Common Skin Lesions.pdf

Johnson & Wales University Physician Assistant Program Dermatology Module Common Skin Lesions 2024 Mark Trott, MBA, MHP, PA-C Diplomate Fellow-SDPA [email protected] Common Skin Lesions Goals Explore the clinical presentation...

Johnson & Wales University Physician Assistant Program Dermatology Module Common Skin Lesions 2024 Mark Trott, MBA, MHP, PA-C Diplomate Fellow-SDPA [email protected] Common Skin Lesions Goals Explore the clinical presentation and management of common skin lesions Skin Lesions Skin lesions can be… Benign Malignant Precancerous A Manifestation of Systemic Disease Starting Point “Learn normal!” 6 mm Seborrheic Keratosis (SK) “SK’s” “Sebs” “Barnacles” Most prevalent acquired benign lesion in older adults Pathogenesis Clonal proliferation of immature keratinocytes Seborrheic Keratosis Clinical Presentation Keratotic papule or plaque with variable surface characteristics and a “stuck-on” appearance Verrucous…warty Cerebriform…brain like Waxy White or yellow cysts…milia-like Open comedones…blackheads Variable colors Seborrheic Keratosis Cerebriform Verrucous Milia-like cysts Open Comedones Seborrheic Keratosis Cerebriform Open comedones Challenging Presentations of SK’s Irritated SK’s (ISK) Common Often itchy Not always easy to differentiate from other keratotic lesions Irritated SK Challenging Presentations of SK’s SK’s with complex morphology Is it all the same diagnosis…or more than one diagnosis? Lentigo; Nevus; Melanoma Multi-component pigmented lesion Challenging Presentations of SK’s Eruptive SK’s Sign of Leser Trelat Abrupt development of hundreds of pruritic SK’s over months Potential marker for internal malignancy Gastrointestinal Adenocarcinoma Eruptive SK’s in younger patients is a red flag and warrants a malignancy workup Rapid onset of many SK’s Seborrheic Keratosis Variants Stucco Keratosis Clusters of gray-white keratotic papules around ankles and feet or hands and wrists Epidemiology Adults > 40 Seborrheic Keratosis Variants Dermatosis Papulosa Nigra (DPN) Clusters of pigmented keratotic papules on face and neck Epidemiology More common in skin of color > 50% Familial Onset in young adulthood Seborrheic Keratosis DX Clinical RX Reassurance Cosmetic or Symptomatic Cryosurgery Ablative Laser Electrodessication for DPN Emollients for Stucco Keratoses Sign of Leser Trelat Malignancy work-up Solar Lentigo Actinic Lentigo Sun Freckles; Age Spots; Liver Spots Localized increased expression of melanin in the skin Risk Factors Fair skin Excessive UV exposure Solar Lentigo Clinical Presentation Circumscribed tan/brown macules or patches on photodamaged skin DX Clinical Always photodistributed Can be challenging to differentiate from some Melanoma variants Lentigo Maligna Melanoma Solar Lentigo RX Reassurance Photoprotection Cosmetic Topical Retinoids Tyrosinase inhibitors Hydroquinone Kojic Acid Cryosurgery Laser or IPL 3mm Labial Melanotic Macule “Oral Melanotic Macule” A “freckle” on the lip Epidemiology Average age of presentation ~40 Pathogenesis Focal increased melanin associated with an increased number of melanocytes Labial Melanotic Macule Clinical Presentation Circumscribed brown to black macules Sometimes multiple Labial Melanotic Macule Multiple pigmented lesions on lips or oral mucosa may be associated with various syndromes Laugier-Hunziker Syndrome Hyperpigmentation of mucocutaneous surfaces and nails Peutz-Jeghers Syndrome Mucocutaneous pigmentation and multiple intestinal polyps Labial Melanotic Macule DX Clinical Biopsy changing or atypical lesions RX Monitor Cosmetic Laser Surgical removal Penile and Vulvar Melanosis “Genital Melanosis” Benign irregular pigmentation of the penis or vulva Pathogenesis Idiopathic benign expression of melanin Epidemiology Can be seen in children and adults Childhood genital melanosis can be associated with a number of syndromes Penile and Vulvar Melanosis Clinical Presentation Asymptomatic circumscribed pigmented macules on genitalia Penile and Vulvar Melanosis DX Clinical Biopsy large, changing or atypical lesions RX Reassurance Monitor for stability 3mm Ink Spot Lentigo “Irish Freckle” A darkly pigmented often quite irregular macule seen most commonly in context of fair skin and Celtic ancestry Pathogenesis Focal increased number of melanocytes Ink Spot Lentigo Clinical