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but, if in doubt, the lesion should be examined histologically.

Seborrheic Keratoses
It is a rare elderly patient who does not have any seborrheic
keratoses. These are the unattractive “moles” or “warts”
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that perturb the elderly patient, occasionally become irritated, but are
benign (Fig. 26-1).

TABLE 26-3 ▪ Classification of Tumors Based on Location

Kaposi’s sarcoma Possible Tumor Type


(legs, classic Scalp
type)Clear cell
acanthoma
(legs)XanthomaLi
pomaMelanomaS
quamous cell
carcinomaActinic
keratosisHistiocyt
omaWartLentigoS
eborrheic
keratosisEccrine
poromaVerrucous
carcinomaSeborrh
eic keratosisAcral
lentigines
melanomaNevi
Blue
nevusHandsSebor
rheic keratosis
Actinic
keratosisWartHidr
adenoma
papilliferum (labia
majora)Verrucous
carcinomaMedian
raphe cyst of
penisBowen’s
diseaseErythropla
sia of
QueyratSeborrhei
c
keratosisSquamou
s cell
carcinomaPearly
penile papules
(around edge of
glans)Angiokerato
ma
(scrotum)Epiderm
al cystSquamous
intraepithelial
lesionsMolluscum
contagiosumWart
Extramammary
Paget
diseaseBowen’s
diseaseWartSebor
rheic keratosis
Molluscum
contagiosumChes
t and
backAngioma
NeviSeborrheic
keratosisLentigo
(multiple lentigo
in axillae
neurofibromatosis
called Crowe’s
sign)Epidermal
cyst
Molluscum
contagiosumLip
and mouthLentigo
Venous lake
(varix)Fordyce’s
diseaseKeloidSeb
orrheic keratosis
Epidermal
cystEyelidsSeborr
heic keratosis
MiliumPedunculat
ed fibromaBlue
nevusAngiolymph
oid hyperplasia
with
eosinophiliaAtypic
al
fibroxanthomaWa
rty
dyskeratomaNevu
s of
OtaAngiosarcoma
(elderly
men)Merkel cell
carcinomaTrichofo
lliculomaTrichilem
momaEccrine
hydrocystomaApo
crine
hydrocystomaAde
noma
sebaceumHemang
iomaEphelidesSpit
z nevusPyogenic
granulomaKeratoa
canthomaDilated
pore of
WinerFibrous
papule of the
noseTrichoepitheli
omaFlat
wartLentigo
maligna
melanomaSquam
ous cell
carcinomaBasal
cell
carcinomaNeviMili
umLentigoActinic
keratosisSebaceo
us gland
hyperplasiaSeborr
heic
keratosisGouty
tophusVenous
lakes
(varix)Chondroder
matitis nodularis
helicisEpidermal
cystKeloidSquamo
us cell
carcinomaNevusB
asal cell
carcinomaActinic
keratosesSeborrh
eic
keratosisSyringoc
ystadenoma
papilliferumCylind
romaProliferating
trichilemmal
tumorNevus
sebaceousSquam
ous cell
carcinomaBasal
cell
carcinomaTrichile
mmal
cystWartActinic
keratosis (bald
males)NevusEpide
rmal cyst (pilar
cyst)Location

Arms and legs

Feet
Wart
Dupuytren
contracture
Xanthoma
Traumatic fibroma
Recurrent
infantile digital
fibroma
Acquired digital
fibrokeratoma
Pyogenic
granuloma
Giant cell tumor
of tendon sheath
Acral lentigines
melanoma
Common blue
nevus
Ganglion
Glomus tumor
(nail bed)
Squamous cell
carcinoma
Myxoid cyst
(proximal nail
fold)
Lentigo

Genitalia

crural areas
Groin and
Pedunculated
fibroma
Becker’s nevus
Nevus of Ito
Blue nevus
Eruptive vellus
hair cyst
Steatocystoma
multiplex
Histiocytoma
Hemangioma
Melanoma
Squamous cell
carcinoma
Café-au-lait spot
Lentigo
Keloid

