Epidermal Nevi, Neoplasms and Cysts – Part 1 JoAnne M. LaRow, D.O. March 23, 2004
Keratinizing Epidermal Nevi <ul><li>Aka hard nevus of Unna </li></ul><ul><li>Soft epidermal nevus </li></ul><ul><li>Nevus ...
Keratinizing Epidermal Nevi <ul><li>Hyperkeratosis without cellular atypia characteristic of all </li></ul><ul><li>Nevus c...
Linear Verrucous Epidermal Nevus <ul><li>Not pruritic, onset birth or before age 10. </li></ul><ul><li>Verrucous papules, ...
Linear Verrucous Epidermal Nevus <ul><li>Histology: hyperkeratosis, acanthosis, & papillomatosis (60% of the time) </li></...
Linear Verrucous Epidermal Nevus
<ul><li>Note shedding of scale within several lesions </li></ul>
Linear Verrucous Epidermal Nevus <ul><li>62% variable hyperkeratosis, acanthosis and papillomatosis </li></ul><ul><li>Rare...
<ul><li>Linear erythematous scaly plaque with a psoriasform appearance on leg </li></ul>
<ul><li>Acanthotic epidermis with zones of parakeratosis devoid of a granular layer alternating with zones of orthohyperke...
ILVEN <ul><li>Inflammatory Linear Verrucous Epidermal Nevus. </li></ul><ul><li>Pruritic, usually on female extremity. </li...
ILVEN <ul><li>Believed to be a type of epidermal nevus </li></ul><ul><li>Familial patterns reported & sporadic mosaic form...
LVEN
Blaschko’s lines <ul><li>Albert Blaschko </li></ul><ul><li>1901 </li></ul><ul><li>Do not follow nerves, lymphatics or vess...
LVEN following Blaschko’s lines
ILVEN
Epidermal Nevus Syndrome
ENS – 5 Syndrome types <ul><li>Schimmelpenning  – sebaceous nevus, cerebral anomalies, coloboma, lipdermoid conjunctiva </...
Nevoid Hyperkeratosis of the Nipple
Nevoid Hyperkeratosis of the Nipple <ul><li>Extremely rare, usu. females, any race </li></ul><ul><li>Isolated finding, una...
Nevus Comedonicus <ul><li>Closely arranged slightly elevated papules,  with keratin plugs resembling comedos. </li></ul><u...
Nevus Comedonicus
Nevus Comedonicus
Clear Cell Acanthoma <ul><li>AKA  Degos Acanthoma  or  Acanthome cellules claires of Degos and Civatte </li></ul><ul><li>U...
Clear Cell Acanthoma
<ul><li>A: erythematous papule on lower extremity;note peripheral scale & erosion in superior portion </li></ul><ul><li>B:...
Seborrheic Keratosis <ul><li>Onset 4 th -5 th  decade </li></ul><ul><li>Chest and back most common </li></ul><ul><li>Only ...
Seborrheic Keratosis
Sign of Leser Trelat <ul><li>Sudden appearance of numerous itchy SK’s </li></ul><ul><li>Pathogenesis? Neoplasm may secrete...
Borst-Jadhasson Phenomenon <ul><li>Descrete groups or ‘clones’ of basaloid, squamatized, or pale keratinocytes in epidermi...
Borst-Jadhasson Phenomenon <ul><li>Clonal variant  </li></ul><ul><li>“ Nested”  </li></ul><ul><li>Diagnosis is still SK </...
Inverted Follicular Keratosis
Inverted Follicular Keratosis <ul><li>Bengin lesion of middle-aged & older adults </li></ul><ul><li>Typically solitary; mo...
Inverted Follicular Keratosis <ul><li>Irritated SK? </li></ul><ul><li>2-10mm papules </li></ul><ul><li>Flesh colored </li>...
<ul><li>An endophytic proliferation of keratinocytes with prominent squamous eddies </li></ul>
Dermatosis Papulosa Nigra <ul><li>Multiple hyperpigmented sessile to filiform papules  </li></ul><ul><li>Most common in in...
Dermatosis Papulosa Nigra <ul><li>Familial predisposition </li></ul><ul><li>Variant of SK? Delayed presentation of nevoid ...
Dermatosis Papulosa Nigra
Stucco Keratosis <ul><li>AKA Keratoelastoidosis verrucosa or keratosis alba </li></ul><ul><li>Males >40 years old. </li></...
Stucco Keratosis
Multiple Minute Digitate Hyperkeratosis <ul><li>AKA Spiny keratoderma </li></ul><ul><li>3 types-AD, sporadic type, and pos...
Multiple Minute Digitate Hyperkeratosis
 
 
 
Hyperkeratosis Lenticularis Perstans (Flegel’s Disease) <ul><li>Very rare, possibly AD disorder </li></ul><ul><li>Multiple...
Flegel’s Disease <ul><li>Etiology unknown </li></ul><ul><li>Absent or altered keratinocyte membrane-coating granules (Odla...
Hyperkeratosis Lenticularis Perstans (Flegel’s Disease)
Hyperkeratosis Lenticularis Perstans (Flegel’s Disease)
Flegel’s Disease <ul><li>Pathology: discrete compact hyperkeratotic mound, contrasting with normal basket-weave cornified ...
