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LESSON 5
SKIN AND SOFT
TISSUE CONDITIONS
Inflammatory conditions, Neoplasms,
Others
OBJECTIVES
By the end of this lesson, you should be able to:
1. Describe rare infections of the skin
2. Classify neoplasms of the skin
3. Describe the main types of Benign growths of the skin
4. Describe the main vascular lesions of the skin
5. List premalignant lesions of the skin
6. Describe the major malignancies of the skin – BCC,
SCC, MM
7. Describe cystic lesions of the skin
8. List other lesions of the skin
Rare infections of the skin
1. Fourniers gangrene
2. Hydradenitis suppurativa
3. Lupus Vulgaris
Fourniers Gangrene
• Neclotising fasciitis (meleney’s streptococcal
gangrene)
• Causes destructive invasive infection of the skin,
subcutaneous tissue and deep fascia with relative
sparing of muscle
• Caused by either polymicrobial involving anaerobes
and facultative species such as coliforms or non gp
A strep or monomicrobial due to beta haemolytic
strep
• Common site is groin, genitalia, lower abdomen
• Treatment – Wide excision, antibiotics
Hydradenitis suppurativa
• Chronic suppurative process caused by apocrine
gland hyperplasia
• Common in 2nd and 3rd decades of life; F>M
• Common site is axillae; also groin and perineum
• Due to destruction from keratin plug leading to
rupture into dermal and epidemal region and
subsequent superinfection
• Can present with severe pain
• Treatment – metronidazole or erythromycin for long
period can be curative
• Surgical excision and skingrafting if conservative
Lupus vulgaris
• TB of the skin
• Commonest in 10-25 yr of age
• Common site – face, appear as brownish nodes
(apple-jelly) followed by ulceration, slow
• Blood expressed shows TB tubercles
• Mucous membranes of mouth & nose may be
affected
• Treatment is anti TB or surgical excision if healing
delays
• Sq cell carcinoma can occur on lupus scars
NEOPLASMS
Neoplasms are abnormal growths of the
skin
They are classified into: 1. Benign growths
2. Premalignant growths
3. Malignant grwowths
Benign Growths
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Congenital Naevi (birth marks)
Keratin Horns
Saborrhoeic Keratosis
Dermatofibroma
Molluscum fibrosum
Pilomatrixoma
Sabeceous adenoma
Cylidroma
Rhinophyma
Congenital naevi
• Congenital (verrucous, epidermal) naevi
are common entities which may single or
multiple
• They appear at birth or in early childhood
• They are warty growth of brownish
colour
• A bit large horny excrescences may also
occur
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Keratin horn
A papilloma with excess keratin formation
Seen in old people
Saborrhoeic keratosis
Also called basal cell papilloma, seborrhoeic wart or senile
wart
Caused by overgrowth of epidermal keratinocytes
Usually in large numbers and pigmented
Occur on trunk, face and arms
In middle life or elderly
F=M, usually not seen as a disease and therefore not
mentioned. Treatment is by curretage, diathermy or shave
excision
Dermatofibroma (fibroma)
• Also called sclerosing angioma, histiocytoma,
fibroma simplex, subepidermal nodular fibrosis
• Occurs on the skin as a firm indolent, single or
multiple nodules
• May follow minor trauma or insect bites which
initiate tissue reaction
• Usually in extremities
• In all age after puberty with M=F
• Small, well defined nodule, touching the epidermis
• Treatment is by Excision
Molluscum fibrosum
• Polypoid or filiform soft freshy skin tags
that occurs on the neck, trunk or face
• Associated with seborrhoeic warts
• Frequently pendiculated, round, soft,
elastic frequently pigmented lesions
• Treatement is by excision or cautery
Rhinophyma
• “Potato nose”
• This is a glandular form of acne rosascea
• The skin of the nose becomes markedly thickened
and sabeceous follicles opening are easily seen
• Capillaries become dilated and the nose assumes a
bluish-red colour
• It can rarely be a basal cell carcinoma
• Treatment is by surgery to improve the condition
Vascular lesions
• Structural and morphological anomalies due to
faulty embryological morphogenesis
• Present at birth, grows with the child and does not
