4. Benign lesions
Epidermal nevus (linear nevus)
1-Present at birth or early childhood.
2-Clinical presentation: Tan or brown
warty papules.
3-May be associated with
Ocular or central nervous abnormalities.
Treatment: Excision, laser therapy(CO2), dermabrasion,
or cryotherapy.
5. Benign lesions
Seborrheic keratosis: Cystic inclusions of
keratinous material.
1-Clinical presentation: Waxy, stuck-on
appearance; warty papule or plaque.
2-May be yellow, light brown, dark brown, or
black in color.
3-Treatment: Dermabrasion, cryotherapy,
shaving, and excision.
9. Sebaceous nevus of Jadassohn
1-Appears at birth
2-After puberty, 10% to 15% degenerate into BCC.
May also develop SCC or keratoacanthoma.
3- Clinical presentation: Appears as yellow/orange,
waxy, smooth plaques prior to puberty.
4- Appear as rough, verrucous, orange plaques after
puberty.
5-Anatomic location: Most commonly found on
scalp.
6- Treatment: Excision.
11. PYOGENIC GRANULOMA
Pyogenic granulomas are vascular nodules composed of proliferating
capillaries in a loose stroma.
They often follow trauma with rapid growth and the tendency to
bleed easily.
Most common on hands and around mouth.
Treatment : surgical excision.
12. Cysts
1. Epidermal inclusion cyst (epidermoid cyst)
#Occurs due to implantation of epidermis into the dermis.
#Appears in adulthood.
Clinical presentation: Fluctuant, flesh-colored, well-
circumscribed nodules.
i. Punctum may be visible.
ii. Contains foul-smelling keratinous debris.
Treatment: Simple excision if uninfected; if infected, perform
incision and drainage with interval excision.
13. Epidermal inclusion cyst (epidermoid
cyst)
May be incorrectly called a sebaceous cyst;
however, not sebaceous in origin.
14. Dermoid cyst
Appears at birth or early childhood.
Anatomic location: Most commonly found
along supraorbital ridge, lateral brow,
or nasal midline(CT or MRI prior to excision to
determine intracranial extension).
Treatment: Excision.
16. SKIN MALIGNANCIES
Generally grouped into three types (listed from
most common to least)
a. Basal cell carcinoma (BCC)
b. Squamous cell carcinoma (SCC)
c. Melanoma
17. BASAL CELL CARCINOMA (BCC)
BCC is the most common skin cancer, accounting for
≈80% of all skin cancers.
#Derived from the pluripotential cells of the epidermis or
outer root sheath of the hair follicle.
Risk factors:
1- Sun exposure(especially repeated sunburn in
childhood).
2- Advanced age
3-Immunosuppression, most commonly seen in
transplant patients.
18. BCC (CONTINUED)
4-Fair complexion
5-Nevus sebaceus of Jadassohn
6-Arsenic exposure
7. Syndromes associated with BCC
a. Basal cell nevus syndrome (Gorlin’s syndrome)
i. Autosomal dominant inheritance
ii. Multiple nevi/lesions often seen early in childhood
with malignant degeneration more likely by the age of
puberty.
iii. Skin pits on palms and soles, jaw cysts (odontogenic
keratocysts), rib abnormalities, mental retardation.
19. BCC (CONTINUED)
b. Xeroderma pigmentosum (XP): Patients have
increased incidence of BCC, SCC, and malignant
melanoma.
c. Albinism
21. SUBTYPES of BCC
1. Nodular BCC: a. The most common type, usually
presenting as a single lesion consisting of pearly
papules with telangiectasias, pruritus, and occasional
bleeding.
b. Lesion breakdown over time leads to nodulo-
ulcerative BCC (“Rodent ulcer”).
22. SUBTYPES of BCC
2. Superficial spreading BCC
a. Slow-growing, erythematous, with minimal induration,
and located primarily on the
trunk.
b. It is easily confused with other scaly, eczematous
dermatoses.
23. SUBTYPES of BCC
3. Morpheaform (sclerosing, fibrosing) BCC
a. Flat, often yellowish or hypopigmented,
sometimes resembling scars or normal skin.
b. The true extent of the lesion is usually greater
than the clinical appearance.
c. There is a high incidence of recurrence or
incomplete excision due to “finger-like”
extensions.
25. 4. Pigmented BCC:
Similar to nodular BCC; easily confused with
melanoma due to its deep pigmentation and
nodularity.
26. TREATMENT OF BCC
Wide local excision of BCC:
3- to 5-mm safe margins for nonaggressive
types and 7-mm safe margins for morpheaform
type.
Curettage and electrodessication can be
used for BCC <1 cm that is NOT a recurrent
disease or morpheaform type.
Cryotherapy is effective for small BCC
27. TREATMENT OF BCC
Imiquimod: Immune stimulant,only for
superficial BCCs, with cure rates
between 80% and 90%. The 5% cream is applied
5 times per week for 6 weeks or longer.
