Benign skin lesion Dermatology

2. Benign Skin Lesions
‫صالح‬ ‫غسان‬ ‫عزيز‬
‫اشراف‬
:
‫ا‬
.
‫د‬
.
‫معن‬
‫العيسمي‬

3. Introduction
The skin is the largest organ in the human body.
It serves as a mechanical and immunologic
barrier and is responsible
for thermoregulation and sensibility.

4. The skin is composed of two layers:
the thin epidermis and the thicker dermis.
Deep to the dermis is subcutaneous fat.
There are two types of human skin:
skin with hair and glabrous skin (without hair).
The latter is found on the palms and soles
and has a much thicker epidermis.

5. Embryology
A. Ectoderm: Epidermis, pilosebaceous glands, apocrine glands, eccrine sweat glands, nails
B. Mesoderm: Langerhans cells, macrophages,
mast cells, Merkel cells, fibroblasts, blood vessels,
lymph vessels, fat cells
C. Neuro-ectoderm: Melanocytes, nerves,
specialized sensory receptors

6. Anatomy
A. Epidermis
1. Cell types: Keratinocytes, melanocytes,
Langerhans cells, Merkel cells
2. Superficial to deep: Stratum corneum, lucidum,
granulosum, spinosum, basale
In glabrous skin, an additional layer (stratum lucidum)
Lies between the stratum comeum and
the stratum granulosum
B. Dermis

7. Anatomy
B. Dermis
1. Cell types: Collagen, elastin, ground substance
2. Nerves, blood vessels, lymphatics, muscle fibers, pilosebaceous/
apocrine/ eccrine glands
3. Two layers superficial to deep
a. Papillary —fibroblasts, mast cells, histiocytes,
Langerhans cells, lymphocytes
b. Reticular —thicker than papillary dermis
i. Extends to underlying fat
ii. Contains elastin with interspersed large collagen fibers

8. The skin appendages like hair follicles, sebaceous
glands, and apocrine and eccrine glands are also found
in the dermis.
Plastic surgeons
require a working knowledge of both benign and malignant
skin conditions; appropriate treatment can only be rendered
if the correct diagnosis is made.

9. EPIDERMAL LESIONS
Pigmented Lesions
Premalignant Lesions
HAIR FOLLICLE TUMORS
ECCRINE TUMORS
APOCRINE TUMORS
SEBACEOUS TUMORS
CYSTS
Smooth muscle tumor
FIBROUS TUMORS

10. EPIDERMAL LESIONS
Seborrheic Keratosis
Keratoacanthoma
Verrucous Nevus
Verruca vulgaris

11. Seborrheic Keratosis
This is a common benign, usually pigmented, neoplasm in elderly people,
arising from the basal layer of the epidermis and consisting of keratinocytes.
The etiology is unknown, and factors like virus infection,
genetics, and sun exposure can be related.
Usually seborrheic keratoses are not photoinduced.
These lesions occur in any body site (frequently in the face and upper trunk)
and are usually asymptomatic or associated with itching.
They are superficial verrucous plaques, smooth or rough, varying
from 1 mm to several centimeters in size and varying from
dirty yellow to dark brown.
The classic description is of a "stuck-on," waxy appearance.

12. Surgical excision or shave excision is appropriate if the
patient complains of cosmetic appearance.
Other treatment options include curettage, cryotherapy, or trichloroacetic acid (TCA).
There are times when the lesion is atypical and an excisional biopsy is indicated for diagnostic purposes

13. Keratoacanthoma
This is a common epithelial tumor related to sun exposure than may be better placed in the next
chapter on malignant lesions.
It is more comon in white phototypes and is usually found on the face or upper limbs.
Classically, it presents as a solitary papule that develops a crater-like central, keratotic core;‘
The history is one of rapid growth over a few weeks. Spontaneous regression is said to occur, but
most lesions are excised before it becomes clear if regression would have ever occurred.
The histology is similar to squamous cell carcinoma and many consider it a low-grade squamous
cell cancer.
Surgical excision is usually the treatment of choice.
Other potential treatment options are curettage, coagulation, and topical 5· fluorouracil

