FINAL YEAR MEDICAL STUDENTS Skin Tumours Dr Tan Suat Hoon ( Sr Consultant ) Dr Joyce Lee ( Consultant

Approach to Skin Tumours • Skin tumours can broadly be divided under the following categories: • Benign Malignant Premalignant

Histological classification - tissue/cell of origin - tumour differentiation Tumours in the skin can arise from practically every cell constituent in the skin. Tumours can be further categorised under tumours arising from : - Epidermis - Adnexal structures eg. hair follicles, sweat ducts - Blood vessels - Lymphatic vessels - Nerves - Melanocytes BENIGN SKIN TUMOURS

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Epithelial Tumours : Seborrhoeic Keratosis Occurs in the elderly - on the face, upper trunk. Looks like a greasy warty plaque “stuck” on the epidermis. May be pedunculated. Dark brown to black in colour with keratin plugs in the follicles - 1 mm to several cms. Complications Irritation or infection. May have bleeding, oozing and crusting. Treatment 1. Curettage 2. Liquid nitrogen (smaller lesions) Dermatosis papulosa nigra Common in Negroes. Variant of seborrhoeic keratosis. Resemble skin tags. Multiple black or dark brown papules. Usually on the malar region, forehead, chest, back and neck. Treatment 1. Cautery Skin Tags Occurs in the middle-aged and elderly. Usually multiple, pedunculated (approximately 2mm diameter), soft, often pigmented but may be skin-coloured. Occurs on the side of the neck, face, chest, back, axillae and groins. Treatment


Treatment 1. Slowly growing. 2 . Snip excision 2. Occurs in young and middle-aged adults. May be eruptive. Excision Milia Small keratin cyst. Treatment 1. Excision if large Cysts Of The Skin : Epidermal Cyst Keratin-containing cyst. firm. Usually on the scalp. Yellowish. May be multiple. Excision + Histology 2. Treatment 1.nose. Liquid nitrogen Keratoacanthoma Common tumour occuring in middle-aged. May be multiple and may be familial. Starts as a firm. Appear at puberty.1. May get inflamed and suppurate. elastic dome-shaped mobile protuberance. translucent papules. Large lesions may be lobular. Syringoma Treatment 1. may get inflamed and suppurate and sometimes may calcify. Keratin-containing cyst. Occurs in all ages. Small. also on the dorsum of the hands. radiotherapy. 3. May follow trauma such as blistering. white or skin-coloured. 6. mobile. cheeks. wrist and forearms. Resembles squamous cell carcinoma histologically. dermabrasion. Firm. round. Milia 2. Excision Pilar Cyst 1. Rapid growth within a few weeks. steroid atrophy. 5. eyelids and nasolabial folds. Smooth. Occurs on cheeks. grows into a nodule with a keratin-filled central crater covered with a crust. eyelids and lips. Cautery 3. often multiple. 4. Occurs on the central part of the face . leaving a scar. 2. rounded nodule. Different diagnoses 1. flesh-coloured or erythematous papule. Radiotherapy Hair Follicle Tumours : Trichoepithelioma Often familial. Spontaneous resolution occurs usually within 3 months.

head. mucosal surfaces of the mouth and perianal area. Excision (esp. Autosomal dominant inheritance. Treatment 1.10 mm. Incision and squeezing out cyst contents. Bleed easily. “V” of the chest and the extensor surfaces of the forearms. 2. Cautery for small lesions 2. Commonly occur on the fingers. Most commonly situated on the face. Reaching a limiting size. Females more than males. backs of hands and wrists. Treatment 1. May look yellowish. Older lesions usually eroded. Senile Lentigo. Liquid nitrogen Pigment laser Tumours of Blood Vessels : Pyogenic Granuloma Occurs at any age. Clinically appear as yellow. upper trunk.White or yellowish firm papule. after minor injury. Small. Grows to a limited size of 5 . Old Age Spot. Bilateral symmetrical distribution . Vascular nodule . 3 . usually penetrating. Multiple. Commonly on presternal area of the trunk and the forearms. lips. Liver Spot) A benign pigmented macule that develops only on skin that has been damaged by years of exposure to sunlight. crusted. skin-coloured. reaching a limiting size of few mm to 20 mm. Oily fluid expressed if pricked. Steatocystoma Multiplex Occurs in adolescence or early adult life. translucent papules. feet. smooth elastic nodules within the dermis. tan or brown macules from a few millimetre to more than a centimetre in diameter. Round or oval and may be sharply demarcated. May be eruptive.bright red to brownish red to blue-black colour. Sweat Duct Tumours : Syringoma In adults. Pedunculated base with a collar of epidermis.upper and lower eyelids. Treatment 1. Treatment 1. Laser Lentigines : Solar Lentigo (Syn. if occuring on lower eyelids) 3. Leave alone.