Fluorouracil (5-FU): Chemotherapy,only
superficial BCCs, with similar cure rates to
imiquimod.
Radiotherapy in the older age group with a cure
rate of 92%.
28. FOLLOW-UP
There is a 35% risk of developing another skin
cancer in 3 years, 50% in 5 years. Recurrence
may take up to 5 years.
Patients treated for BCC should be observed
every 6-12 months.
29. Cutaneous SCC
SCC is second most common skin cancer after BCC.
Occurs in sun-exposed regions.
Risk Factors:
1-Fitzpatrick skin type: Types I and II have increased risk
2-Sun exposure: Cumulative exposure strongly correlated
to SCC
3- Carcinogen exposure: Pesticides, arsenic, organic
hydrocarbons
4- Viral infection: HPV and herpes simplex
5- Radiation: Long-term latency between exposure and
disease
6-Immunosuppression: like HIV patients
30. Risk Factors(Continued)
7-Marjolin’s ulcer: SCC arising in a chronic wound (i.e., chronic
burn scars and pressure sores) secondary to genetic changes caused
by chronic inflammation.
8- Premalignant lesions
A-Actinic keratoses:
Erythematous macules and
with coarse, adherent scale
33. Types of SCC
1. Verrucous SCC: Slow-growing, exophytic, and
less likely to metastasize.
2. Ulcerative SCC: Grows rapidly and is locally
invasive with very aggressive growth
characteristics.
3. Majorlin’s ulcer
a. Arise from chronic wounds (burn, pressure
ulcer, fistula, osteomyelitis tracks)
b. Commonly metastasize to lymph nodes.
34. SCC TREATMENT
1. Wide local excision of SCC: 5- to 10-mm safe margins
are usually sufficient.
2-Curettage, electrodessication, and cryotherapy are
used much less in SCC treatment than in BCC treatment,
because of higher risk associated with missed deep tumor
portions,and the risk of scarring obscuring SCC
recurrences
3-Radiation is reserved for unresectable lesions or for the
very elderly.
Follow-Up:
skin and nodal examinations every 3-6 months for 2 years,
then every 6-12 months for 3 years, then yearly.
36. Melanoma
Less than 3% of all skin cancers, but cause of 75% of
skin cancer-related deaths.
Risk Factors:
1- UV exposure:Australia, New Zealand
2-Prior melanoma
3- Family history of MM
4-Age
5-Fitzpatrick types I, II,Lighter hair color.
6-male gender
37. Risk factors(continued)
7- Xeroderma pigmentosum (XP)
8-Precursor lesions:
a-Dysplastic nevus
b-Congenital nevus: 6% lifetime risk depending on size.
c-Melanoma in situ: Lesions have intraepidermal proliferation
with fully developed cellular atypia.
d-Lentigo maligna
38. Classification of melanoma types
1. Superficial spreading melanoma
a. Most common type, ≈70% cases
b-Usually arises from preexisting nevus
c-Long horizontal growth phase before vertical growth.
d-Irregular, asymmetric borders with color variegation.
39. Melanoma types
2. Nodular melanoma
a-Second most common: 15% to 30% cases
b. Most aggressive type
c. Typically do not arise from preexisting nevi
d-No clear association with sunlight exposure
e- Typically bluish-black, with uniform, smooth borders
f-5% are amelanotic
Vertical growth phase is
a hallmark feature;
no radial growth.
40. Melanoma types
3. Lentigo maligna melanoma (LMM)
a-Least aggressive type
b- Most clearly associated with sunlight/UV
exposure
c. Head, neck, and arms of elderly (sun-exposed
areas) typically affected
d-Usually greater than 3 cm in diameter;
irregular, asymmetric with color variegation.
42. Acral lentiginous melanoma
a-2% to 8% of melanomas in Caucasians, 35% to 60% of
melanomas in African-Americans, Hispanics, and Asians.
b. Presents in palms, soles, and beneath nail plate
(subungual).
c- Long radial growth phase.
43. Diagnosis
Common clinical features of melanoma lesions:
(ABCDE)
1. Asymmetry
2. Border irregularity
3. Color variation
4. Diameter >6 mm
5. Enlarging/evolving lesion
44. Diagnosis
Excisional biopsy is preferred for lesions <1.5 cm
in diameter. If possible, excise lesion
with 1- to 2-mm margins.
Breslow thickness is reported in millimeters;
thus, it is more accurate and reproducible
than Clark level (level of invasion) and is a better
prognostic indicator.
45. MELANOMA TREATMENT
#Wide local excision is the treatment of choice.
#safe margin depends on tumor thickness.
# Subungual melanoma requires amputation
proximal to the DIPJ for fingers and proximal
to IP joint for the thumb.
#Management of regional lymph nodes
#follow up
