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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