<ul><li>A.multiple symmetric keratotic papules on shins </li></ul><ul><li>B. spinous layer is maredly thinned, & there is ...
HK & PK overlying a thinned epidermis, irreg. acanthosis at periphery, band-like infilt.
Warty Dyskeratoma <ul><li>Solitary skin-colored to red-brown papule or nodule with a central pore containing a keratotic p...
Keratotic Plug, Cup-like Invagination
<ul><li>A portion of cup-shaped lesion is seen. The central keratotic plug is seen on left. </li></ul><ul><li>Lower portio...
Corps ronds and grains
Benign Lichenoid Keratosis <ul><li>Solitary papules </li></ul><ul><li>Dusky red/violaceous </li></ul><ul><li>Women, photod...
Lichenoid Keratosis <ul><li>Aka: lichen planus-like-keratosis, solitary lichen planus, solitary lichenoid keratosis </li><...
Colloid or Civatte bodies in BLK <ul><li>LP-like </li></ul><ul><li>Parakeratosis </li></ul><ul><li>Lichenoid Infiltrate </...
Arsenical Keratoses <ul><li>Precancerous papules seen most often on palms & soles </li></ul><ul><li>Present as symmetric, ...
Arsenical Keratosis <ul><li>Arsenic is ubiquitous elemental metal </li></ul><ul><li>Exists in nature as metalloids, alloys...
 
<ul><li>A. guttate hypopigmentation superimposed on hyperpigmentaion resembles ‘raindrops on a dusty road’ </li></ul><ul><...
 
Actinic Keratosis <ul><li>Multiple, discreet, flat or elevated, verrucous or keratotic, red, pigmented or skin colored usu...
Actinic Keratosis <ul><li>0.25% to 20% risk of nonmelanoma CA </li></ul><ul><li>P53 mutation present in SCC and AK usu.  <...
Actinic Keratosis <ul><li>Risk factors other than UV: </li></ul><ul><li>Tanning beds </li></ul><ul><li>X-rays </li></ul><u...
Actinic Keratoses <ul><li>Tx: varied </li></ul><ul><li>Cryo with liquid nitrogen most effective & practical with limited n...
Actinic Keratosis <ul><li>Rub 5-FU gently BID for 3-4 weeks on head & neck, 4-6 weeks for other areas, or until there is a...
Actinic Keratosis <ul><li>Another tx cycle for –FU is 4 times daily for 7-21 days </li></ul><ul><li>Shorter cycle may resu...
Cutaneous Horn <ul><li>Face, scalp, hands, penis, eyelid </li></ul><ul><li>Horny excresences, skin colored </li></ul><ul><...
Cutaneous Horn
Leukoplakia <ul><li>Whitish thickening of mucosal epithelium </li></ul><ul><li>Glistening, opalescent, may be reticulated ...
<ul><li>Sharply demarcated, white plaque involving ventral surface of tongue & floor of mouth </li></ul>
Leukoplakia <ul><li>Bx reveals orthokeratosis or parakeratosis with minimal inflammation or varying degrees of  dysplasia ...
Leukoplakia <ul><li>Vulvar often mistaken for LS&A; mainly in obese women after menopause </li></ul><ul><li>Penile more of...
Leukoplakia Treatments <ul><li>If dysplastic complete removal is the goal. </li></ul><ul><li>Cryo, CO2 Laser, surgical exc...
 
Leukoplakia with Tylosis and Esophageal Carcinoma <ul><li>Extremely rare, AD </li></ul><ul><li>PPK age 5-15 </li></ul><ul>...
White Sponge Nevus <ul><li>Spongy overgrowth of mucosa </li></ul><ul><li>Most common on buccal, but can be vaginal or rect...
White Sponge Nevus
Oral Florid Papillomatosis <ul><li>Distinctive “Cauliflower” white mass </li></ul><ul><li>Covering tongue & adjacent mucos...
Oral Florid Papillomatosis
Elastotic Nodules of Antihelix <ul><li>Bilateral semi-translucent  nodules  </li></ul><ul><li>Exclusively upper antihelix ...
Elastotic Nodules of Antihelix
Keratoacanthoma <ul><li>4 types </li></ul><ul><li>Solitary </li></ul><ul><li>Multiple </li></ul><ul><li>Eruptive </li></ul...
Solitary KA <ul><li>Type of KA rapidly growing papule enlarging from 1mm to as large as 25 mm in 3-8 weeks </li></ul><ul><...
Solitary KA
Multiple KA <ul><li>Ferguson-Smith type of multiple self-healing keratoacanthomas </li></ul><ul><li>Histologically & clini...
Multiple KA
Eruptive KA <ul><li>Eruption of dome-shaped, skin-colored papules from 2-7 mm in diameter </li></ul><ul><li>Eruption is ge...
Eruptive KA – Generalized, esp. shoulders and arms, but palms and soles are spared
Eruptive KA – oral lesions, bilateral ectropion and narrowing of oral aperture
KA Centrifugum Marginatum <ul><li>16 cases (uncommon variant) </li></ul><ul><li>Peripheral expansion with central healing ...