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15. Verrucous Nevus
These are congenital lesions that pres ent as verrucous papules or plaques that are skin colored
or brown. A linear configuration is common and it can be found in any body site.
Malignant transformation is very rare. The treatment options due to cosmetic concerns are
surgical excision, laser, electrodissection, dermabrasion, cryotherapy,TCA, or topical retinoic acid

16. Verruca vulgaris
Caused by human papillomavirus (HPV) Scaly, rough appearance with a cap of friable keratotic
material Lesions arise from stratum granulosum
Treatment: Cryotherapy, chemical ablation, or excision

17. Pigmented Lesions
Nevus or Melanocytic Nevus
Congenital Melanocytic Nevus
Blue Nevus
Halo Nevus
Spitz Nevus
Nevus of Ota
Atypical Moles-Dysplastic Nevi
Solar Lentigo
Ephelides (Freckles)

18. Nevus or Melanocytic Nevus
Nevi are acquired lesions that present after birth and consist of a concentration of nevus cells
that are classified according to their location as junctional (at the epidermal-dermal junction),
intradermal, or compound (both in the dermis and at the junction).
Examples of melanocytic nevi: (A) junctional nevus, (B) intradermal nevus, (C) compound nevus, (D) dysplastic nevus

19. ;

20. •Junctional nevi are frequently found on the palms and soles and tend to be uniform, macular,
and round with smooth and regular borders.

21. •Intradermal nevi are found on the face and are usually homogeneous, elevated, dome-shaped,
skin-colored lesions.
•Compound nevi are raised above the epidermal surface and may be round or oval.
•Nevi are rarely premalignant

22. Congenital Melanocytic Nevus
Congenital nevi are present at birth, usually singular and small.
They are classified in three types depending on the size: small, intermediate, and giant (>20 cm)
They have some potential to develop melanoma, although this risk is low except in the giant variety.
Except for size, the overall appearance of congenital melanocytic nevi and acquired nevi is similar.
Congenital nevi, however, may have dark, thick hair.
Histologically, congenital nevi are distinguished by the pres ence of nevomelanocytes in the epidermis
and in the dermis as sheets, nests, cords, or single cells.
The most common anatomic location for a giant CMN is the posterior trunk, followed in frequency by
the extremities and head and neck

23. Some interesting variants of CMN include the "kissing nevus,“
occurring on adjacent aspects of the upper and lower eyelids,
appearing as a single contiguous lesion when the eyelids are closed

24. The differential diagnosis for CMN includes other congenital pigmented lesions, such as
epidermal nevus, nevus sebaceous, cafe au lait spot, and Mongolian spot.
Features that should prompt biopsy, if not complete early exision, include those suggestive of
dysplasia or melanoma, such as ulceration, uneven pigmentation, bleeding, a change in shape,
focal growth, or pain
MANAGEMENT
The fundamental guiding principle in the management of CMN relates to achieving a balance between treatment goals,
namely, elimination (or at least reduction) of the risk of malignant transformation, preservation of function, and
cosmetic appearance.
Intervention, if performed, should be done early in life, as the risk of malignant transformation is greatest in the first
decade of life.
Chemical peds, lasers, curettage, have been reported as treatment for CMN
Excisional methods include primary excision and closure, serial excision, skin grafting, tissue expansion and skin
sbstitutes.
To address the malignant potential, only complete excision of the nevus can be recommended as a solution.
When the lesion can be excised in three stages or less, serial excision would be the recommended treatment of choice.
This method is tolerated better by patients and has many fewer complications compared with other techniques
In general, 6 months is allowed between successive excisions to allow for scar maturation and relaxation of the tissue.

