Download Benign Skin LeSiOnS

Benign Skin Lesions
Resident Author: Lise Huynh, MD
Faculty Advisor: David Esho, MD, CCFP
Created: February 2013
Overview1
Benign skin lesions are often diagnosed based on the clinical appearance and history. However if the diagnosis is uncertain or
the lesion has changed unexpectedly in appearance or symptoms, a diagnostic procedure (i.e., biopsy, excision) is indicated to
rule out malignancy. Lesions commonly encountered in family practice are outlined below.
Diagnostic Considerations1,2
Dermal/Epidermal Tumours
Lesion
Description and Common
Locations (L)
Differential Diagnosis
Management
Acrochordon* (skin tag)
Pedunculated lesions on narrow
Neurofibromas* – usually larger &
None unless symptomatic
stalks; usually between 1-5mm diam-
firmer
eter; typically asymptomatic
Pedunculated dermal nevus
(L)Sites of friction (axilla, neck, inguinal regions)
1) Sharp removal (scalpel/scissors)
2) Cryotherapy (mainly LN)
3) Electrodesiccation
4) OTC kits/solutions
Dermatofibroma*
Firm, often hyperpigmented nodule;
Melanocytic Nevi* - softer, do not
None unless symptomatic or chang-
usually secondary to trauma; dimples
dimple when pinched
ing (small chance of conversion
when pinched; typically asymptomatic, though may be pruritic
Nodular Basal Cell CA* – usually
more waxy with telangiectasias
to dermatosarcoma); otherwise,
removal mainly for cosmesis
1) Cryotherapy
(L)Lower extremities
2) Shave Excision
Seborrheic Keratosis*
Usually > 50yrs of age
Nevi* – no stuck-on appearance
Can be solitary or multiple; “stuck-
Melanoma* – blurring of borders,
on”, well circumscribed,often scaly,
asymmetry, changes over time
hyperpigmented
Pigmented basal Cell CA* – waxy
appearance, dilated blood vessels
(L)trunk, face, and upper extremities
and ulceration
1) Topical: Ammonium lactate,
alpha hydroxyl acids, TCA, topical
tazarotene
2) Liquid N2 or C02 +/- curettage –
may cause pigment changes.
3) Snip or shave excision
4) Electrodesiccation +/- curettage
5) Excisional bx into subcut fat to r/o
melanoma or basal cell CA
Appendage Tumours
Epidermoid Cyst and Pilar Cyst*
Firm slow growing subcutaneous
Nasal Gliomas – Congenital lesion,
nodule with central punctum; may
located on the face (usu centrally
expel caseous material from lesion;
close to nose)
Surgical removal
called Pilar cysts if occur on scalp
or face
Dr. Michael Evans developed the One-Pager concept to provide clinicians with useful clinical information on primary care topics.
Benign Skin Lesions
Lesion
Description & Common Locations (L)
Differential Diagnosis
Management
Common among middle aged and el-
Spitz nevus* – isolated erythematous
1) Electrocautery
derly; mature capillary proliferations,
dome shaped nodule, usually in
erythematous, usually 0.1-0.4cm,
children
Vascular Tumours
Cherry Angioma*
diameter blanchable; bleed profusely
if ruptured
Amelanotic melanoma* – friable
2) Shave excision
3) Pulsed dye laser therapy
lesion
(L)trunk
Pyogenic Granuloma*
Small red papule, grows rapidly over
Amelanotic melanoma* – der-
1) Shave excision or curettage
weeks-months, then stabilizes; rarely
moscope exam may show subtle
2) Surgical excision (non-pedunculated lesions)
>1cm; pedunculated or sessile, base
melanocytic structures, likely require
often surrounded by collarette of
histologic exam to differentiate
acanthotic epidermis; friable surface
Nodular basal cell CA* – pearly
(L)Head, neck, fingers, mucous
slow-growing papule, sometimes with
membranes
surface crust or ulceration
3) Electrocautery
4) Chemical cauterization (silver nitrate)
4) Laser: pulse dye, CO2 (cosmetically sensitive
areas)
5) Topical phenol or topical imiquimod cream
for pts who refuse surgery or for some periungual lesions
6) Injectable sclerosing agents (monoethanolamine oleate)
Adipocyte Tumours
Lipoma*
Collection of mature fat cells; slow
Angiolipoma* - painful
growing; asymmetrical; malignant
1) Surgical excision
2) Liposuction in some cases
transformation into liposarcoma is
rare
(L)Subcutaneous tissue, fascia or
muscle
Melanocytic Proliferation
Melanocytic Nevi*
Common, from proliferation of
Melanoma* – often has irregular
cutaneous melanocytes’; present
borders and may change rapidly
1) Biopsy or wide margin surgical excision
as pigmented macules, papules, or
plaques, but may also be flesh-colored or pink depending on type
Solar Lentigo*
Most commonly occur in Caucasians
Seborrheic keratosis* – scale and
Removal for cosmesis
with fair complexion; present as flat,
palpable
1) cryotherapy and trichloroacetic acid (TCA) –
may result in hypopigmentation of area. If nodule or papule recurs in area, should be biopsied
oval, evenly pigmented macules in
areas of chronic sun exposure
(L)Face, dorsum of hands, shoulders, back
Lentigo Maligna* – variable pigmentation, irregular borders, gradual
enlargement
Lentigo Maligna melanoma* – same
clinical appearance but may have
2) Bleaching agent - Hydroquinone 4% cream
plus sun protection can lighten appearance of
lesion
3) Keratolytic agent - tretinoin 0.025 – 0.1%
creams are also used for lightening
papule or nodule within plaque
4) Laser therapy and intense pulsed light
therapy in some cases
Isolated yellow papule with no hx of
Basal cell CA* – usually hx of recent
Removal for cosmesis
change
change, tend not to be yellow
1) Electrocautery with curettage
(L)central face
Sebaceous CA – similar appearance
2) Shave excision
but usually hx of recent change in
3)Topical chemical tx: Trichloroacetic acid 35%
size or shape
For diffuse lesions, consider referral to CO2
laser or dermabrasion
Sebaceous Hyperplasia
Sebaceous Hyperplasia
4) Oral isotretinoin has proven effective in clearing some lesions after 2-6 weeks of treatment,
but lesions often recur upon discontinuation of
therapy
*All Links used with permission from: New Zealand Dermatology Society. DermNet NZ: the dermatology resource. Accessed
May 5 2013: http://dermnetnz.org/
References can be found online at http://www.dfcm.utoronto.ca/programs/postgraduateprograme/One_Pager_Project_References.htm