KA Centrifugum Marginatum
KA Centrifugum Marginatum
KA-Etiology <ul><li>? Variant of regressing SCC </li></ul><ul><li>Conditions known to promote progression of AK’s & malign...
<ul><li>KA-note keratin-filled crater </li></ul>
KA- Treatment <ul><li>Can spontaneously involute, but impossible to tell how long it will take. </li></ul><ul><li>Grade I ...
KA-tx <ul><li>Podophyllum in compound tincture of benzoin useful in giant keratoacanthomas </li></ul><ul><li>Oral retinoid...
Upcoming SlideShare
Loading in …5
×

Epidermal Nevi, Neoplasms and Cysts – Part 1 Epidermal Nevi, Neoplasms and Cysts – Part 1

5,320 views
5,003 views

Published on

Published in: Health & Medicine

Epidermal Nevi, Neoplasms and Cysts – Part 1 Epidermal Nevi, Neoplasms and Cysts – Part 1

  1. 1. Epidermal Nevi, Neoplasms and Cysts – Part 1 JoAnne M. LaRow, D.O. March 23, 2004
  2. 2. Keratinizing Epidermal Nevi <ul><li>Aka hard nevus of Unna </li></ul><ul><li>Soft epidermal nevus </li></ul><ul><li>Nevus verrucosus (verrucous nevus) </li></ul><ul><li>Nevus unius lateris </li></ul><ul><li>Linear epidermal nevus </li></ul><ul><li>Systematized nevi </li></ul><ul><li>Ichthyosis hystrix </li></ul>
  3. 3. Keratinizing Epidermal Nevi <ul><li>Hyperkeratosis without cellular atypia characteristic of all </li></ul><ul><li>Nevus cells do not occur </li></ul>
  4. 4. Linear Verrucous Epidermal Nevus <ul><li>Not pruritic, onset birth or before age 10. </li></ul><ul><li>Verrucous papules, pink, gray or brown. </li></ul><ul><li>Horny excrescences, comedos may be interspersed. </li></ul><ul><li>Bilateral = Icthyosis hystrix </li></ul><ul><li>Extensive = “systematized”(linear hyperkeratotic papules & plaques-often showing a parallel arrangement);unilateral or bilateral (often symmetrical) </li></ul><ul><li>Extensive + CNS abnormalities = Syndrome </li></ul>
  5. 5. Linear Verrucous Epidermal Nevus <ul><li>Histology: hyperkeratosis, acanthosis, & papillomatosis (60% of the time) </li></ul><ul><li>16% show epidermolytic hyperkeratosis </li></ul><ul><li>Rare malignancies have been reported:trichoepithelioma, keratoacanthoma, & verruciform xanthoma </li></ul>
  6. 6. Linear Verrucous Epidermal Nevus
  7. 7. <ul><li>Note shedding of scale within several lesions </li></ul>
  8. 8. Linear Verrucous Epidermal Nevus <ul><li>62% variable hyperkeratosis, acanthosis and papillomatosis </li></ul><ul><li>Rarely trichoepithelioma, KA, verruciform xanthoma </li></ul><ul><li>Etiology possibly chromosomal mosaicism </li></ul><ul><li>Tx: Phenol, 5-FU, Tretinoin, Shave excision, Cryotherapy, CO2 laser. </li></ul>
  9. 9. <ul><li>Linear erythematous scaly plaque with a psoriasform appearance on leg </li></ul>
  10. 10. <ul><li>Acanthotic epidermis with zones of parakeratosis devoid of a granular layer alternating with zones of orthohyperkeratosis </li></ul>
  11. 11. ILVEN <ul><li>Inflammatory Linear Verrucous Epidermal Nevus. </li></ul><ul><li>Pruritic, usually on female extremity. </li></ul><ul><li>Onset usually childhood, can be 40’s, 50’s </li></ul><ul><li>Chronic, resistant to topical or IL treatments </li></ul><ul><li>Psoriasiform histo – linear psoriasis? </li></ul><ul><li>Tx: Deep shave excision, dermabrasion, Protopic? </li></ul>
  12. 12. ILVEN <ul><li>Believed to be a type of epidermal nevus </li></ul><ul><li>Familial patterns reported & sporadic mosaic forms exist </li></ul><ul><li>May be associated with CHILD syndrome (congential hemidysplasia with ichthyosiform erythroderma & limb defects) </li></ul><ul><li>Differs from LEN by presence of erythema & pruritus clinically & histologically by inflammation & parakeratosis </li></ul>
  13. 13. LVEN
  14. 14. Blaschko’s lines <ul><li>Albert Blaschko </li></ul><ul><li>1901 </li></ul><ul><li>Do not follow nerves, lymphatics or vessels. </li></ul><ul><li>Proposed embryologic origin </li></ul>
  15. 15. LVEN following Blaschko’s lines
  16. 16. ILVEN
  17. 17. Epidermal Nevus Syndrome