Epidermal cyst
Basal cell
carcinoma
Lipoma
Actinic keratosis
Ephelides

Axilla
Pedunculated
fibroma
Acral lentiginous
melanoma
White sponge
nevus
Verrucous
carcinoma
Giant cell epulis
(gingivae)
Granular cell
tumor (tongue)
Squamous cell
carcinoma
Pyogenic
granuloma
Leukoplakia
Mucous retention
cyst

Neck
Pedunculated
fibroma
Xanthoma
Basal cell
carcinoma
Syringomas

Face
Ear

Colloid
miliumDermatosis
papulosa nigra (African
American
women)Seborrheic
keratosis
Dermatosis papulosa nigra is a form of seborrheic keratosis of African
Americans that occur on the face, mainly in women. These small,
black, multiple tumors can be removed, but there is the possibility of
causing keloids or hypopigmentation. Stucco keratoses are numerous
white 1- to 3-mm seborrheic keratoses mainly over feet, ankles, and
lower legs. A very large seborrheic keratosis is sometimes referred to
as a melanoacanthoma.
Presentation and Characteristics
Description
The size of seborrheic keratoses varies up to 3 cm for the largest, but
the average diameter is 1 cm. The color may be flesh-colored, tan,
brown, or coal black. They are usually oval in shape, elevated, and
have a greasy, warty sensation to touch. White, brown, or black
pinhead-sized keratotic areas called pseudohorned cysts are
commonly seen within this tumor. There is an appearance of being
superficial and “stuck on” the skin. Pruritus is common and sudden
appearance may occur. Numerous lesions coming on rapidly can be a
marker of underlying cancer (sign of Leser-Trélat).
Distribution
The lesions appear on the face, neck, scalp, back, and upper chest,
and less frequently on arms, legs, and the lower part of the trunk.
Course
Lesions become darker and enlarge slowly. However, sometimes they
can enlarge rapidly and this can be accompanied by bleeding and
inflammation, which is very frightening to the patient. Trauma from
clothing occasionally results in
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infection and bleeding, and this prompts the patient to seek medical
care. Any inflammatory dermatitis around these lesions causes them
to enlarge temporarily and become more evident, so much so that
many patients suddenly note them for the first time. Malignant
degeneration of seborrheic keratoses is doubted.

TABLE 26-4 ▪ Classification of Skin Tumors Based on Clinical


Appearance

1. Seborrheic Possible Tumor Type


keratosesHem
angiomasWart
s (viral)Warts
(viral)Nevi,
usually
junctional
typeAppearan
ce
2.
3. Nevi
4. Granuloma
pyogenicum
5. Malignant
melanomas
6. Blue nevi
7. Thrombosed
angiomas or
hemangiomas
Raised, blackish
tumors
1. Actinic
keratoses
2. Granuloma
pyogenicum
3. Glomus
tumors
4. Senile or
cherry
angiomas
Raised, reddish
tumors
1. Nevi, usually
compound
type
2. Actinic
keratoses
3. Seborrheic
keratoses
4. Pedunculated
fibromas (skin
tags)
5. Basal cell
epitheliomas
6. Squamous
cell carcinoma
7. Malignant
melanoma
8. Granuloma
pyogenicum
9. Keratoacanth
omas
Raised, brownish
tumors
1. Pedunculated
fibromas (skin
tags)
2. Nevi, usually
intradermal
type
3. Cysts
4. Lipomas
5. Keloids
6. Basal cell
carcinomas
Squamous
7.
cell carcinoma
8. Molluscum
contagiosum
(viral)
9. Xanthogranul
oma
(yellowish,
usually
children)
Raised, skin-colored
tumors
1. Lentigo
2. Café-au-lait
spot
3. Histiocytomas
4. Mongolian
spot
5. Melanoma
(superficial
spreading
type)
Flat, pigmented
tumors
1. Flat warts (viral)
2. Histiocytomas
3. Leukoplakia
Flat, skin-colored tumors