25. The lesion was complet!lly excised in two stages, with each excision spaced 6 months apart

26. If the lesion cannot be treated in three stages or less, tissue expansion
is the preferred option

27. An alternative to tissue expansion is the use of skin grafts and skin substitutes.
These, however, have inferior aesthetic and functional outcomes compared with tissue
expansion and should be reserved for cases where tissue expansion is not possible in difficult
anatomical regions or has failed.
Back lesions are ideal for tissue expansion.
For lesions in the abdomen, a combined tissue expansion/abdominoplasty approach can be
used, providing additional tissue for coverage.
In the breast, care must be taken to avoid traumatizing the developing breast bud
reconstruction with tissue expanders can potentially lead to distortion of the breast mound or
nipple-areolar complex.
Breast asymmetry resulting from tissue expansion may require subsequent reconstruction with
implants

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29. ;

30. Tissue expansion is associated with more morbidity and a higher failure rate in the extremities.
In the proximal part of the arm and leg, expanded flaps originating in the back and groin may be
transposed to reconstruct defects.
For larger lesions distal to the knee or elbow may require other options such as skin grafting-
Expanded abdominal flaps may also be used
CMN in the forehead may also be treated with tissue expanders if less than two-thirds of the
forehead is involved. Otherwise,
reconstruction of the entire forehead with a single full-thickness skin graft is an option.
CMN in the nasal area may be reconstructed in continuity with forehead lesions using an
expanded forehead flap
Giant CMN in the cheek can be treated with expanded cervical or postauricular flaps

31. Blue Nevus
Blue nevi appear bluish because the nevus cells are deep in the dermis.
These lesions are usually benign but the literature suggests they can be malignant.
Appears during adolescence on Head, neck,
and dorsum of hands/feet.
Clinically, blue nevi are solitary, nodular lesions with
a smooth surface that tend to be blue or blue-gray

32. These lesions are generally treated conservatively unless there has been a change in their
appearance or the patient requests excision for cosmetic reasons.
The excision should include the subcutaneous component to ensure complete removal of deep
dermal melanocytes
Cutaneous metastasis of malignant melanoma can resemble blue nevus

33. Halo Nevus
When a melanocytic nevus is surrounded by a hypopigmented halo, it is termed a halo nevus.
These lesions tend to occur on the torso in older children and teenagers.
They are common, frequently multiple,
usually acquired and asymptomatic.
The central nevus tends to gradually disappear
leaving a macular area of non-pigmented skin.

34. This hypopigmented area may persist for years and may gradually return to a normal color.
When biopsies are performed there may be no trace of the original lesion.
The treatment is expectant. avoiding sun exposure at the hypopigmented areas unless there are
cosmetic concerns or the lesions have atypical features

35. Spitz Nevus
This is a common and usually acquired lesion predominantly in children and young adults but
can be found in older people as well.
Spitz nevi are usually firm, domedshaped, reddish or
dark brown nodules, frequently on the head and neck.
They are compound nevus variations,
which have distinctive histologic features
that make the differentiation from
malignant melanoma difficult.

36. The treatment is surgical excision.
There is controversy over whether an entity known as a malignant Spitz nevus exists or if these
lesions are malignant melanomas.
For these reasons, Spitz nevi require complete excision with margins to decrease recurrence risk
(range from 1 to 2 mm to 1 to 2 cm depending on concern for melanoma) with histologic
confirmation of clear margins

37. Nevus of Ota
Nevi of Ota are hamartomatous melanocytic Found in patients with Asian ancestry.
Appears at birth as large, blue-gray patch
lesions that occur on the face in the distribution of
the ophthalmic and
maxillary division of the trigeminal nerve.

38. They are much more common in women. The sclera is involved in
two-thirds of cases.t The treatment consists of laser therapy using the Q-switched ruby,
(Nd:YAG) or alexandrite laser

39. Nevus of Ito
;

40. Atypical Moles-Dysplastic Nevi
Dysplastic nevi are melanocytic nevi that have the clinical features of melanoma:
asymmetry, border irregularity, color variability, and diameter greater than 6 mm .
Appear after puberty on trunk.
When patients present with many atypical moles,
they are at higher risk for melanoma.
Patients who present with many atypical
moles and a strong family history of malignant melanoma
are at much higher risk for melanoma and must have at
least annual full body examinations for their entire lives

41. It is difficult for even an experienced dermatologist to know when to recommend excisional
biopsy. The best indication for biopsy is a change in clinical appearance.
The ideal surveillance involves total body photographs, which are compared annually with the
patient's current condition in order to determine if any lesions have changed over time and
Sunscreen and avoidance of sunburning/tanning
The treatment is excisional biopsy with margins to prevent recurrence

42. Solar Lentigo
Solar lentigo occur on sun-exposed areas of the face, arms,
and dorsum of hands, especially in lighter skinned white people
with light eye color.
These acquired lesions are pigmented macules
that can be small or large, with a tendency to confluence
and range in size from 0.2 to 2 cm.
They become more numerous with advancing age.