  18. 18. ENS – 5 Syndrome types <ul><li>Schimmelpenning – sebaceous nevus, cerebral anomalies, coloboma, lipdermoid conjunctiva </li></ul><ul><li>Nevus Comedonicus - cataracts </li></ul><ul><li>Pigmented hairy EN – Becker nevus, ipsilateral breast hypoplasia, scoliosis </li></ul><ul><li>Proteus –Hyperplasia of hands and feet, hemangiomas, lipomas, macrocephaly, hyperostosis, hypertrophy of long bones </li></ul><ul><li>CHILD – C ongenital H emidysplasia, I cthyosiform erythroderma, L imb D efects </li></ul>
  19. 19. Nevoid Hyperkeratosis of the Nipple
  20. 20. Nevoid Hyperkeratosis of the Nipple <ul><li>Extremely rare, usu. females, any race </li></ul><ul><li>Isolated finding, unassociated with other conditions </li></ul><ul><li>Unilateral NHN Should be distinguished from breast carcinoma via biopsy, in addition, mammography may be warranted. </li></ul><ul><li>Bx results identical to seb. K. </li></ul><ul><li>Course varies, unpredictable. </li></ul><ul><li>Tx: Keratolytics such as Lactic Acid 12%, Salicylic acid Gel 6%, topical corticosteroids; oral retinoids are ineffective </li></ul>
  21. 21. Nevus Comedonicus <ul><li>Closely arranged slightly elevated papules, with keratin plugs resembling comedos. </li></ul><ul><li>Hamartomas of pilosebaceous unit-resulting in dilated, keratin-filled pores </li></ul><ul><li>Rarely pruritic; usually asymptomatic </li></ul><ul><li>Onset usually before age 10, but variable </li></ul><ul><li>Most common site is face, then trunk </li></ul><ul><li>Tx: difficult;localized lesions:excise; manual extraction, dermabrasion, keratolytics(helpful); ammonium lactate applied every 2 weeks has been helpful to remove keratin plugs </li></ul>
  22. 22. Nevus Comedonicus
  23. 23. Nevus Comedonicus
  24. 24. Clear Cell Acanthoma <ul><li>AKA Degos Acanthoma or Acanthome cellules claires of Degos and Civatte </li></ul><ul><li>Usually solitary lesion on leg </li></ul><ul><li>Blanchable, erythematous, discrete papule or plaque; may have attached ‘wafer-like’ scale at periphery </li></ul><ul><li>1-2 cm, shin, calf, thigh, asymptomatic, slow growing </li></ul><ul><li>SCC has been reported </li></ul><ul><li>Tx: EDC, Shave biopsy, Excision, Cryo </li></ul>
  25. 25. Clear Cell Acanthoma
  26. 26. <ul><li>A: erythematous papule on lower extremity;note peripheral scale & erosion in superior portion </li></ul><ul><li>B:psoriasiform epidermis contains large pale keratinocytes </li></ul>
  27. 27. Seborrheic Keratosis <ul><li>Onset 4 th -5 th decade </li></ul><ul><li>Chest and back most common </li></ul><ul><li>Only on hair-bearing areas </li></ul><ul><li>Etiology: Local arrest of maturation of keratinocytes. </li></ul><ul><li>At least 6 different types of histologic types: acanthotic, hyperkeratotic, reticulated, clonal, irritated, & melanoacanthoma </li></ul><ul><li>Borst Jadhasson phenomenon may occur, this is normal. </li></ul><ul><li>Sign of Leser Trelat </li></ul>
  28. 28. Seborrheic Keratosis
  29. 29. Sign of Leser Trelat <ul><li>Sudden appearance of numerous itchy SK’s </li></ul><ul><li>Pathogenesis? Neoplasm may secrete growth factor leading to epithelial hyperplasia </li></ul><ul><li>Validity controversial </li></ul><ul><li>60% Adenocarcinoma of Stomach </li></ul><ul><li>Lymphoma, Breast CA, Lung SCC. </li></ul><ul><li>For sign to be valid SK’s must parallel the course of the cancer, ie, resolve with removal of cancer. </li></ul>
  30. 30. Borst-Jadhasson Phenomenon <ul><li>Descrete groups or ‘clones’ of basaloid, squamatized, or pale keratinocytes in epidermis appear different than their neighbors </li></ul><ul><li>This can be benign or malignant </li></ul><ul><li>Mainly seen with irritated seborrheic keratosis, Bowen’s dx, & rarely with hidroacanthoma simplex ( a form of eccrine poroma limited to epidermis) </li></ul>
  31. 31. Borst-Jadhasson Phenomenon <ul><li>Clonal variant </li></ul><ul><li>“ Nested” </li></ul><ul><li>Diagnosis is still SK </li></ul><ul><li>R/O porocarcinoma via neg. CEA stain. </li></ul><ul><li>R/O Bowen’s via lack of atypical cells </li></ul>
  32. 32. Inverted Follicular Keratosis
  33. 33. Inverted Follicular Keratosis <ul><li>Bengin lesion of middle-aged & older adults </li></ul><ul><li>Typically solitary; most commonly on face & neck </li></ul><ul><li>Asymptomatic, firm, white-tan to pink papule </li></ul><ul><li>Histologically, endophytic growth pattern with squamous eddies & inflammation </li></ul>