regress
• Can lead to underlying soft tissue or bone
hypertrophy
• They are grouped into:
1. High-flow – arterial malformations, AV
malformations
2. Low-flow – lymphatics, venous, capillary,
combined
3. Ectasias – Telengenctasia ( spider naevi)
Miscallaneus vascular lesions
• Pyogenic granuloma – arise from minor
trauma, acquired, vascular lesion of the skin
and mucus membrane. Look like
haemagiomas
• Macular stains – salmon patch, present at
birth over the fore head in the midline and
over the occiput; disappear by age 1 yr
Benign Pigmented lesions
1. Simple melanocytic tumour
• Derived from neurocrest cells
• Increased melanocytes from benign pigment naevi
which include
• Lentigo – in basal cell layer of epidermis
• Junctional naevi – localized aggregations projecting
into the dermal
• Dermal naevi – entirely within the dermis
• Compound naevi – features of both junctional and
dermis naevi
Café au lait spots
• Light brown flat macules that are of often
apparent at birth
• Solitary lesion or increased numbers in
syndromes such as neurofibromatosis
and albrights syndrome
Premalignant lesions
• Actinic Keratosis
• Bowen’s disease
• Erthyroplastic of Querat ( Bowen’s disease of
the grans penis)
• Radiodermatitis
• Chronic scars
• Sabeceous epidermal naevus
• Porokeratosi
Actinic Keratosis
• Also known as senile keratosis, solar keratosis
• Formed by areas of epidermal dysplasia giving rise
to cutanous scaling usually observed in sunexposed fair skin
• Potentially malignant
• Solitary lesion should be excised
• Multiple lesions might clear with 5-fluorouracil
Bowen’s disease
• Intraepidermal squamous cell carcinoma that
is potentially malignant and appears as a
persistent, progressive flat red scaly or crusted
plaque
• Mostly found in the elderly
• Triggered by solar radiation
• Untreated, 3-5% will develop invasive
squamous cell carcinoma
• Treatment is by complete excision
Erythroplasia of Querat
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Bowen’s disease of the penis
Occurs usually in uncircumcised males
Radiodermatitis
Due to excessive exposure to X-ray irradiations
Presents with early erythema which
progresses to desquamation and
pigmentation
• Eventually leads to squamous cell carcinoma
Chronic scars
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Carcinoma develops in a chronic scar
Referred to as Majolin’s ulcer
Grows slowly, relatively avascular
Painless since the scar contains no nerves
No secondary lymph nodes deposit until it
spreads to normal tissue
Sabeceus Epidermal naevus
• Frequently affecting the scalp
• Initially appears as a raised papular yellow
areas developing into a papillomatous area as
the child matures
• 10% developes into basal cell carcinoma
• Treatment is complete excision
Porokeratosis
• Characterized by annular plaques with horny
borders
• 13% may transform into basal cell carcinoma
Malignant Lesions
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Basal cell carcinoma
Squamous cell carcinoma
Virrucous carcinoma
Kerato acanthoma
Malignant melanoma
Basal cell carcinoma (rodent’s ulcer)
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Commonest kind of skin cancer
Commonly affects ages 40-79yr
>50% affects males
85% affects neck region
Arises from pluripotent basal layer of dermis and
hair follicles
• Metastasis is rare
• Presents as spots which do not heal
• Has nodular appearance with rolled edges
BCC cont…
• Classified into: 1. Nodular – 50-54%
2. Superficial – 9-11%
3. Cystic - 4-8%
4. Pigmented – 6%
5. Morpheic – 2%
Treatment of choice is by surgical excision (85-95%
success)
Other modes of treatment are Electrodessication and
curretage(85-100% success, radiotherapy (92% success
since BCC is very radiosensitive
Squamous cell carcinoma (SCC)
• Arises from areas with premalignant lesions or
chronic irritation
• More inflammatory and indurated than BCC
• Squamous layer of the skin is involved in
development of cancer
• Related to radiation with UV light
• Follows chronically ulcerated lesions and scars
• Metastasis is mainly via lymphatic to regional nodes
• Treatment of choice is surgical excision.
