Skin Disorders: Necrotizing Fasciitis, Skin Tumors Overview

Skin Disorders
Necrotizing fasciitis, skin tumors overview
Dr. Mahmoud W. Qandeel

Important Skin infections

Erysipelas
• Acute, superficial infection and inflammation in the dermis and upper

subcutaneous tissue involving the superficial dermal lymphatics
4
Cellulitis
This inflammation of the skin occurs at a deeper level
than erysipelas
5
6
Therapy
• Elevation and rest of the affected limb are recommended to reduce local
swelling and inflammation
• Complete rest
• Saline wet dressings
• Antipyretics
• Systemic antibiotics:
– Penicillin
– Cephalosporin
– Dicloxacillin.
– At least 10 days
8
Prophylaxis
(at least 6 months)

–if three relapses within a few years
–benzathine penicillin 1.2 – 1.5 mega units im. every 4
weeks or more frequently or erythromycin 250mg
3xdaily
9
Complications
• Complications occur in 13-17% of patients with erysipelas.

• Abscess, gangrene, and thrombophlebitis.
• Recurrent erysipelas may lead to lymphoedema
• Less common complications (<1%) are acute glomerulonephritis,
endocarditis, septicemia.
10
Necrotizing fasciitis

• Necrotizing infections can manifest with bullae, skin necrosis, pain
beyond the margins of erythema, crepitus, gas on imaging, hypotension,
or other signs of SIRS.
• Common sites of origin are the genitalia, perineum (Fournier’s

gangrene), and abdominal wall.

Three types of necrotizing infections can be distinguished based on the
organisms involved.
• Type 1 is the most common, with a polymicrobial source including

gram-positive cocci, gram-negative rods, and anaerobes (Bacteroides
species, Clostridium perfringens and septicum), occurring in the
perineum and trunk of the immunocompromised host.
• Occasionally an entry site can be identified (incisions, lines, or intestinal
perforation), but in 20% to 50% of cases, a risk factor is not identified.

• Type 2 is a less common, monomicrobial infection with β-hemolytic
streptococci or staphylococci (MRSA rising in frequency to 40%).
• It can be associated with toxic shock and occur in a previously healthy
host, typically on the trunk or extremities, with a history of trauma
commonly elicited.
• Type 3 is a rare but fulminant subset resulting from a V. vulnificus

infection of traumatized skin in sea divers.

• Laboratory findings are nonspecific.
– Leukocytosis,
– Low calcium,
– Elevated lactate, creatine kinase, and creatinine may be seen.
– Coagulopathy and
– Acidemia.
• Blood cultures may or may not be positive.

• A retrospectively developed scoring system, called the Laboratory Risk
Indicator for Necrotizing Fasciitis (LRINEC) score, which
– CRP,
– WBC ,
– Hemoglobin,
– Plasma sodium,
– Creatinine, and
– Glucose
• Can be of diagnostic assistance with a high sensitivity and specificity.
• Tissue samples will demonstrate necrosis, WBC count infiltration,

thrombosis, angiitis, and microorganisms.
Management
• ICU for initial evaluation, resuscitation, and treatment.
• Operative exploration and debridement should not be delayed.
• Broad-spectrum IV antibiotics should be started as soon as possible,

with vancomycin (for MRSA) in addition to clindamycin or linezolid (to
inhibit toxin synthesis) and gram-negative rod coverage (in the form of a
third-generation cephalosporin or a quinolone).

• Surgery is the definitive treatment.
• Incisions should be made over the involved skin, parallel to

neurovascular bundles, extending to and exposing the deep
fascia to assess tissue viability.

• Necrotic tissue will appear dull, gray, and avascular and should be excised.
• Characteristic “murky dishwater”– like fluid.
• Borders for debridement are where tissue planes cease to readily separate.
• Rapid quantitative tissue cultures (if available) and frozen section analysis
may help guide the debridement.
• Revision surgery should be planned (“second look”) within 24 to 48 hours.

• In Fournier’s gangrene, one should aim to preserve the anal sphincter
as well as the testicles (blood supply is independent of the overlying
tissue; usually not infected).
• Wound closure is performed once bacteriologic, metabolic, and

nutritional balances are obtained.
• Mortality ranges from 25% to 40% and is higher in truncal and perineal
cases.

Skin lesions

Macule
• A macule is a change in the color of the skin less than 1 cm.
• It is flat.
Patch
• A macule greater than 1 cm may be referred to as a patch.

Papule
• A papule is a solid raised lesion that has distinct borders and is less than
1 cm in diameter.
• Papules may have a variety of shapes in profile (domed, flat-topped,
umbilicated)

Plaque
• Is a plateau-like lesion > 10 mm or a group of confluent papules

Nodule
• A solid lesion that has distinct edges and that is usually more
deeply rooted than a papule and more than 1cm in diameter

Vesicles
• Vesicle is a circumscribed, elevated lesion containing serous
fluid that is < 5 mm

Bulla
• Circumscribed collection of free fluid > 0.5 cm

Pustule
• Vesicle containing pus (inflammatory cells)

Wheal
• Edematous, transitory plaque

Skin Tumors

Skin Tumors
• Benign
• Premalignant
• Malignant

BENIGN

Seborrhoeic keratosis
• This is a common benign epidermal

tumour, unrelated to sebaceous glands
• Seborrhoeic keratoses usually arise after
the age of 50 years
• They are often multiple but may be single.
• Lesions are most common on the face and
trunk

Nevi
• The term nevus refers to a skin lesion that has a localized excess
of one or more types of cell in a normal cell site.