  34. 34. Inverted Follicular Keratosis <ul><li>Irritated SK? </li></ul><ul><li>2-10mm papules </li></ul><ul><li>Flesh colored </li></ul><ul><li>Firm w/ central scaling </li></ul><ul><li>Sharply marginated </li></ul><ul><li>Squamous Eddies </li></ul><ul><li>Tx: shave </li></ul>
  35. 35. <ul><li>An endophytic proliferation of keratinocytes with prominent squamous eddies </li></ul>
  36. 36. Dermatosis Papulosa Nigra <ul><li>Multiple hyperpigmented sessile to filiform papules </li></ul><ul><li>Most common in individuals of African descent with darkly pigmented skin </li></ul><ul><li>Found almost exclusively on face ( malar & forehead areas) </li></ul><ul><li>Histologic features similar to acanthotic SKs </li></ul>
  37. 37. Dermatosis Papulosa Nigra <ul><li>Familial predisposition </li></ul><ul><li>Variant of SK? Delayed presentation of nevoid condition like patterned lentiginoses? Variant of acrochordon? </li></ul><ul><li>Irregular Acanthosis and heavy deposits of pigment at the basal layer. </li></ul><ul><li>Tx: Light electrodessication with curettage, cryo( may produce hypopigmentation), snip excision or curettage without electrodesiccation </li></ul>
  38. 38. Dermatosis Papulosa Nigra
  39. 39. Stucco Keratosis <ul><li>AKA Keratoelastoidosis verrucosa or keratosis alba </li></ul><ul><li>Males >40 years old. </li></ul><ul><li>“ Stuck on” appearance </li></ul><ul><li>Lower legs near Achilles tendon </li></ul><ul><li>Easily scratched off </li></ul><ul><li>Histo: Hyperkeratotic SK </li></ul><ul><li>Tx: Lac Hydrin 12%, Emollients or topical retinoids </li></ul>
  40. 40. Stucco Keratosis
  41. 41. Multiple Minute Digitate Hyperkeratosis <ul><li>AKA Spiny keratoderma </li></ul><ul><li>3 types-AD, sporadic type, and postinflammtory </li></ul><ul><li>All characterized by multiple minute keratotic papules unassociated with follicular orifices </li></ul><ul><li>A spiked projection occurs at top of papule </li></ul><ul><li>No associated abnormalities </li></ul><ul><li>6 families described </li></ul><ul><li>Post-inflammatory variant usually result of irradiation therapy. </li></ul>
  42. 42. Multiple Minute Digitate Hyperkeratosis
  43. 46. Hyperkeratosis Lenticularis Perstans (Flegel’s Disease) <ul><li>Very rare, possibly AD disorder </li></ul><ul><li>Multiple keratotic papules with disc-like appearance is symmetric distribution </li></ul><ul><li>Usually expressed mid-to-late adulthood-cases as young as 13 yrs reported </li></ul><ul><li>Individual papules are small-1-5mm; larger lesions>5mm often have collarette of scale& bleed when scale removed </li></ul><ul><li>Most common on dorsum of feet, legs, palms & soles too </li></ul><ul><li>Flegel’s dx has been associated with endocrine disorders (DM & hyperthyroidism) </li></ul>
  44. 47. Flegel’s Disease <ul><li>Etiology unknown </li></ul><ul><li>Absent or altered keratinocyte membrane-coating granules (Odland bodies) on microscopic exam </li></ul><ul><li>Lipid-by-products within Odland bodies felt to influence stratum corneum desquamation, & if absnt or abnormal hyperkeratosis may occur </li></ul>
  45. 48. Hyperkeratosis Lenticularis Perstans (Flegel’s Disease)
  46. 49. Hyperkeratosis Lenticularis Perstans (Flegel’s Disease)
  47. 50. Flegel’s Disease <ul><li>Pathology: discrete compact hyperkeratotic mound, contrasting with normal basket-weave cornified layer of normal epidermis </li></ul><ul><li>Focal parakeratosis & hypogranulosis </li></ul><ul><li>Thin atropic stratum spinosum often sharply indented or depressed at lateral margin </li></ul><ul><li>Band-like infiltrate or lymphocytes present in papillary dermis along with dilated blood vessels </li></ul>
  48. 51. <ul><li>A.multiple symmetric keratotic papules on shins </li></ul><ul><li>B. spinous layer is maredly thinned, & there is a lichenoid infiltrate & obvious hyperkeratosis </li></ul>
  49. 52. HK & PK overlying a thinned epidermis, irreg. acanthosis at periphery, band-like infilt.