• Radiotherapy can be used for large unresectable
tumours
Verrucous carcinoma
• These are well differentiated SCC which invade
locally but rarely metastasize
• Commonly occurs in palms of the hands and
the soles of the feet where they are referred
to as carcinoma ciniculatum
Malignant Melanoma
• This a pigmented malignant tumour arising from
epidermal melanocytes
• Described by Hippocrates in 5th century BC
• 1/3 to ½ develop in premalignant lesions or areas of
chronic irritation
• It has no sex predilection
• Commonest site is the sole of the foot
• May also occur in the eye, mucocutaneus junctions
• Risk factors – albinism, tropical climate, life style,
poor socioeconomic status, Xeroderma pigmentosa,
Hutchinson’s freckles
Malignant melanoma cont…
4 parameters of histological grading
1. Depth
2. Ulceration
3. Mitotic rate
4. Regression
Malignant melanoma cont….
• Clinical features
• Clinically presents in 5 types
1. Superficial spreading – commonest 64%
2. Nodular – most malignant – 12-25%, in young
3. Acral-lentiginous
4. Amelanotic – occurs in palms, sores and
subungual regions – worst prognosis, may be
pinkish or hypopigmente, may present with
regional lymph nodes
5. Lentigo maligna – least common 7-15%
Malignant melanoma cont…
• Unknown before puberty
• Development of malignancy in a mole should be
suspected if the following signs occur: – Major signs – Change in size, shape or colour
– Minor signs –inflammation, crusting or bleeding, sensory
change eg itch, diameter >5mm
• Spread is via: – Local spread
– Lymphatics – by embolism or permeation
– Haematogenous spread – to lung, liver, brain, skin, small
intestines – secondary sites deposits are back in colour
Malignant Melanoma cont….
Treatment
• Treatment of choice is surgical – wide excision
with a margin of normal tissue of 1-2cm – do
not excise beyond the deep fascia
• Regional node dissection of involved –
diagnosis by FNAC recommended
• Malignant Melanomas in children are very
rare
Other malignancies affecting the skin
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Dermatofibroma protuberans
Kaposis sarcoma
Angiosarcoma
Lymphagiosarcoma
Primary cutaneous malignant lymphoma
Merkes cell tumour
Metastatic malignant tumours
Other lesions of the skin
• Cysts
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–Epidermoid cysts (sebaceous cyst)
–Pilar cyst
–Implantation dermoid cyst
Callosity
Corn
Warts
Venereal warts and moist warts
Epidermal Cysts (sebaceous cysts)
• Cysts containing keratin and its breakdown products
surrounded by a wall of stratified sq keratinized
epithelium
• Have a punctum
• Inherited in autosomal dominant fashion
• Common sites – face, neck, shoulder and chest
• Can be solitary but often are multiple
• Suppuration may occur if superinfected
• May form “sebaceous horn” if content slowly leaks
• Treatment – Excision but when inflammed – I&D
• May recur if not completely excised
Pilar cysts
• Multiple lumps in the scalp
• Have no punctum
• Histologically – similar to external root of the hair
follicle
Implantation Dermoids
• From deep implantation of a fragment of dermis
by penetrating injury
• Traumatic inclusion cysts may appear on the
palmar surface of the hand, buttock or knees
Callosity
• Localized thickened or hardened patches of
hyperkeratinized skin. Acquired, superficial,
circumscribed yellowish-white lesions
• Occurs at pressure areas or friction areas of the
hands, feet. Not painful. Require no treatment
Corn
• Horny induration of the curticle with a hard center
caused by undue pressure. Chiefly found on the
toes and feet.
• Treatment is by surgical excision or application of
abrasive chemical e.g. 50% podophyllin
Wart
• A viral induced tumour that undergoes spontaneous
resolution. Contangious, usually in
immunosuppressed patient
• Tends to affect areas of trauma e.g beard, genitalia,
hands, feet
• Have no 100% cure – Curretage, diathermy, or 50%
podophyllin can be used
Venereal Warts and Moist wart
• Referred to as papillomata accuminata
• Warty papillomatous lesions occuring at most areas
of the genitalia
Conclusion
Rare infections of the skin
Neoplasms of the skin
Benign
Vascular lesions
Premalignant
Malignant – BCC, SCC, MM
Cysts
Other lesions
4/30/2017