Plastic Surgery (12 Nov 07) COMMON BENIGN SKIN LESIONS EDGARDO T. ORLINA, M.D. FPCS, FPAPRAS I.

EPIDERMAL LESIONS: NEVI Acquired: - Classified depending on location of nevus cells = stages in maturation of nevi - Junctional accumulate in epidermis - Compound migrate partially into dermis - Dermal rest completely in dermis - Most undergo involution Congenital: - Rarer (1% of neonates) - Larger - Oftentimes contain hair KERATOSIS seborrheic, actinic, lentigo II. EPIDERMAL APPENDAGES: seb. Glands., hair follicles, eccrine and apocrine glnds TRICHOEPITHELIOMA CYLINDROMA ECCRINE POROMA SEBACEOUS- nevus, adenoma, hyperplasia III. CYST - walls consist of layer of epidermis oriented w/ the basal superficial & more mature layers deep - desquamated cells (keratin) collect in the center & form creamy substance of the cyst - usually asymptomatic - may rupture & cause local inflammation - may become infected abscess I&D - remove entire wall to prevent recurrence EPIDERMAL - Blockage of excretory gland secretions are retained in the skin - Tx: excision - DDx: lipoma, sebaceous cyst (has no hole) - Most common type of cutaneous cysts - Can occur anywhere on body as a single, firm nodule INCLUSION DERMOID - Skeleton fold lines - Contain all elements of the skin - Orbital area is most common location - Present at birth - Result from epithelium trapped during midline closure in fetal development

Most often found in midline of face (nose, forehead) & on lateral eyebrow TRICHILEMMAL (pilar) - 2nd most common - F>M - Characteristic strong odor - > scalp IV. DERMAL DERMATOFIBROMA - Solitary nodules - 1-2 cm in diameter - >legs & sides of trunk - Whorls of connective tissue containing fibroblasts - Not encapsulated - Vascularization variable - When lesions enlarge to 2-3 cm, excisional biopsy is recommended to assess for malignancy NEUROFIBROMA (multiple) - Elevations in skin - Broad based - Soft - Components of both nerve sheaths & nerve cells - 25% of nerve sheath tumors - 40% w/ mediastinal fibromas have generalized form - 70% benign - 25-30% may degenerate into neurofibrosarcomas NEURILEMOMA (isolated) - Schwannomas - From schwann cells in intercostals nerves - Firm, well-encapsulated - Dumbbell configuration cord compression & paralysis - Resection open thoracotomy or VATS approach DERMATOFIBROMA PROTRUBERANS (exaggerated form) V. MISC LIPOMA - Tumor of fat cells - Most common subcutaneous neoplasm - > trunk - Microscopic: lobulated containing normal fat cells - Excision for dx & to restore normal tissue contour HIDRADENITIS - Inflammatory condition commonly seen in axillae

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ACROCHORDONS (skin tags) - Fleshy, pedunculated masses - Axillae, trunk, eyelids - Hyperplastic epidermis over fibrous connective tissue stalk - Usually small - Always benign

Reasons for Removal Prevent malignancy Improve appearance Avoid psychological sequela VS. RISK OF SURGERY

Bathing trunk distribution or on chest & back - May develop malignant melanoma in 1-5% ( Schwartz) - Excision is tx of choice Sebaceous nevus (Jadassohn) Actinic keratosis Bowens Disease Xeroderma pigmentosum - Autosomal defect - Usually die in 2nd decade d/t multiple skin CA

PREMALIGNANT 1. Low risk (<5% incidence) Trichoepithelioma Apocrine cylindroma (Turban Tumor) - Benign tumor of sweat glands in scalp Intradermal nevus - Dome-shaped, congenital - May appear during adolescence & has tendency to grow Hypertrophic scar - Especially those d/t burns may undergo malignant transformation; keloids usually dont unless irradiated Chronic idiopathic Lymphedema Post-mastectomy Lymphedema - Previous breast CA, lymphedema usually due initially to block in lymphatic system due to destruction of tissues 2. Moderate Risk (5-10%) Junctional nevus - Palm & sole of foot no increased risk of transformation Cellular blue nevus Dysplastic nevus Neurofibromatosis - Von Recklinghausen disease Cutaneous horns Keratorcanthoma - Usually mistaken for SCC - Grow rapidly, w/ central ulceration 3. High Risk (>10%) Lentigo malignant (Hutchingson Freckle) Neural nevus Giant hairy nevus 20% (lec) - Congenital gian lesions

Nevi : Risk of Malignancy Acquired - higher risk Congenital -small -large higher risk Remove if: Bleeds, painful Progressively enlarges Change in pigmentation Nevi: Modifiers of Risk Size: Giant - > 100cm2 Large - 10 - 100cm2 Small - < 10cm Location Posterior (more immature, usually of neural origin) Histology - Ext. cellular blue nevi Neural nevi Junctional atypia

10% of melanomas usually arise from a nevus

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VASCULAR ANOMALIES I. HEMANGIOMAS - strawberry - manifestation of true tumor - usually disappear by 10 y/o w/o leaving a mark - if 13 y/o and it is still there, wont disappear anymore - common vascular tumors 30% at birth 80% 1st month - small red or deep bluish patch - rapidly proliferate during 1st 2 years - steadily involute - spontaneous resolusion 50% 5 yrs 60% 6 yrs 70% 7 yrs - F>M - > head & neck - indications for treatment: Visual or airway impairment Bleeding or ulceration Infection Kasabach-Merritt syndrome CHF - noninvasive modalities: Systemic cortecosteroids Intralesional cortecosteroids Subcutaneous interferon alpha-2a - invasive techniques: Surgical excision Laser Cryotherapy Embolization - MRI: gold standard in dx of hemangiomas II. VASCULAR MALFORMATION - structural abnormalities d/t embryonic dysmorphogenesis - present at birth - grow concurrently - no sexual predilection 1. slow-flow lesions VENOUS CAPILLARY (port wine stain ) - Usually dont disappear because they contain mature capillaries LYMPHATIC ( microcystic,/macrocystic ) 2. fast-flow lesions ARTERIAL ARTERIOVENOUS - accompanying manifestations: Skeletal distortion or hypertrophy Increased skin temperature Bruit or thrill High-output c ardiac failure Bleeding or ulceration Pain Tissue overgrowth

- standard care: arteriography and super selective embolization followed by surgical resection - other tx modalities: Sclerotherapy Compression garments Laser thermolysis Surgical excision

MANAGEMENT (VASCULAR ANOMALIES) 1. Observation and reassurance. - Document changes - Usually regress 2. Sequential photographs and measurements. 3. Indications for early interventions: a. Obstruction or malalignment of visual axis. b. Ulceration/ hemorrhage c. Coagulopathy/ platelet sequestration. d. Impending airway obstruction. e. Cong. Heart failure f. Progressive deformation of adjacent structure. 4. Specific treatment: a. Mild ulceration std. Wound care. b. Systemic Corticosteroid < 18 mos c. Interferon Alpha 2a d. Pulse dye laser e. Embolization f. Excision.

WARTS - some may resolve spontaneously d/t viral origin - cautery - common in high strung individuals
Lecture slides + notes Italicized from baby Schwartz

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