  50. 53. Warty Dyskeratoma <ul><li>Solitary skin-colored to red-brown papule or nodule with a central pore containing a keratotic plug </li></ul><ul><li>Usually located on head: face, neck, scalp. </li></ul><ul><li>Relatively uncommon, without a genetic predisposition </li></ul><ul><li>No malignant degeneration has been reported </li></ul><ul><li>Histology is characteristic… </li></ul>
  51. 54. Keratotic Plug, Cup-like Invagination
  52. 55. <ul><li>A portion of cup-shaped lesion is seen. The central keratotic plug is seen on left. </li></ul><ul><li>Lower portion of cup is occupied by numerous villi with acantholytic epithelium </li></ul>
  53. 56. Corps ronds and grains
  54. 57. Benign Lichenoid Keratosis <ul><li>Solitary papules </li></ul><ul><li>Dusky red/violaceous </li></ul><ul><li>Women, photodist. </li></ul><ul><li>Forearms, hands, chest </li></ul><ul><li>Tx: LN </li></ul>
  55. 58. Lichenoid Keratosis <ul><li>Aka: lichen planus-like-keratosis, solitary lichen planus, solitary lichenoid keratosis </li></ul><ul><li>Solitary, usually asymptomatic, lesion </li></ul><ul><li>Most commonly on upper chest or forearms </li></ul><ul><li>Represents an inflammatory stage of solar lentigo, actinic keratosis, or seborrheic keratosis </li></ul><ul><li>Histologically, appears almost identical to lichen planus </li></ul>
  56. 59. Colloid or Civatte bodies in BLK <ul><li>LP-like </li></ul><ul><li>Parakeratosis </li></ul><ul><li>Lichenoid Infiltrate </li></ul><ul><li>DIF + IgM @ DEJ </li></ul><ul><li>Plasmas, Eos, Lymphs </li></ul><ul><li>Histo mimics MF, LP </li></ul>
  57. 60. Arsenical Keratoses <ul><li>Precancerous papules seen most often on palms & soles </li></ul><ul><li>Present as symmetric, punctate, yellow, corn-like papules 2-10 mm </li></ul><ul><li>Common areas are thenar & hypothenar eminences, distal plams, lateral fingers & dorsal interphalangeal joints </li></ul><ul><li>Weight-bearing plantar surfaces on feet </li></ul><ul><li>Persistent lesions may coalesce into kertotic plaques </li></ul><ul><li>SCC may arise, often producing pain, bleeding, fissuring, or ulceration </li></ul>
  58. 61. Arsenical Keratosis <ul><li>Arsenic is ubiquitous elemental metal </li></ul><ul><li>Exists in nature as metalloids, alloys, and chemical compounds </li></ul><ul><li>Deposited into water, soil, & vegetation </li></ul><ul><li>Pesticides, rodentcides, herbicides </li></ul><ul><li>Dessicants, feed additives </li></ul><ul><li>Pressure treated lumber – shipbuilders, carpenters </li></ul><ul><li>American cigarette tobacco in 1960’s(mostly from use of arsenic-containing insecticides) </li></ul><ul><li>Chinese proprietary medicines </li></ul>
  59. 63. <ul><li>A. guttate hypopigmentation superimposed on hyperpigmentaion resembles ‘raindrops on a dusty road’ </li></ul><ul><li>B. arsenical keratoses on plantar surface </li></ul>
  60. 65. Actinic Keratosis <ul><li>Multiple, discreet, flat or elevated, verrucous or keratotic, red, pigmented or skin colored usually with adherent scale but sometimes smooth </li></ul><ul><li>Photodistributed, 3-10mm </li></ul><ul><li>Hypertrophic AK may become cutaneous horn, and SCC may be present at the base. </li></ul>
  61. 66. Actinic Keratosis <ul><li>0.25% to 20% risk of nonmelanoma CA </li></ul><ul><li>P53 mutation present in SCC and AK usu. </li></ul><ul><li>Be most suspicious of AK’s on lip, temple and hand as higher risk metastasis if SCC. </li></ul><ul><li>Risk of SCC metastasis is related to thickness, so palpate “AK’s” before deciding whether to destroy vs biopsy. </li></ul>
  62. 67. Actinic Keratosis <ul><li>Risk factors other than UV: </li></ul><ul><li>Tanning beds </li></ul><ul><li>X-rays </li></ul><ul><li>Polycyclic aromatic hydrocarbons </li></ul><ul><li>Arsenic exposure </li></ul><ul><li>Thermal injuries, Scars, HPV </li></ul><ul><li>Organ transplants, BCC/SCC ratio flips </li></ul>
  63. 68. Actinic Keratoses <ul><li>Tx: varied </li></ul><ul><li>Cryo with liquid nitrogen most effective & practical with limited number of sites </li></ul><ul><li>Repetitive superficial freezes (3 cycles) very effective & minimizes scarring </li></ul><ul><li>Healing usually occurs within 1 week on face & up to 4 weeks on arms & legs </li></ul><ul><li>5-fluorouracil topically for extensive, broad or numerous lesions </li></ul><ul><li>Fluoroplex crm or solution, 1%, or Efudex, 2% recommended for face; 5% Efudex crm for trunk, scalp, hands, arms, neck </li></ul>