43. Treatment is not required. A biopsy is taken to exclude melanoma from any lentigo that develops
a highly irregular border, a localized increase in pigmentation, or localized thickening.
Bleaching agents like hydroquinone are not particularly effective.
Topical tretinoin, microdermabrasion, or cryotherapy can be used.

44. Ephelides (Freckles)
These are small, less than 3 mm, red or light brown macules that appear on sun-exposed areas
predominantly in fair skinned people with red or blond hair, but can appear in darker skinned
individuals as well.
There is no increase in the number of melanocytes, but rather an increase in the amount of melanin
in the skin. They are common in childhood; however, they can be seen at any age.
They are usually confined to the face, arms,
and back. The number varies from a few spots on the
face to hundreds of confluent macules on the face and arms.
Treatment is not required, but sunscreen is recommended.
Bleaching agents such as hydroquinone,
peels, and intense pulsed light (IPL) can be used for
cosmetic reasons

45. Premalignant Lesions
Actinic Keratosis
Leukoplakia
Cutaneous Horn
Bowen's Disease

46. Actinic Keratosis
Actinic keratosis may be the most common of the premalignant skin conditions.
*Approximately 5% to 20% will develop into squamous cell carcinoma
Caused by sun exposure in people with Fitzpatrick skin types I, II, and III,
they are macules or papules with a scaly surface, generally between 1 mm and 2 cm in diameter.

47. Most commonly located on sunlight-exposed areas (scalp, ears, face, and hands).
Actinic chelitis (aggressive form involving lips).
These lesions frequently require biopsy to rule out a carcinoma.
Multiple lesions are usually treated with 5-fluorouracil or the immune stimulator imiquimod
(Aldara)

48. Leukoplakia
Leukoplakia is white intraoral plaque Cannot be wiped away and is the most common
precancerous lesion of the oral cavity.
Associated with chronic inflammation/irritation (Alcohol or tobacco). These lesions do not
frequently become squamous cell cancer but must be followed and biopsied if they persist or
undergo a change in appearance with Remove the irritant

49. Cutaneous Horn
Cutaneous horn is considered a premalignant lesion. They are usually yellowish brown
protuberant "horns" and are found on the face and ears.
Histologically, they are characterized by a compact proliferation of keratin.
The treatment is surgical excision.

50. Bowen's Disease
Bowen's disease is squamous carcinoma in situ of the skin. This tumor presents as a slowly
growing, red lesion with a scaly surface and irregular borders.
Ulceration or bleeding may be a sign of invasive malignancy. The treatment of choice is surgical
excision, but cryotherapy, curettage, cauterization, topical agents like 5-fluorouracil, and
topical photosensitizer can also be considered

51. Adnexal tumors
Excised for aesthetic reasons
May be classified as nevus, adenoma, or epithelioma
May include sebaceous glands, hair follicles, apocrine, or eccrine sweat glands

52. HAIR FOLLICLE TUMORS
Located in lower dermis and subcutaneous fat
Trichofolliculoma
Trichoepithelioma
Trichilemmoma

53. Trichofolliculoma
This is a rare hamartoma of the pilosebaceous follicle. They are typically solitary, small, raised
nodules with two or three hairs, usually white, protruding together in a tuft.
They frequently appear on the face and scalp. Malignant change is not typical but has been
reported in a single case with perineural invasion.
The treatment recommended is surgical excision.