Presentation Reticulated darkly pigmented macule DX Clinical RX Photoprotection Monitor for stability Café au Lait Macule (CALM) “Café au Lait Spots” Common benign birthmarks with a characteristic “coffee-milk” color Etiology Localized lifelong increased expression of melanin Epidemiology Appear at birth or in early childhood ~1% of healthy adults have up to 3 Café au Lait Macules Multiple CALM’s can be associated with a number of underlying systemic diseases Neurofibromatosis 1 Inherited neurocutaneous disorder 6 or more CALM’s may be the earliest clinical manifestation Café au Lait Macules Clinical Presentation One or more well demarcated, homogeneous tan-brown macules or patches ranging from a few mm to >20cm Café au Lait Macule DX Clinical RX Reassurance Monitor for stability Consider systemic diseases with multiple CALM’s 5mm Neurofibroma (NF) Neurofibroma Isolated benign tumor of neuro- mesenchymal tissue Schwann cells, perineural cells, fibroblasts, and mast cells Epidemiology Adult onset 90% occur as isolated lesions Multiple Neurofibromas can be associated with underlying syndromes Neurofibromatosis Neurofibroma Clinical Presentation Asymptomatic, soft, skin colored papule or nodule Button Hole Sign Lesion can be compressed back through the dermis Neurofibroma DX Clinical Biopsy for diagnostic uncertainty RX Observation Further evaluation if multiple Neurofibromas or other features of Neurofibromatosis Lichenoid Keratosis Lichenoid Keratosis Common inflammatory lesion most often located on sun damaged skin Epidemiology Middle aged to older adults Fair skin F>M- 3:1 Lichenoid Keratosis Pathogenesis Felt to be an inflammatory reaction occurring in a preexisting lesion Solar Lentigo Seborrheic Keratosis Actinic keratosis Lichenoid Keratosis Clinical Presentation Discrete red to violaceous scaly macules, papules or plaques Often Pruritic Lichenoid Keratosis DDX Irritated Seborrheic Keratosis Lichen Planus Actinic Keratosis Skin Cancers Squamous Cell Carcinoma Basal Cell Carcinoma Melanoma Superficial Basal Cell Carcinoma Lichenoid Keratosis DX This is a difficult clinical diagnosis Biopsy is often required to rule out malignancy RX Reassurance Topical steroids can help pruritus Squamous Cell Carcinoma in Situ Acrochordons Skin Tags Benign outgrowth of normal skin Risk Factors Family history Obesity Pregnancy Insulin resistant states Acrochordons Clinical Presentation Fleshy pedunculated or sessile skin colored papules commonly found in body folds or friction areas Acrochordons Fibroepithelial Polyp (FEP) Large acrochordon Acrochordons DX Clinical RX Reassurance Cryosurgery Scissor removal Electrodessication 4 mm Cherry Angioma Cherry Hemangioma Dilated capillaries extending upward to the papillary dermis Pathogenesis Vascular proliferation Risk Factors Age- onset in 30’s Genetics- Family History Pregnancy Cherry Angioma Clinical Presentation Dome shaped bright red to violaceous smooth papules Cherry Angioma Dermoscopy Lacunar Pattern Small round or oval globules separated by fibrous septae Cherry Angioma DX Clinical RX Reassurance Cosmetic Laser Shave removal with electrodessication 8mm Angiokeratoma Angiokeratoma Benign neoplasm with vascular and epidermal features Pathogenesis Dilation of superficial vessels with thickening of the overlying epidermis Angiokeratoma Clinical Presentations Solitary Angiokeratomas Purple-black circumscribed keratotic papule most common on extremities Multiple Angiokeratomas Angiokeratoma of Fordyce Clusters of purple-black papules on scrotum or vulva Angiokeratoma DDX Pigmented Basal Cell Carcinoma Spitz Nevus Kaposi Sarcoma Nodular Melanoma Angiokeratoma DX Solitary Angiokeratomas are difficult to diagnose clinically so may require biopsy to rule out more ominous pathology Angiokeratoma of Fordyce is a common clinical diagnosis RX Reassurance Laser Surgical removal 3 mm Sebaceous Hyperplasia Sebaceous Hyperplasia Benign hypertrophy of the sebaceous glands Epidemiology >25% of middle aged and older individuals Sebaceous Hyperplasia Clinical Presentation Smooth skin colored-to-yellow umbilicated papules on the forehead and central face Sebaceous Hyperplasia DDX Basal Cell Carcinoma Other Sebaceous Neoplasms Dermal Nevus Sebaceous Hyperplasia DX Clinical Biopsy atypical presentations RX Reassurance Laser Electrodessication 4 mm Fibrous Papules