  64. 69. Actinic Keratosis <ul><li>Rub 5-FU gently BID for 3-4 weeks on head & neck, 4-6 weeks for other areas, or until there is a severe inflammatory rxn </li></ul><ul><li>1% solution is effective on lips </li></ul><ul><li>Use extreme care around eyes & mouth </li></ul><ul><li>Individual sensitivity differs:burning rxn will occur within several days </li></ul><ul><li>Stop tx when peak response occurs-characterized by color change from bright to dusky red, by re-epithelialization, & crust formation </li></ul>
  65. 70. Actinic Keratosis <ul><li>Another tx cycle for –FU is 4 times daily for 7-21 days </li></ul><ul><li>Shorter cycle may result in better compliance? </li></ul><ul><li>Topical application of a 20% solution of aminolevulinic acid to lesions followed by exposure to a red light source (580-740 nm) (photodyna,ic therapy) </li></ul><ul><li>Dermabrasion for severe ak’s useful on hairless scalp </li></ul><ul><li>Chemical peels, CO2 laser </li></ul>
  66. 71. Cutaneous Horn <ul><li>Face, scalp, hands, penis, eyelid </li></ul><ul><li>Horny excresences, skin colored </li></ul><ul><li>Diagnosis at the base varies, often benign </li></ul><ul><li>55% SK, VV, Angioma, Tricholemmoma </li></ul><ul><li>25% AK </li></ul><ul><li>20% SCC or BCC </li></ul><ul><li>More malignancy in elderly, fair skin </li></ul>
  67. 72. Cutaneous Horn
  68. 73. Leukoplakia <ul><li>Whitish thickening of mucosal epithelium </li></ul><ul><li>Glistening, opalescent, may be reticulated or pigmented </li></ul><ul><li>Attempts to remove it cause bleeding </li></ul><ul><li>Common sites: floor of mouth, lateral & ventral surfaces of tongue, soft palate </li></ul><ul><li>May arise on genitalia, anus </li></ul><ul><li>Seen mainly in males over age of 40 </li></ul><ul><li>Non-homogeneous lesions & those of tongue & floor of mouth have higher rate of malignant transformation </li></ul>
  69. 74. <ul><li>Sharply demarcated, white plaque involving ventral surface of tongue & floor of mouth </li></ul>
  70. 75. Leukoplakia <ul><li>Bx reveals orthokeratosis or parakeratosis with minimal inflammation or varying degrees of dysplasia </li></ul><ul><li>Benign form usually occurs from chronic irritation; very little chance of conversion to dysplasia </li></ul><ul><li>Premalignant features seen in only 10-20% </li></ul><ul><li>Dysplasia is clinically impossible to predict </li></ul><ul><li>Changes may be more or less hyperemia & tenderness-with bleeding tendency </li></ul><ul><li>Most commonly has a chronic course in which malignant transformation follows 1-20 year lag time. </li></ul>
  71. 76. Leukoplakia <ul><li>Vulvar often mistaken for LS&A; mainly in obese women after menopause </li></ul><ul><li>Penile more often Erythroplasia of Queyrat </li></ul><ul><li>Risks: UV, Biter, Smoker, esp. pipe </li></ul><ul><li>Oral Hairy Leukoplakia (white, corrugated plaques occurring primarily on sides of tongue)in pt with AIDS - virally induced lesion </li></ul>
  72. 77. Leukoplakia Treatments <ul><li>If dysplastic complete removal is the goal. </li></ul><ul><li>Cryo, CO2 Laser, surgical excision. </li></ul><ul><li>In actinic cheilitis + leukoplakia of tongue exposed surface of lip may be removed & replaced by sliding forward mocosa from inner aspect of lip </li></ul><ul><li>Cryotherapy is effective or Isotretinoin 1 to 2mg/kg/day for 3 months or 5-FU </li></ul>
  73. 79. Leukoplakia with Tylosis and Esophageal Carcinoma <ul><li>Extremely rare, AD </li></ul><ul><li>PPK age 5-15 </li></ul><ul><li>Howell-Evans Synd. </li></ul><ul><li>38x risk esoph ca </li></ul><ul><li>TOC gene 17q25 </li></ul><ul><li>H-E Synd 17q23 </li></ul><ul><li>Variable oral leukokeratosis and follicular keratosis </li></ul>
  74. 80. White Sponge Nevus <ul><li>Spongy overgrowth of mucosa </li></ul><ul><li>Most common on buccal, but can be vaginal or rectal </li></ul><ul><li>No extramucosal lesions; no tx </li></ul><ul><li>Progression stops at puberty-usually </li></ul><ul><li>AD mut of K4, K13 </li></ul><ul><li>Tetracycline is helpful </li></ul><ul><li>EM show aggregated tonofilaments. </li></ul><ul><li>Histo: Acanthosis, vacuolated prickle cells and acidophilic condensations in cytoplasm. </li></ul>
  75. 81. White Sponge Nevus
  76. 82. Oral Florid Papillomatosis <ul><li>Distinctive “Cauliflower” white mass </li></ul><ul><li>Covering tongue & adjacent mucosa </li></ul><ul><li>Slow growing, fungating, no lymphadenop. </li></ul><ul><li>Expect eventual epidermoid carcinoma in most pts </li></ul><ul><li>Well differentiated SCC- mets rare, late </li></ul><ul><li>Progressive, may become SCC </li></ul><ul><li>AKA Verrucous Carcinoma </li></ul><ul><li>TX: Surgical Excision; however often recurs & spreads; recombinant-alpha 2a interferon + CO2 laser has been used </li></ul>