Kaposi’s Sarcoma and AIDS Occurs in homosexuals with AIDS. Occurs on the feet.4 mg/kg/day of Prednisolone 2. 2.occasionally effective but slow onset of action. ulcerated or fungating. Lesions may be very subtle or very extensive. ears or nose. 3. Treatment 1. Systemic corticosteroids . High output cardiac failure due to shunting of large volumes of blood. Platelet and plasma transfusions 5. Vascular Malformation : (Not a tumour) Port-Wine Stain : 4 . Radiotherapy . Adjacent areas may fuse to form a plaque or tumour.due to platelet sequestration and consumption of clotting factors. regarded as non-neoplastic reactive vascular proliferation probably viral in etiology (Human Herpes Virus-8) Classical Kaposi’s Sarcoma Occurs in Central and Eastern European Jews and in Africa. Sharply circumscribed oval or round. May become eroded. Excision 2. Treatment 1. occurring in 75% by age 7.may result in severe bleeding. Subcutaneous angiomatous naevi feel like a “bag of worms”.2 . Most common on the head and neck. Cytotoxic drugs for extensive lesions. hands. Surgical treatment . May be multifocal. Curettage and cautery Strawberry Naevus or Haemangioma Appear during first few weeks of life Superficial angiomatous naevus. Dark blue or purplish nodules or macules. Angiomas may be superficial or subcutaneous. Radiotherapy 4. soft domed swelling of intense red colour. Reach ultimate size by 3 to 6 months.Treatment 1. Tumour composed of proliferating capillaries and perivascular connective tissue cells. Also occurs on the trunk. Laser Kaposi’s Sarcoma . Complications 1. Usually single but may be multiple. Cryotherapy 3. 4. The haemangioma-haemorrhage syndrome (Kasabach-Merritt Syndrome) . Surface smooth or lobulated. perianal area and vulva. Bleeding and ulceration. Complete spontaneous resolution is common.

May have coarse hair. Sharply circumscribed. derived from epidermal melanocytes. neck and sometimes other parts of the body. May undergo malignant change. 2. Junctional Nevus Benign proliferation of epidermal melanocytes that are organised into nests at the dermoepidermal junction. round or oval pigmented papules.The Sturge-Weber Syndrome Unilateral facial port-wine stain involving the areas served by the ophthalmic and maxillary divisions of the trigeminal nerve. May be extensive. The most common type of melanocytic nevus. proximal parts of limbs. May evolve into compound or intradermal nevi. 5 . 50% of cases have eye involvement .grand mal type.most commonly chroidal angioma or congential glaucoma. tongue and buccal mucous membrane.excision 2. May be papillomatous or polypoid Flesh coloured or slightly pigmented. Tan to dark brown in colour. 3. Commonest sites . Intradermal Nevus Benign proliferation of melanocytes. Epilepsy occurs in 80 . body and limbs. Involves much of one side of the face.90% of cases . Associated with homolateral leptomeningeal angiomatosis. Usually in adults. scalp. Sharply demarcated hyperpigmented macules or slightly elevated papules that occur anywhere on the skin. Occurs in all ages. Starts during infancy usually. dome shaped papules. that are orgnised into nests within the dermis. shoulders. Compound Nevi Benign proliferation of melanocytes that are organised into nests at the dermoepidermal junction and within the dermis. Develop during childhood. Laser Tumours of Nerve : Neurofibroma May be solitary or multiple (von Recklinghousen’s disease). Tends to be extensive. Tumours of Lymphatic Vessels : Lymphangioma Circumscriptum The commonest type of lymphangioma. Usually at birth or during childhood. Slightly elevated to dome-shaped or sessile. Tumours of Melanocytes : Benign Melanocytic Nevi 1. Treatment 1. Smooth. scalp.axillary folds. Oral and nasal mucosae and lips may be greatly swollen. Skin-coloured soft nodules occuring on the face. Surgery . May be bilateral. perineum. neck.

Slow growing.picked off with difficulty. vermillion of the lower lip. Treatment 1. Treatment 1. especially around the eyes. translucent or pearly. raised and rounded areas covered by thin epidermis through which a few dilated superficial vessels show. May become thick and horny with a sharp edge. Uneven pigment is seen. Excision with primary closure 2. PREMALIGNANT EPITHELIAL TUMOURS Solar Keratosis Occurs after middle-age on sun-exposed fair skin. Bones of the face and skull may be invaded. xeroderma pigmentosum . Liquid nitrogen 2. 5-Fluorouracil 6 . nose or ears. Liquid nitrogen 4. Radiotherapy 3. May spread deeply causing great destruction. Sign of malignant change is an indurated base.Immunosuppression eg. Caucasian skin more susceptible than pigmented skin . 5-Fluorouracil ointment or lotion C.UV radiation from sun exposure . MALIGNANT SKIN TUMOURS Predisposing Factors to Skin Cancers (Malignant Epithelial Tumours) • Environmental Factors . Rarely metastasizes.Chronic ulcers • Malignant Epithelial Tumours : Basal Cell Carcinoma Commonest malignant tumour of the skin. Cytotoxic agents eg. or a keratotic or slightly indurated area or a small superficial ulcer. dry adherent yellow or dirty brown scale . Rough.May have coarse hairs.Genetic diseases eg. Early tumours are small. Occurs on the face. Occurs usually on the head and neck especially upper central part of the face. Usually multiple. Curettage 5. human papilloma virus Host Factors . Cautery 3.Arsenic exposure .Viruses eg. transplant patients . B. back of hands and forearms. Other presentation : A small pearly erythematous lichenoid papule or plaque.Skin type.

scrotum. Radiotherapy Extramammary Paget’s Disease A marginated plaque resembling Paget’s disease clinically and histologically. upper part of the face. intermittently moist area on the nipple.Squamous Cell Carcinoma Occurs in later life. 7 .small. Itching. Surgery 2. Treatment 1.may have excoriation or lichenification. pricking or burning sensation. Early lesions are small. Sharp margin. poorly circumscribed with scalloped borders with variations in colour from tan to brown. tumid or ulcerated. 20% of cases have a primary carcinoma of other organs . Early changes . Become papular or nodular or ulcerated. crusted or eroded. Complete regression is a sign of poor prognosis. Treatment 1. marginated scaling or crusting of the nipple and areola due to invasion of the epidermis by tumour cells (Paget’s cells). penis and axillae. Radiotherapy Malignant Melanocytic Tumours : Risk Factors for Melanoma • congenital melanocytic naevus (giant) • dysplastic melanocytic naevus • 100 or more melanocytic naevi • personal or family history of melanoma Melanoma Malignant neoplasm of melanocytes that begins with proliferation of melanocytes within the epidermis and may eventuate in extension of atypical melanocytes into the dermis. Usually on sun-exposed skin . May arise in chronic conditions such as scars and chronic ulcers. Gradually produce an eczematous appearance. Occurs in the anogenital area or the axillae. ears and lower lip. urethra or cervix. lightly pigmented --. and sometimes. Zones of whiteness indicate partial regression. May arise de novo (75%) or in association with a pre-existing congenital melanocytic nevus. Uncommon tumour. Cutaneous Adnexal Carcinoma : Paget’s Disease Of The Nipple Progressive. Starts in the 5th decade or later. 25% have an underlying cutaneous apocrine carcinoma. erythematous.backs of hands and forearms. verrucous. Slow spreading. Commonest area : vulva. Pruritic . crusted. may be scaly. May be plaque-like. Occurs in women.rectum. May have a serous or blood stained discharge from the nipple. Mastectomy 2. May have a lump in the breast. These cells originate in the intraductal carcinoma of the breast which is present in this condition. into the subcutaneous fat from which sites that may metastasize.become asymmetrical.

which further contributes to the dismal outcome. May appear nodular. GIT Malignant Vascular Tumour : Angiosarcoma Malignant tumour of blood vessel or lymphatic differentiation. Screen for primary site . with an aggressive behaviour. Radiotherapy 3. Usually occurs in 6th or 7th decade. Eczematization may occur.anogenital tract. in the head and neck region. May also occur against background of chronic lymphoedematous limbs eg. Chemotherapy 8 . post-mastectomy and post-irradiation. ill-defined edge. Characteristic appearance : bruise-like dusky red macules or plaques. Treatment 1. Relentless progression Treatment 1. Often delayed diagnosis because of insiduous onset and asymptomatic nature. Surgical excision 2. Surgical excision 2.Itching and burning.