and Angiofibromas Fibrous Papule of the Nose Benign fibrous tumor most typically on or near the nose Histologically and often Clinically indistinguishable from solitary Angiofibromas Epidemiology Onset in middle age Fibrous Papules and Angiofibromas Clinical Presentation Discrete firm dome-shaped skin- colored to red papule on the nose or central face with varying degrees of ”fibrous” and “vascular” tissue Fibrous Papule vs Angiofibroma Multiple Angiofibromas Multiple facial angiofibromas in a patient with Tuberous Sclerosis Fibrous Papules and Angiofibromas DDX Basal Cell Carcinoma Dermal Nevus Sebaceous Hyperplasia DX Clinical Biopsy sometimes necessary to rule out Basal Cell Cancer Fibrous Papules and Angiofibromas RX Reassurance Shave Removal or Excision Electrodessication Laser Pearly Penile Papules Pearly Penile Papules Common benign papules on the penis Normal anatomic variant visible in ~30% of adult men Histologically indistinguishable from Fibrous Papules and Angiofibromas Pearly Penile Papules Clinical Presentation Multiple rows of dome shaped to filiform skin-colored papules around the corona or in the coronal sulcus of the penis DDX Condyloma Molluscum Contagiosum Pearly Penile Papules DX Clinical RX Reassurance Normal “Not Condyloma” Cosmetic Laser Cryosurgery Syringomas Syringomas Benign tumors of the eccrine sweat gland ducts presenting as papules typically around the eyes Epidemiology More common in women Syringomas Clinical Presentation Clusters of skin-colored papules in the periorbital region Syringomas DX Clinical RX Reassurance Cosmetic Excision Electrodessication Laser 3 mm Hidrocystomas Hidrocystomas Benign lesions arising from- A. Cystic dilation of eccrine sweat gland ducts- Eccrine Hidrocystomas B. Blockage of the apocrine sweat gland coils- Apocrine Hidrocystomas Hidrocystomas Clinical Presentation Most commonly on the temples, periorbital areas, and forehead Eccrine Hidrocystoma Multiple translucent bluish papules Apocrine Hidrocystoma Discrete dome-shaped translucent bluish papule Hidrocystomas DX Clinical RX Reassurance Cosmetic Excision Electrodessication Laser Xanthelasma Palpebrarum Xanthelasma Palpebrarum Disorder of fat metabolism resulting in localized lipid deposits in the skin of the eyelids Epidemiology Onset 40’s-50’s 50% associated with lipid disorders Xanthelasma Palpebrarum Clinical Presentation Yellow to orange papules or plaques on the eyelids- most commonly medial upper lids DX Clinical Lipid Profile Xanthelasma Palpebrarum RX Observation Cosmetic Excision Laser Cryosurgery Electrodessication Tiny yellow papules on upper lip Fordyce Spots Fordyce Granules Naked Sebaceous Glands Not associated with a hair follicle Epidemiology Present at birth Become larger at puberty Visible in 80–95% of adults Fordyce Spots Clinical Presentation Clustered 1-2 mm yellow papules on oral mucosal surfaces or on genitalia DDX Candidiasis HPV Fordyce Spots DX Clinical RX Reassurance Cosmetic Electrodessication Laser Telangiectasia Telangiectasia Dilated superficial blood vessels Arterioles, venules or capillaries Telangiectasia Associations Aging Sun damage Rosacea Pregnancy Oral Contraceptives Corticosteroids Liver disease A feature of hereditary or acquired disorders Telangiectasia Variants Linear Telangiectasia Mat-like Telangiectasia Rosacea Systemic Sclerosis Telangiectasia Variants Spider Telangiectasia Generalized Essential Telangiectasia Telangiectasia DX Clinical RX Reassurance Cosmetic Laser Electrosurgery Sclerotherapy 5 mm Venous Lake Venous Lake Benign localized dilation of venules Etiology A feature of chronic sun exposure Epidemiology Most common in older males on the lip or ears Venous Lake Clinical Presentation Compressible blue to violaceous papule Venous Lake DX Clinical RX Reassurance Cosmetic Laser Excision Oral Mucocele Mucocele Benign asymptomatic swelling on the mucosal surface of the lip Etiology Damage to salivary gland ducts results in mucin escaping and infiltrating the surrounding soft tissue Oral Mucocele Clinical Presentation Translucent compressible bluish papule or soft nodule most commonly on the mucosal surface of the lower lip Oral Mucocele DX Clinical RX Reassurance Surgical excision ”Lump” on back Lipoma Lipoma Benign fatty tumor Epidemiology The most common soft tissue tumor Etiology Localized collection of