54. Trichoepithelioma
Trichoepitheliomas are hamartomas of the hair follicle typically found in the center of the face.
They tend to be small, skin-colored or slightly pink papules that are usually distributed
symmetrically on the cheeks, eyelids, and the nasolabial region.
Treatment is not required; excision may be contemplated for cosmetic reasons. Other options
include electrodissection and curettage or cryotherapy. Recurrence is common.

55. Trichilemmoma
Smooth papule Found on scalp or other hair-bearing regions Glycogen-rich epithelial cells
surrounded by sheaths of cells resembling hair follicles on histology
Cowden disease (multiple hamartoma syndrome) should be suspected if patients have multiple
such tumors
Treatment: Laser therapy (CO2), electrodessication with curettage, or simple excision due to
similar appearance with BCC

56. Cowden disease

57. ECCRINE TUMORS
Syringomas
Eccrine Poroma
Cylindroma
Eccrine hidrocystoma
Clear Cell Hidradenoma

58. Syringomas
This is a benign tumor that usually presents as firm, skin-colored to yellowish dermal papules on
the lower eyelids, predominantly in females. Syringomas can be sporadic or familial and are
frequently associated with Down's syndrome.
The treatment is punch or surgical excision for
cosmetic reasons only.
Electrodissection, curettage, and
carbon dioxideLaser can be considered

59. Eccrine Poroma
An eccrine poroma is a solitary, firm, skin-colored or erythematous papule, usually on the sole or
palm in adults.
Ulceration and bleeding may occur at points of pressure.
May resemble amelanotic melanoma
and pyogenic granuloma
The treatment is surgical excision

60. Cylindroma
Cylindromas can be solitary or multiple. The multiple lesion type has a genetic component.
They are classically found on the scalp as numerous small papules or large nodules with
smooth surfaces.
Sometimes they cover the entire scalp like
a turban explaining the name turban tumor.
They are usually benign, but malignant
development has been reported.
Treatment options include surgical excision,
and carbon dioxide laser

61. Eccrine hidrocystoma
Dilated and obstructed sweat ducts histologically
Translucent vesicles Appears on lower eyelids and upper cheeks
Swell in heat/humidity; regress in cooler/dry climate
Treatment: Puncture to release pressure

62. Clear Cell Hidradenoma
Clear cell hidradenoma is an eccrine sweat gland tumor.
It occurs as a slow growing usually solitary nodule. Classically, it is a firm nodule, 0.2 to 5 cm in
size . Some of these tumors discharge serous material, whereas others tend to ulcerate. Lesions
may occur on any body part, but are most frequently found on the arms, thigh, and scalp.
They can develop malignant tumors. The treatment is surgical excision

63. APOCRINE TUMORS
Apocrine Cystadenoma
Chondroid Syringoma

64. Apocrine Cystadenoma
This lesion results from a cystic dilatation of an apocrine secretory gland. It is generally a solitary,
nodular lesion on the face that tends to be skin colored to bluish.
The treatment is surgical excision.

65. Chondroid Syringoma
This tumor is a firm intradermal nodule usually found on the head and neck that is composed of
both sweat gland elements and cartilaginous elements.
It is rare and there can be malignant degeneration. Surgical excision is recommended

66. SEBACEOUS TUMORS
 Sebaceous Nevus
Sebaceous Epithelioma
Sebaceous Hyperplasia
Rhinophyma

67. Sebaceous Nevus
Sebaceous nevi are common tumors of childhood.
Two-thirds are present at birth; the remaining one-third develop in infancy or early childhood.
The lesions are usually solitary, oval to linear, yellowish in color, varying from O.5 cm to several
centimeters, and frequently present on the scalp.

68. Surgical excision is recommended before adolescence because of the potential for development
of BCC and other malignant tumors.
*After puberty, 10% to 15% degenerate into BCC
The rare nevus sebaceous of Jadassohn syndrome consists of the triad of a linear sebaceous
nevus, convulsions, and mental
retardation

69. Sebaceous Epithelioma
This lesion looks like a BCCA, but tends to be more yellowish because of the sebaceous cellular
elements. It is most frequently located on the scalp and face.