• Nevi may be composed of keratinocytes (e.g. in epidermal
nevi), melanocytes (e.g. in congenital melanocytic nevi),
connective tissue elements (e.g. in connective tissue nevi) or a
mixture of epithelial and connective tissue elements (e.g. In
sebaceous nevi).

Classification of melanocytic nevi
• Congenital melanocytic nevi
• Acquired melanocytic nevi
• Junctional nevus
• Compound nevus
• Intradermal nevus
• Spitz nevus
• Blue nevus
• Atypical melanocytic nevus

Congenital melanocytic nevus
• These are present at birth or
appear in the neonatal period
and are seldom less than 1 cm
in diameter
• If > 20 cm risk of melanoma

Atypical moles
• can occur sporadically or run in families as
an autosomal dominant trait, with
incomplete penetrance
• Patients with multiple atypical melanocytic
or dysplastic naevi with a positive family
history of malignant melanoma should be
followed up 6-monthly for life

Viral wart
• A wart is a benign tumour in
humans that is caused by a virus,
the human papilloma virus.

Skin tag
• These common benign outgrowths of skin affect mainly the middle-aged
and elderly
• This is unknown but the trait is sometimes familial.
• Skin tags are most common in obese women.
• Occur around the neck and within the major flexures

Pyogenic granuloma
• A relatively common benign vascular
lesion of the skin and mucosa whose
exact cause is unknown.
• The lesion usually occurs in children
and young adults as a solitary
glistening red papule or nodule that
is prone to bleeding and ulceration.
• It is typically evolve rapidly over a
period of a few weeks

Hemangioma
• Strowberry Hemangioma
• Port -wine Stain

Strowberry Hemangioma

Strowberry Hemangioma

Port-wine Stain

Glomus tumour
• Uncommon benign lesions that
typical present in young adults as
small, blue-red papules or nodules
of the distal extremities, with a
predilection for subungual sites.
• Glomus tumors are typically

painful, esp. in response to
temperature changes or pressure.

Dermatofibroma
• A common cutaneous nodule of
unknown etiology that occurs more
often in women.
• Frequently develops on the

extremities and is usually
asymptomatic.
• Removal of the tumor is not

necessary unless diagnostic
uncertainty exists or particularly
troubling symptoms are present.

Neurofibroma
• A neurofibroma is a benign nerve
sheath tumor in the peripheral
nervous system.
• Usually found in individuals with

neurofibromatosis

Lipoma

PREMALIGNANT

Actinic keratosis
• These discrete rough-surfaced lesions crop up on sun-
damaged skin.

Keratoses
Seborrheic keratoses
• Very common, face, trunks ,eldery.
• Multiple, brown-black, waxy, flaky plaques
Solar keratoses(Actinic)
• Raised,red,hard.
• Sun exposed areas face ,hands, forearms
• 20% change to SCC in one year
Bowen’s disease SCC in situ

• Poorly defined scaly ,erythematous plaques
• Head and neck, ultraviolet A-B exposure
Actinic keratosis
• Pre-cancerous lesions
– Caused by photo-damage
– Can become skin cancer
• Highly prevalent, chronic condition
– Affects 50% of Caucasians >40 yrs
– 58 million North Americans
– 8.2 million treatments annually (1)
• 78% of cases have multiple lesions
• Surgical and medical treatments
1. Source: Lewin Group, The Burden of Skin Diseases 2005

Actinic keratosis Seborrheic keratosis
Actinic keratosis
Actinic keratoses
Seborrheic keratosis

Bowen’s disease
• Carcinoma in situ
• Well-circumscribed,
erythematous scaly patch with
irregular border
• Common in people with chronic
arsenic poisoning

Bowen’s disease
Erythroplasia of Queyrat
In-situ SCC
Uncircumcised men
May progress to invasive SCC

Keratoacanthoma
• Benign, self limited epithelial neoplasm
• Sun exposed areas, trauma, virus infection
• Painless, firm, solitary, raised nodule, shiny color fleshy,
depressed keratin center.
• Rapid growth 6-8 weeks, stationary 6-8 weeks, regress 6-8
weeks.
• May progress to invasive SCC

MALIGNANT

Basal cell carcinoma (BCC)
• The most common form of skin cancer.
• It crops up most commonly on the faces of the middle aged or
elderly.
• Arise from basal layers of the epidermis
• Chronic ultraviolet A-B radiation
• Lesions invade locally but, for practical purposes, never
metastasize