slow growing mature fat cells Lipoma Clinical Presentation Soft or rubbery subcutaneous mass with normal overlying skin Lipoma DDX Angiolipoma Fatty tumors like lipomas but… Smaller and often numerous More vascular and more neural tissue Liposarcoma Malignant tumor of adipocytes Suspect if a lipomatous mass is atypical or enlarging Lipoma DX Clinical Biopsy if… Painful Not uniform in consistency Enlarging RX Observation Excise if Symptomatic or for Cosmesis 8mm Dermatofibroma (DF) Dermatofibroma Benign scar-like nodule of the skin Etiology Possibly a reaction to local trauma or insect bite Epidemiology Adult onset Most common on the legs Dermatofibroma Clinical Presentation Firm nodule Scar-like center Rim of pigment “Dimple Sign” Clinical Behavior Arises slowly as a solitary nodule Grows to a fixed size Then remains stable  Dermatofibroma DX Clinical Biopsy atypical presentations or if rapidly growing RX Observation Excision if desired Nodular Melanoma Dermatofibroma  1.2cm Lump on back Cysts Cysts Circumscribed dermal or subcutaneous papules or nodules True Cysts Have an epithelial lining Filled with keratin debris False Cysts “Pseudocysts” Have no epithelial lining Ganglion Cyst; Baker’s Cyst Epidermal Inclusion Cyst (EIC) Sebaceous Cyst Most common cutaneous cyst Lined with epithelium and fills with lipids and keratin debris Generally asymptomatic unless ruptured or infected Epidermal Inclusion Cyst Clinical Presentation 1 “Non-inflamed" Dome-shaped firm nodule often with an overlying dilated punctum Often associated with a foul odor or cheesy white discharge Epidermal Inclusion Cyst Clinical Presentation 2 “Inflamed” Rapidly progressing erythema, pain, warmth and sometimes spontaneous drainage around a pre-existing EIC following trauma Epidermal Inclusion Cyst DX Clinical RX If not inflamed Observation Consider elective excision If inflamed…it’s an Abscess Incision and Drainage Culture Oral Antibiotics  1.5 cm Enlarging hairless lump on head Pilar Cyst Trichilemmal Cyst Slow growing cyst derived from the hair follicle 90% on the scalp Epidemiology Sporadic Familial Younger age of onset Multiple lesions common Pilar Cyst Clinical Presentation Firm mobile subcutaneous nodule Often with overlying alopecia No overlying punctum Pilar Cyst DX Clinical RX Observation Excision if… Symptomatic or enlarging Cosmetically unacceptable 2 mm Milia Cysts Milia Cysts Tiny superficial epidermal inclusion cysts Clinical Presentation 1-2 mm white “globoid” papules Most common on face Milia Cysts DX Clinical RX Reassurance Cosmetic Management Incision and drainage Topical retinoids 5 mm Digital Mucous Cyst Myxoid Cyst Benign pseudocyst of fingers or toes Etiology Disruption of the joint capsule allows synovial fluid to flow into the adjacent tissue Associations Degenerative joint changes Trauma or Osteoarthritis Digital Mucous Cyst Clinical Presentation Skin colored firm translucent papule on fingers or toes Between the DIP joint and the proximal nail fold Digital Mucous Cyst DX Clinical RX Observation Excision if symptomatic or for Cosmesis 4mm Chondrodermatitis Nodularis Helicis (CNH) CNH Painful inflammatory condition involving cartilage and overlying skin of the ear Pathogenesis Repeated trauma and/or pressure causes decreased blood flow and ischemic necrosis of the cartilage Chondrodermatitis Nodularis Helicis Clinical Presentation Exquisitely tender papule or nodule over cartilaginous prominences of the ear Overlying scaling, crusting, erosions or ulcerations are common Chondrodermatitis Nodularis Helicis DDX Actinic Keratosis Squamous Cell Carcinoma Basal Cell Carcinoma DX Clinical Biopsy Biopsy can be both diagnostic and therapeutic for CNH Chondrodermatitis Nodularis Helicis RX Relieve pressure Topical Steroids Clobetasol Cream BID x 2-4 wks Intralesional Steroids Triamcinolone 5mg/ml monthly x 3 Topical Nitroglycerine Daily for 2-3 months If no relief from above Surgical excision of cartilage ~20% recurrence rate Case: 67 yo with many lesions on the back A close-up view of a representative lesion is shown Clinically this lesion is most consistent with A. Sebaceous Hyperplasia B. Xanthoma C. Neurofibroma D. Seborrheic Keratosis Case: 50 yo male with “Growths around neck!” Which of the following are NOT risk factors for this condition? A. BMI 35 (18.5-24.9) B. Triglycerides 300 (