this time the lesion has a “stuck on” appearance in the form of a plaque;
further on in their course, the surface appears “warty,”,the lesion usually asymptomatic, Rarely pruritic;
tender if secondarily infected. Most commnly site Face, trunk, upper extremities
Leser–Trélat sign: Sudden appearance of multiple small usually pruritic seborrheic keratoses , and in
this case we should excluded the possibility of an underlying malignancy such as abdominal
adenocarcinoma , leukemia or mycosis fungoides.
Management
Curettage, electrocauterations, chemical cauterizations, cryotherapy, ,,
3
Skin Tags (Achrochordon)
Skin tags are common tumors found in approximately 25% of males and females. The most
frequent affected area is the axilla, followed by the neck and inguinal region.
They begin as a tiny, brown or skin-colored, oval excrescence attached by a short, broad-to-narrow
stalk. With time, the tumor can increase to 1 cm as the stalk becomes long and narrow.
Treatment: The stalks are easily removed by scissor excision or with a light touch of the
electrocautery. Local anesthesia is usually not necessary.
Dermatofibroma
Is a common reactive fibrous proliferation. Two most common triggers appear to be arthropod
assault and folliculitis.
Clinical features: 5–10mm firm tumor; commonly on legs . Color varies from skin-colored
through tan to red-brown or even dark brown. When one compresses a dermatofibroma from the sides,
the lesion becomes depressed, rather than protruding as would a melanocytic nevus (dimple sign or
Fitzpatrick sign)
Treatment: Lesions should be removed by excision under local anesthesia.
Pyogenic granuloma
Is a benign vascular skin tumor common in children and pregnant women. The term is pyogenic
granuloma a misnomer. It is caused by vascular proliferation and appears as a red sessile or
pedunculated mass of the skin or mucous membranes. The important differential diagnosis is from an
amelanotic melanoma and, for this reason; the histology should always be checked.
Treatment: Lesions should be removed by curettage under local anesthesia with cautery to the base.
Recurrence is possible.
Hemangioma (Capillary hemangioma)
Is a benign vascular tumor, which typically appears at birth or just thereafter.
Clinical features:
Raised red to purple soft nodules that can become very large. About 30% can be seen at birth, but most
appear later and all continue to grow . Tumors can be compressed, but do not disappear with diascopy.
During the first months of life, hemangiomas can continue to grow (proliferation phase). After about
year of age, no further growth is anticipated and regression starts (Involution ). It may take many years
and often leaves behind scar or loose skin.
Prognosis
30 % of the patients will subside in the 3
rd
year. 50 % in the 5
th
year , 70% in the 7
th
year , 90% in the
9
th
year.
Complications include:
– Obstruction of vital structures: eyes, nose, mouth.
– Bleeding: Serious events surprisingly rare.
– Ulceration.
4
Management :
Nonintervention.
Lesions that are relatively small and indolent should remain untouched if they are to involute
spontaneously. In most cases, the result is very satisfactory.
Treating ulcers and rapidly proliferating lesions.
Ulcerations are painful, may become infected, and heal with scarring. Ulceration is managed
with local wound care, topical and systemic antibiotics, systemic and intralesional corticosteroids,
flashlamp pulsed-dye laser, interferon alfa-2a, topical imiquimod.
Surgery.
Most hemangiomas are managed medically. But large one , failure of medical treatment, even small
hemangiomas but near nose or eye, mouth, and in complicated type.
Keratoacanthoma
Keratoacanthoma (KA) is a special lesion, occurring as an isolated (usually) nodule(s), usually
on the face. It presents as a dome-shaped nodule with a central keratinous crater that mimics squamous
cell carcinoma. Unique features are its rapid growth rate, much faster than a squamous cell carcinoma,
and also its spontaneous remission over a period of several months. Still, in every solitary KA, tissue
must be obtained for histopathological study to rule out squamous cell carcinoma. Onset usually over
50 years; rare below 20 years, male to female 2 : 1
Clinically as rapid growth(nodule, dome-shaped often with a central keratotic plug) , achieving a
size of 2.5 cm within a few weeks. Lesion has Skin-colored or slightly red, tan/brown.
Management
Typically biopsy needed from lesion because KA difficult to differentiated from SSC.
Surgical electrocauterations, , cryotherapy, curettage and electrocauterations ,excision of lesion.