  77. 83. Oral Florid Papillomatosis
  78. 84. Elastotic Nodules of Antihelix <ul><li>Bilateral semi-translucent nodules </li></ul><ul><li>Exclusively upper antihelix location </li></ul><ul><li>“ Orange peel” surface appearance </li></ul><ul><li>Histo: HK, basal cell proliferation, collagen replaced by amorphous elastotic material. </li></ul><ul><li>Frequently mistaken for BCC. </li></ul><ul><li>Sun damage suspected as etiology. </li></ul><ul><li>Tx: removal via shave excision & fulguration of base </li></ul>
  79. 85. Elastotic Nodules of Antihelix
  80. 86. Keratoacanthoma <ul><li>4 types </li></ul><ul><li>Solitary </li></ul><ul><li>Multiple </li></ul><ul><li>Eruptive </li></ul><ul><li>KA Centrifugum Marginatum </li></ul>
  81. 87. Solitary KA <ul><li>Type of KA rapidly growing papule enlarging from 1mm to as large as 25 mm in 3-8 weeks </li></ul><ul><li>Fully developed is dome-shaped, skin-colored nodule with a smooth crater filled with central keratin plug </li></ul><ul><li>Smooth shiny lesion is sharply demarcated from its surroundings </li></ul><ul><li>Telangiectases may run through it </li></ul>
  82. 88. Solitary KA
  83. 89. Multiple KA <ul><li>Ferguson-Smith type of multiple self-healing keratoacanthomas </li></ul><ul><li>Histologically & clinically identical to solitary type </li></ul><ul><li>Most common on face, 3-10 lesions localized to 1 site usu. young men </li></ul><ul><li>Familial type -Ferguson-Smith type of self-healing squamous epithelioma </li></ul><ul><li>Key is pruritis leading to erroneous dx of pruritus nodularis </li></ul>
  84. 90. Multiple KA
  85. 91. Eruptive KA <ul><li>Eruption of dome-shaped, skin-colored papules from 2-7 mm in diameter </li></ul><ul><li>Eruption is generalized but spares palms & soles </li></ul><ul><li>Oral mucous membranes can be involved </li></ul><ul><li>Immunosuppression is key </li></ul><ul><li>SLE, Leukemia, Leprosy, Kidney transplant, photochemotherapy, thermal burn, radiation therapy have all been associated. </li></ul><ul><li>Lesions may be in linear array </li></ul><ul><li>Pruritis sometimes associated, plus bilateral ectropin & narrowing of oral aperture </li></ul>
  86. 92. Eruptive KA – Generalized, esp. shoulders and arms, but palms and soles are spared
  87. 93. Eruptive KA – oral lesions, bilateral ectropion and narrowing of oral aperture
  88. 94. KA Centrifugum Marginatum <ul><li>16 cases (uncommon variant) </li></ul><ul><li>Peripheral expansion with central healing leaving atrophy </li></ul><ul><li>Dorsum hands, pre-tibial </li></ul><ul><li>No tendency for spontaneous resolution (unlike giant solitary KA’s no tendency for spontaneous involution) </li></ul>
  89. 95. KA Centrifugum Marginatum
  90. 96. KA Centrifugum Marginatum
  91. 97. KA-Etiology <ul><li>? Variant of regressing SCC </li></ul><ul><li>Conditions known to promote progression of AK’s & malignant degeneration of premalignant lesions also promote expression & development of KA’s (sun exposure, tar therapy, & immunosuppressed states) </li></ul><ul><li>Inflammatory cells in KA’s mostly are CD4+ T lymphoctes activated by interleukin 2 adhesion molecules-like inflammatory cells in SCC’s </li></ul>
  92. 98. <ul><li>KA-note keratin-filled crater </li></ul>
  93. 99. KA- Treatment <ul><li>Can spontaneously involute, but impossible to tell how long it will take. </li></ul><ul><li>Grade I SCC cannot be excluded even with a bx-biopsy excision or ED&C of an ordinary lesion < 2cm can & should be done –safest course </li></ul><ul><li>5-FU solution straight from ampule & intralesional (0.5- 1 ml of 25 mg/ml methotrexate) </li></ul><ul><li>IM methotrexate (25 mg/week) </li></ul><ul><li>IL Bleomycin (1mg/mL, dil. w/ Xylocaine)-clearing occurred within 20 days of tx </li></ul><ul><li>Recommend excision if involution is not complete after 3 weeks of topical tx </li></ul><ul><li>Mohs’ sx for facial lesions </li></ul>
  94. 100. KA-tx <ul><li>Podophyllum in compound tincture of benzoin useful in giant keratoacanthomas </li></ul><ul><li>Oral retinoids are therapeutic & helpful in large or recalcitrant lesions </li></ul><ul><li>Eruptive forms tend to be very resistant to tx-good results achieved with oral & topical retinoids & cyclophosphamide </li></ul><ul><li>Radiation tx on giant KA’s </li></ul><ul><li>Intralesional IFN-alpha-1 report of regression of 5 of 6 large (>2cm) KA’s (Grob et al) </li></ul>

×