Cause
Heredity is the biggest factor, along with old age.
Differential Diagnosis
● Actinic keratoses: See Table 26-5
● Pigmented nevi: Longer duration, smoother surface, softer to
touch; may not be able to differentiate clinically (see later in
this chapter)
● Flat warts: In younger patients; acute onset, with rapid
development of new lesions, colorless and flat topped without
pseudohorned cysts; tiny black thrombosed capillaries may be
seen usually smaller; may Koebnerize (see Chap. 23)
● Malignant melanoma: Less common, usually with rapid growth,
indurated; examination histologically with biopsy may be
necessary (see later)
Treatment
Case Example
A 58-year-old woman requests the removal of a warty, tannish,
slightly elevated 2- × 2-cm lesion of the right side of her forehead.
1. The lesion should be examined carefully. The diagnosis usually
can be made clinically, but if there is any question, a scissors
biopsy (see Chap. 2) can be performed. It would be ideal if all
of these seborrheic keratoses could be examined histologically,
but this is not economically feasible or necessary.
2. An adequate form of therapy is curettement, with or without
local anesthesia, followed by a light application
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of trichloroacetic acid. The resulting fine atrophic scar will


hardly be noticeable in several months.
FIGURE 26-1 ▪ (A) Actinic keratoses in an oil refinery worker.
(B) Hyperkeratotic actinic keratoses. (C) Seborrheic keratoses
on back. (D) Pedunculated seborrheic keratosis of
eyelid. (Courtesy of Stiefel Laboratories, Inc.)

3. Electrosurgery can be used, but this usually requires


anesthesia.
4. Liquid nitrogen freezing therapy works well, if available. It is
the therapy of choice of most dermatologists. Do not freeze
excessively.
5. Laser therapy has been used recently by some authors.
6. Surgical excision is an unnecessary and more expensive form of
removal.
SAUER’S NOTES
1. For many benign lesions, it often is best cosmetically to err on
the side of surgical undertreatment rather than overtreatment.
You can always remove any remaining growth later, but you
cannot put back what you took off.
2. Scarring should be kept to a minimum.
3. After any surgical procedure, I hand out a “Surgical Notes”
sheet that indicates postoperative care. Skin surgery sites
usually heal without any complication. However, there are
always questions and concerns from the patient about
aftercare.
SURGICAL NOTES FOR THE PATIENT
Minor surgery has been performed for the removal or biopsy of a skin
lesion.
If liquid nitrogen was used to remove the growth, a blister or peeling
at the growth site will develop in 24 hours; if electrosurgery, laser, or
burning was used, a crust and scab will form; if a biopsy was made,
there will be a crust or suture(s).
The sites treated heal better if they are covered with a dressing with
Polysporin ointment underneath during the day for 5 to 7 days and
left uncovered at night and while bathing. Do not pick at the spot and
try to avoid accidentally hitting the area.
You can wash over the area lightly.
A certain amount of redness and swelling around the surgery site is
to be expected. Also you might have a small amount of drainage and
crusting. A mild amount of redness and infection can be treated with
Polysporin ointment locally three times a day.
If more drainage or infection develops, apply a wet dressing with
sheeting, or soak the area. Oral antibiotics can be given. Use a
solution made with 1 teaspoon of salt to 1 pint of cool water or
Domeboro compresses and apply for 20 minutes three times a day.
Make a fresh solution every day.
If the infection becomes excessive, call the office or go to a hospital
emergency department.
If the scab is knocked off prematurely, bleeding may occur. This can
be stopped by applying firm pressure with gauze or cotton for 10
minutes by the clock, and then releasing pressure gradually.
Depending on the size of the surgery site, healing takes from 1 to 8
weeks. Some scarring or loss of pigment at the surgery site is
possible. A few individuals have a tendency to form thick or keloidal
scars, which is not predictable.
If a biopsy was done, you may receive a separate bill for the
pathology study from the laboratory. Call the office in 7 days for this
report.
Return to the office for further care or follow-up as directed.

Sauer’s Manual of Skin Diseases


9th Edition

© 2006 Lippincott Williams & Wilkins