70. Sebaceous Hyperplasia
This is a small tumor composed of sebaceous glands that is commonly located on the forehead,
cheeks, lower eyelids, or nose. lt begins as a pale yellow and slightly elevated papule and can
become dome shaped, and sometimes umbilicated. May be covered with telengiectasia
Sebaceous hyperplasia does not have any relationship with solar exposure. Treatment options
are electrodissection. curettage, cryosurgery, or surgical excision

71. Rhinophyma
Rhinophyma is a localized telangiectatic enlargement of the nose, most often in men.
Histologically, it is characterized by sebaceous gland hyperplasia, fibrous infiltration, and lymphedema.
Rhinophyma is considered a glandular form of acne rosacea. The reported incidence of occult cancer in
the setting of rhinophyma varies from 15% to 30%. BCCA is the most common malignant neoplasm.
Treatment options include surgical excision with reconstruction using a forehead flap.

72. CYSTS
Epidermal Cyst (or Sebaceous Cyst)
Dermoid cyst
Milium
Pilar Cyst

73. Epidermal Cyst (or Sebaceous Cyst)
This is the most common type of cyst and occurs because of proliferation of surface epidermal
cells within the dermis.
Epidermal cysts are rare in children but common in adults. They are generally round, protruding,
smoothsurfaced
masses, varying in size from a few millimeters to several centimeters. Commonly found on face,
neck, and trunk.

74. Epidermal cysts grow slowly and are not symptomatic unless they become infected.
Once infected, rupture is common. The only effective treatment is surgical excision.
If infected, a course of antibiotics is recommended in an effort to prevent rupture and drainage
so that excision can be accomplished. Staphylococcus aureus is the most common pathogen.
The entire capsule must be removed to avoid recurrence

75. Dermoid cyst
Appears at birth or early childhood Clinical presentation: Similar to epidermal inclusion cysts.
Lined with epidermal skin appendages
Anatomic location: Most commonly found along supraorbital ridge, lateral brow, or nasal midline
Treatment: Excision
Midline nasal mass differential diagnosis
i. Dermoid cyst, glioma,
meningocele/encephalocele
ii. CT or MRI prior to excision to determine
intracranial extension

76. Milium
A milium (plural: milia) is a superficial, white epidermal cyst that appears immediately beneath
the epidermis. They are most common on the eyelids and cheek and often appear along a
healing upper blepharoplasty incision.
The treatment is unroofing and removal of the central kernel with a 11 blade or needle.

77. Pilar Cyst
A pilar cyst is similar to an epidermal (sebaceous) cyst and is a common scalp lesion containing
keratin. The treatment of choice is surgical excision. Like epidermal cysts, if they present
in an inflamed, infected state, they may require drainage

78. Smooth muscle tumor
Leiomyoma
Abnormal proliferation of smooth muscle - May become symptomatic with pain on exposure to
cold/pressure.
Appears as firm, pale intradermal nodules with brown hue.
Local recurrence may occur - Malignant degeneration to leiomyosarcoma is rare.

79. FIBROUS TUMORS
Dermatofibroma
This lesion is a myofibroblast proliferation, characterized by a firm, skin-colored or reddish
brown sessile papule or nodule,more commonly in women.
They vary in number from 1 to 10 and can be found anywhere on the extremities and trunk.
They tend to remain stable for years as discrete solitary lesions.
Treatment options include surgical excision for cosmetic reasons only, cryotherapy

80. Angiofibroma
Pale, firm papule. May have telengiectasia or erythema Most commonly on lower third of face
Treatment: Simple excision for cosmesis.
May be associated with tuberous sclerosis if multiple.

81. Lipoma
May be present at any age Painless, soft, flesh-colored nodule
Commonly found in the trunk and extremities
Treatment: Simple excision

82. Neurofibroma
May appear at any age Soft, compressible, flesh-colored or pink nodules;
button-hole sign (can be pushed deeper into dermis). Composed of Schwann cells and
endoneurial fibroblasts
Treatment: Excision
Multiple neurofibromas may be associated
with neurofibromatosis type I or II