Interalesional injuction as MTX, bleomycin, interferon,
Systemic retinoid, MTX,,,
Radiotherapy
Lipomas
Lipomas are common benign tumours of mature fat cells in the subcutaneous tissue. There may be
one or many and lipomas are rarely a familial trait. They are most common on the proximal parts of the
limbs but can occur at any site. They have an irregular lobular shape and a characteristic soft rubbery
consistency. freely movable round or oval subcutaneous mass. They are rarely painful.
They need to be removed only if there is doubt about the diagnosis or if they are painful or unsightly.
Treatment: Excision
5
Epidermoid and pilar cysts
Often incorrectly called ‘sebaceous cysts’, these are common and can occur on the scalp, face,
behind the ears and on the trunk. They are skin colour cystic lesions attached to skin not free movable
often have a central punctum; when they rupture, or are squeezed, foul smelling cheesy material comes
out.
Histologically, the lining of a cyst resembles normal epidermis (an epidermoid cyst) or the outer root
sheath of the hair follicle (a pilar cyst).
Treatment is by excision or incision followed by expression of the contents and removal of the cyst
wall.
Hypertrophic and keloid scar
Excessive connective tissue proliferation following an injury; hypertrophic scar remains confined
to the boundaries of the original insult, while a keloid proliferates beyond these limits.
Predisposing factors include:
Ethnic factors: Far more common in blacks.
Location: Sternum, shoulders, neck (after thyroid operation), ear lobes (piercing), ankles, shins, over
clavicle, edge of chin, and other sites where skin tension is generally increased.
Type of injury: Burns and infections more often form keloids, leading to contractures and impaired
function, as well as considerable cosmetic defects.
Clinical features:
Firm skin-colored to red nodules and plaques rich in telangiectases. Keloids have irregular
“fingers” growing at the periphery. Both may be tender, painful, or pruritic
Therapy:
Topical steroid with occlusion
Injection of corticosteroids,
Injections can be combined with cryotherapy
Pressure dressing Silicon gel sheeting for at least 12hours daily useful for fresh wounds and
especially burn scars as prophylactic measure
Debulking excision radiation therapy.
Excision and coverage with skin graft
Sebaceous Hyperplasia
Senile Sebaceous Hyperplasia , is especially common in persons with significant chronic sun
exposure. The age of onset is usually past 40. The areas of predilection are the forehead, infra-orbital
regions, and temples. The lesions are small, cream-colored or yellowish umbilicated papules 2 to 6 mm
in diameter. Clinically, they may mimic an early basal cell carcinoma.
6
Premature sebaceous hyperplasia, also known as familial presenile sebaceous hyperplasia,
presents with extensive sebaceous hyperplasia with onset at puberty and worsening with age.
Treatment is solely for cosmetic purposes and employs electrosurgery, laser treatment, shallow
shave biopsy. Isotretinoin will reduce lesions,
Syringoma
Benign tumor that originate the eccrine dermal duct. More common in women, starting in puberty.
Usually multiple skin-colored to yellow papules . Most common site is periorbital, although axillae,
umbilicus, and genital region also seen.
Eruptive syringomas: Sudden onset of multiple papules usually on trunk; usually in young women. .
Therapy: In most instances, best left alone; if cosmetically disturbing, a variety of
destructive measures including laser ablation, dermabrasion or electrosurgery is
possible. Recurrences is common.
Congenital melanocytic nevus
Is a melanocytic nevus present at birth.
Clinical Types
Lesions are subdivided by size .
Small: less than 1.5cm diameter.
Medium: 1.5–20cm diameter.
Large or giant: more than 20cm .
Most congenital melanocytic nevi are heavily pigmented, have a papillomatous surface and contain
hairs.
Prognosis: There is a risk of developing malignant melanoma, varying with the type of congenital
melanocytic nevus:
Large congenital melanocytic nevus with risk of malignant melanoma is around 10% .
Medium and small congenital melanocytic nevus: Risk is much lower, clearly less than 5%.
Therapy:
Two goals:
(1) Avoid malignant melanoma;
(2) cosmetic improvement, as patients with large disfiguring nevi have marked psychosocial problems.
Small and medium lesions can be excised, either in a single step or as part of a staged excision.
If larger, skin expanders can be helpful to facilitate closure.
Early dermabrasion or curettage removes much of the melanocyte load and improves cosmetic
appearance. Laser therapy can helpful.
Whether it reduces the risk of malignant melanoma remains controversial.