Types
• Nodulo-ulcerative
• Cystic
• Cicatricial (morphoeic, sclerosing)
• Superficial (multicentric)
• Micronodular, infiltrative.
• Pigmented

Treatment of BCC
• Curettage electrodessication (ED/C)
• Surgical excision 95% Cure Rate

• Traditional
• Mohs surgery
• Radiation therapy
• Topical therapy 50-75% Cure Rate

5-FU cream Efudex, imiguimod Aldara oint

Squamous cell carcinoma (SCC)
• This is a common tumour in
which malignant keratinocytes
show a variable capacity to form
keratin

SCC
• 2ND,commonest skin cancer
• Sun exposed areas upper face,trunk,neck
• Marjolin’s ulcer
• Ultraviolet A-B exposure
• Prognostic factors for recurrence and metastasis

– Size 2 cm, thickness 4mm
– Perineural invasion
– Aetiology,and differentiation
– Site lip, ear digit

• SCC is locally invasive and
destructive
• Metastases in 1-3% of cases
• To lymph nodes
• 50-73% survival
• Distant sites (lungs)

• Incurable

Invasive SCC

Treatment of SCC
• Efudex or aldara
• Bowen’s disease • Liquid nitrogen

cryotherapy
• Erythroplasia of Queyrat • Radiation therapy
• Curettage
electrodessication
(ED/C)
• Surgical excision

• Surgical excision
• Invasive squamous cell
– Traditional
carcinoma
– Mohs surgery
• Radiation therapy

Malignant melanoma
• The incidence increased over last 4 decades
• 5TH cancer in men,1 in 74 in US will develop M.
• 90% are Cutaneous, 10% subcutaneous.
• 10% of malignant skin cancer
• 20 time more common in whites

Risk factors
• Susceptibility genes
• Susceptible phenotypes most common in
• White people with
• Blond or red hair,
• Many freckles and a
• Fair skin that tans poorly
• Sunlight
• Pre-existing dysplastic melanocytic nevi
• Immunosuppression
• Family history of melanoma 10%

• There is a higher incidence in white people living near the
equator.
• The tumour is rare before puberty and in black people.

The ABCDE of malignant melanoma
• Asymmetry
• Border irregularity
• Colour variability
• Diameter greater than 0.5 cm
• Evolution (change)

• When you see a pigmented lesion
• Draw a line down the middle
• If one half does not look like the other

half -
• TAKE A BIOPSY
It is asymmetrical
83
Types of malignant melanoma
• Lentigo maligna melanoma
• Superficial spreading melanoma
• Acral lentiginous melanoma
• Nodular melanoma
• Amelanotic melanoma

Lentigo maligna melanoma

Superficial spreading melanoma

Nodular melanoma

Acral lentiginous melanoma

Staging of melanoma (Breslow)
Stage Breslow thickness 5 years survival (%)
(mm)
Ia Up to 0.75 95
Ib 0.76 _ 1.5 85
IIa 1.51 _4 65
IIb >4 45
III Nodular 40
IV metastatic < 10

Clark’s level
I Epidermis
II Papillary dermis
III Upper reticular dermis
IV Lower reticular dermis
V Subcutaneous fat

Prognostic factors
• Clinical prognostic factors
– Age and gender: male , old
– Anatomical location: scalp head,neck,trunk,acral areas
– Presence of ulceration
– Vascular invasion
– Lymph node mets
– LDH level
• Histological prognostic factors
– Tumor thickness
– Breslow's thickness
Treatment
• Surgery
– Margin
– LNs
• Chemotherapy
• Targeted immunotherapy

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Skin Disorders

Necrotizing fasciitis, skin tumors overview

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Acute, superficial infection and inflammation in the dermis and upper

(at least 6 months)

• Complications occur in 13-17% of patients with erysipelas.

Dr. Mahmoud W. Qandeel

• Common sites of origin are the genitalia, perineum (Fournier’s

Dr. Mahmoud W. Qandeel

• Type 1 is the most common, with a polymicrobial source including

Dr. Mahmoud W. Qandeel

• Type 3 is a rare but fulminant subset resulting from a V. vulnificus

Dr. Mahmoud W. Qandeel

• Blood cultures may or may not be positive.

Dr. Mahmoud W. Qandeel

• Tissue samples will demonstrate necrosis, WBC count infiltration,

• Operative exploration and debridement should not be delayed.

• Broad-spectrum IV antibiotics should be started as soon as possible,

Dr. Mahmoud W. Qandeel

• Incisions should be made over the involved skin, parallel to

Dr. Mahmoud W. Qandeel

• Revision surgery should be planned (“second look”) within 24 to 48 hours.

Dr. Mahmoud W. Qandeel

• Wound closure is performed once bacteriologic, metabolic, and

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• This is a common benign epidermal

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• If > 20 cm risk of melanoma

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Glomus tumors are typically

Dr. Mahmoud W. Qandeel

• Frequently develops on the

• Removal of the tumor is not

Dr. Mahmoud W. Qandeel

• Usually found in individuals with

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel