Definition: circumscribed, hyperkeratotic, slightly raised lesion with a central conical core of keratin resulting in a thickening of the stratum corneum. The result of trauma to the skin surface and part of the epithelium is forced into the superficial dermis.
ASSESSMENT
COMMON THERAPEUTIC MODALITIES
HOME CARE CONSIDERATIONS
PATIENT EDUCATION Cysts
DERMATOFIBROMA (FIBROMA)
OVERVIEW
The surface texture may be shiny, dull, smooth, or crusted as a result of trauma from shaving or excoriation. The healing area may remain difficult if some fibrous material remains after treatment.
HYPERTROPHIC SCARS
Diagnosis by clinical examination, biopsy is not guaranteed unless there is clinical suspicion because another skin procedure may involve further hypertrophic scarring.
KELOIDS
Keloid scars extend in the form of claws beyond the border of the original injury and can also develop spontaneously, usually in the area in front of the uterus. Keloids may begin to appear years after the initial injury and may continue to grow for decades (Figure 14-7).
PATIENT EDUCATION Scars and Keloids
LIPOMA
SEBACEOUS HYPERPLASIA
Multiple soft yellowish and erythematous papules, 1 to 3 mm in size, on forehead and cheeks.
PATIENT EDUCATION Sebaceous Hyperplasia
SEBORRHEIC KERATOSIS
PATIENT EDUCATION Seborrheic Keratoses
Cherry Angioma
PATIENT EDUCATION Cherry Angioma
BIBLIOGRAPHY
STUDY QUESTIONS
- Acrochordons are benign neoplasms and cosmetic disorders with which of the following features?
- Calluses are caused by all of the above except
- Appropriate treatment for corns includes which of the following?
- All of the following are common therapeutic modalities for cysts except
- Dermatofibroma is
- Keloid development can
- Lipomas are the most common of the benign soft tissue neoplasms
- Characteristics of sebaceous hyperplasia include which of the following?
- Seborrheic keratosis is an autosomal dominant trait and is extremely common; it has been found in 88% of people older than 65 years and is more prevalent in white-skinned
Caused by spontaneous development of localized accumulation of fibroblasts or a reaction to an insect bite. Seborrheic keratosis is an autosomal dominant trait and is extremely common; it has been found in 88% of people over 65 years of age and is more common in white-skinned individuals.
Answers to Study Questions
CHAPTER 15 Photodamage, Photodermatoses, and Aging
OBJECTIVES
KEY POINTS
Definition: a term that describes the skin of people who have been chronically exposed to UV radiation. The smaller the molecular structure of the acid, the more it can penetrate the skin.
PATIENT EDUCATION Sunscreens
All sunscreens must include standard "drug facts" information on the back and/or side of the container. Never spray sunscreen on your face (you can spray it on your hand and then use it on your face), and never spray it with someone below you "catching" the spray.
PATIENT EDUCATION Photodermatoses
LENTIGINES
There are many different types of lentigines, but three of the most common will be discussed here. Spots (ephelides) are found on areas exposed to the sun, such as the face, arms and back of the hands.
PATIENT EDUCATION Lentigines
POLYMORPHOUS LIGHT ERUPTION (PMLE)
Large papular lesions show very little epidermal response, but parakeratosis and acanthosis are often present. PMLE on the sun-exposed area of the neck, stopping at the shirt collar line.
PATIENT EDUCATION SunAWARE
SUNBURN
Definition: sunburn is the superficial inflammation of the skin caused by excessive exposure to UV light from the sun or artificial UV sources. Overexposure to UV radiation can cause eye damage resulting in painful, gritty eyes and even temporary blindness.
UVA absorbers
UVB absorbers
Sunscreen stabilizers
UVA/UVB absorbers
PATIENT EDUCATION Sunburn
PORPHYRIA CUTANEA TARDA
PCT is one of several porphyrias associated with defective enzymes in the heme biosynthetic pathway. When the metabolic pathway is blocked by a deficiency in the UROD enzyme, porphyrinogens are broken down and therefore oxidized to porphyrins.
PATIENT EDUCATION Porphyria Cutanea Tarda
SOLAR URTICARIA
CHRONIC ACTINIC DERMATITIS (CAD)
In severe cases, CAD may be treated with PUVA or immunosuppressive agents such as cyclosporine, azathioprine, and systemic corticosteroids.
AGING
Use of emollients and moisturizing creams can be used to increase skin suppleness, reduce inflammation and improve skin texture.
Texture changes
Vascular changes
Pigmentation changes
Papular changes
XEROSIS
The lower legs and feet are more commonly affected than the arms among older people. The goal of all treatment is to add water to the skin and its environment.
PATIENT EDUCATION Xerosis
SEBORRHEIC KERATOSIS
The lesions occur mostly on the scalp, face, neck and upper body and are less common on the appendages. There may be an increase of melanin in the keratinocytes and the granular layer is not prominent.
PATIENT EDUCATION Seborrheic Keratosis
- When looking for a sunscreen, which of the following must be included on the label for best sun protection?
- Photo damage can result in which of the following?
- Which of the following is a common treatment for actinic keratosis?
- Which of the following describes polymorphous light eruption?
- Preventive photodamage education should include which of the following?
- All of the following are examples of photoaging except
- Porphyria cutanea tarda can be diagnosed using which of the following?
- When educating a patient on the use of imiquimod or 5-FU, which of the following are important points to discuss?
- Best care for xerosis includes which of the following?
- Which of the following are the most common complications of treating seborrheic
- Treatment for solar urticaria includes which of the following?
- Over 45% of actinic keratoses turn into squamous cell carcinoma
When looking for a sunscreen, which of the following should be included on the label for the best sun protection. When educating a patient about the use of imiquimod or 5-FU, which of the following points are important to discuss.
ANSWERS TO STUDY QUESTIONS
CHAPTER 16 CUTANEOUS MALIGNANCIES
The four types of malignant melanoma include superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma, and acral lentiginous melanoma. Patients with a chronic skin rash that delays improvement, progresses through varying degrees of lesions, and repeated cycles of regression and relapse should be evaluated for cutaneous T-cell lymphoma.
ACTINIC KERATOSIS
- CLINICAL VARIANTS
- LABORATORY AND DIAGNOSTIC TESTS
- DIFFERENTIAL DIAGNOSIS
- TREATMENT MODALITIES
- PROGNOSIS
Common AK: several millimeters to 2 cm in diameter, pink or erythematous, keratotic papule or plaque (Figure 16-1). Electrodesication and curettage: ideal treatment for hyperkeratotic AKs and those resembling the appearance of invasive SCC.
PATIENT EDUCATION
Patient should not be confused with the number of AK lesions removed by various types of treatment methods in the report of skin cancer history. Reasons for removing AK lesions on the skin include cosmetic concerns (unsightliness), frequent irritation and potential risk of developing into an SCC (rarely BCC).
BASAL CELL CARCINOMA I. OVERVIEW
Tissue sample is marked with color coding ink to maintain the orientation of the sample and the defect (surgical site). Precise margin control and conservative removal of the benign skin around the tumor offers benefit in cosmetically sensitive areas and higher healing rate.
PATIENT EDUCATION Basal Cell Carcinoma
SQUAMOUS CELL CARCINOMA I. OVERVIEW
Continuous progression in tumorigenesis with genetic alteration enables the acquisition of the metastatic capacity in the metastasis of SCC. SCC can arise from erythroplakia (premalignant erythematous patches) or leukoplakia (persistent white plaques) in the oral mucosa.
PATIENT EDUCATION Squamous Cell Carcinoma
KERATOACANTHOMA I. OVERVIEW
The risk of metastasis and prognosis of SCC depends on tumor size, location, depth, perineural involvement, and immunosuppression. The risk of metastasis is low in KA, but complete excision of the lesion is recommended when there is no clear distinction between KA and SCC.
PATIENT EDUCATION Keratoacanthoma
Complete excision; close similarity in clinical and histological appearance of KA and SCC suggests treatment of KA as invasive SCC. Although some consider a KA to be a benign tumor, it is commonly treated rather than observed for spontaneous resolution.
MALIGNANT MELANOMA
- CLINICAL ASSESSMENT FOR MELANOMA
- LABORATORY AND DIAGNOSTIC TESTS
- DIFFERENTIAL DIAGNOSES
- STAGING CLASSIFICATION
The appearance of pigmented skin of the nail fold and destruction of the nail plate may indicate advanced ALM. It occurs on the exposed surface of the body, often on the face and scalp of older people.
Node–Metastasis Definitions Primary Tumor (T)
By convention, it should be used after complete excision of the primary melanoma with clinical assessment for regional and distant metastases. The inclusion of this information herein does not authorize any reuse or further distribution without the express, written permission of Springer, on behalf of the AJCC.
Regional Lymph Nodes (N)
Distant Metastasis (M)
METASTATIC AND RECURRENT MELANOMA
Local recurrence is related to tumor thickness and is defined as recurrence in the vicinity of the surgical scar or site of primary cutaneous melanoma (3% rate). Lesions that occur within 2 cm of the primary tumor are called satellites, while in-transit metastases are more than 2 cm from the site.
THERAPEUTIC MODALITIES BY STAGE
The SLNB is recommended by the AJCC for ulcerated lesions greater than 1 mm in thickness to identify local lymph node involvement and guide treatment options. SLNB is recommended before surgery to identify local lymph node involvement and guide treatment options.
PROGNOSIS
Immunotherapies (e.g. IL-2, INF-α2a and ipilimumab): vaccine treatment strategies using tumor cells, antibodies, peptides and dendritic cells. Specific target therapies: Treatment with vemurafenib for genetic signaling pathways for BRAF mutations in metastatic and unresectable (unresectable) melanoma.
PATIENT EDUCATION Melanoma
Radiation therapy, including X-rays and gamma rays aimed at cancer cells, and relief of symptoms to control pain in metastatic diseases involving the brain.
CUTANEOUS T-CELL LYMPHOMA I. OVERVIEW
CLINICAL VARIANTS AND PRESENTATION
It is intensely pruritic with lymphadenopathy that begins either de novo, after the premalignant eruption, or after the established plaque phase of the disease. The prognosis of CTCL depends on the stage of the disease at the time of diagnosis, age, gender, immunocompetence, and the choice and tolerance of treatments.
PATIENT EDUCATION Cutaneous T-Cell Lymphoma
Although there is no cure for MF and SS, treatment should focus on controlling and limiting the skin lesions, slowing progression, and minimizing recurrence of the disease.
KAPOSI SARCOMA I. OVERVIEW
THERAPEUTIC MODALITIES
The prognosis depends on the size and location of the KS lesions, the function of the immune system and the patient's comorbidities.
PATIENT EDUCATION Kaposi Sarcoma
- Which of the following conditions is the most common reason for dermatology visits in the United States?
- Many studies have shown that excessive sun exposure is the most common cause of skin damage and development of skin cancers. Which of the following describes the
- Assessment of an infiltrative squamous cell carcinoma includes which of the following?
- Which of the following types of cutaneous malignancies grows rapidly from a small papule to a large volcano-like nodule, with a central keratotic plug, in just 2 to 6 weeks?
- Which two types of cutaneous malignancies highly resemble each other clinically, as well as histologically?
- The American Academy of Dermatology and the American Cancer Society recommend the use of the A (asymmetry), B (border), C (color), D (diameter), and E (evolution)
- Which of the following describes a change in the 2010 American Joint Commission on Cancer Melanoma Staging System, 7th edition?
- Which of the following genetic diseases is most susceptible to developing both basal cell carcinoma and squamous cell carcinoma?
- Which of the following is optimal patient education for preventing melanoma and nonmelanoma skin cancers?
- CHAPTER 17 Disorders of Pigmentation and
Which of the following conditions is the most common reason for dermatology visits in the United States? Which of the following genetic diseases is most susceptible to the development of both basal cell carcinoma and squamous cell carcinoma.
The Melanocyte
Disorders of Pigmentation
Ephelide (french): small orange-brown or light brown macules induced by sun exposure that fade in the winter months; usually on the face, arms and back; benign. Coffee au lait spots: uniform pale brown macules seen on any surface of the skin; present at birth; six or more macules larger than 1.5 cm would require a checkup for neurofibromatosis (von Recklinghausen's disease).
Disorders of Hypopigmentation Vitiligo
Note: These associations are commonly observed in a high percentage of normal subjects and have not been epidemiologically shown to be more common in patients with vitiligo. If no pigmentation is observed within 3 months, the steroids should be stopped for approximately 6 months and then reinstituted or another treatment method can be used.
Albinism
In lighter skinned individuals, hair can range from white to cream, yellow to yellow-red to bright red.
Piebaldism
Tuberous Sclerosis
Culture grafts: not always cosmetically acceptable C. PUVA: not always cosmetically acceptable. scalp, hair, eyebrows and eyelashes 4. Hypopigmentation spots of the iris and fundus.
Disorders of Hyperpigmentation Melasma
Irregular light to dark brown hyperpigmentation 3. 2) Affects cheeks, forehead, upper lip, nose and chin b. 1) Localized on cheeks and nose (2) Second most common presentation c. 1) Involves the ramus of the lower jaw. (2) Least common presentation.
Chemically Induced Hyperpigmentation
In areas of scarring, such as acne scars, hemosiderin and ferritin are present in macrophages and appear blue-black. Blue-black, brown or slate gray spots on limbs have pigmented macrophages that stain for both melanin and iron.
Nevi
Melanocytic Nevi
Halo nevi: biopsy is unnecessary unless the nevus is otherwise suspicious or has an atypical presentation, atypical history of the lesion, or in patients with a history or high risk for melanoma. DN may be the single most important precursor lesion of melanoma occurring in persons with a family history of melanoma and in persons lacking a family history of melanoma and a personal history of melanoma.
Variants of Ethnic Skin Types
Fibroblast hyperresponsiveness, thought to be induced by mast cell/fibroblast interaction and prolonged by a decrease in collagenase activity, leads to another feature of darker skin types (typically types IV to VI), in the case of keloid formation. Hair can be straightened with chemicals and heat and hot oils and tends to cause hair shaft breakage and scalp scarring, which can lead to temporary or permanent alopecia.
Normal Skin Changes in Darker-Skinned Patients
Curly hair: in people of African descent, hair tends to curl and spontaneously knot and break.
Treatment Modalities
Nail Pigmentation (Longitudinal Melanonychia)
Treatment Modalities
Palmar and Plantar Pigmentation
Common Diseases in the Darker-Skinned Adult
Papular and papulovesicular variants of pityriasis rosea may be more common in darker skin types. All disorders are more likely to cause postinflammatory hyperpigmentation or hypopigmentation in darker skin types (Figure 17-10).
Follicular Occlusion Triad
Therapeutic Modalities
Axillary hidradenitis suppurativa may respond well to surgical excision of the skin to include removal or scarring of apocrine sweat glands. Oral retinoids may have more positive effect in early disease when combined with surgical excision of individual lesions.
Keloids
Keloids differ from hypertrophic scars in that the growth of keloidal tissue at a traumatized site extends beyond the boundary of the injury. Hypertrophic scars are likely to form shortly after the injury, while keloids do not begin to grow until months later.
Hair Loss
Compression bandages are most effective when maintained for at least 4 to 6 months after surgery.
Traction Alopecia/Central Centrifugal Cicatricial Alopecia
CCCA
Hair loss in the frontal and temporal hairline in traction alopecia and vertex in CCCA (Figure 17-14). Punch/follicular transplantation and flap rotation techniques of hair transplantation to correct permanent hair loss/scarring.
Acne Venenata (Pomade Acne)
Disorders Unique to African Americans Pseudofolliculitis Barbae
Before shaving, gently brush your beard to remove hairs that try to re-penetrate the skin.
Dermatosis Papulosa Nigra
Melanocytic Lesions/Conditions Common in the Asian Patient
Nevus of Ota
Therapeutic Modalities
Laser surgery has been shown to reduce the appearance of nevus Ota pigment.
Nevus of Ito
The classic lesion has its onset at birth or childhood and shows increased pigmentation in the skin.
Congenital Dermal Melanocytosis
- Piebaldism is an acquired disease of hypopigmentation
- Albinism is a disorder of hypopigmentation secondary to a defect in which of the following?
- Which of the following statements regarding melasma is false?
- Hyperpigmentation of the skin may be caused by which of the following?
- First-line treatment for Becker nevus is surgical excision
- Nevus spilus commonly evolves into melanoma
- Congenital dermal melanocytosis occurs rarely on the buttocks of Asian newborns
- Which of the following comprise the follicular occlusion triad?
- Dermatosis papulosa nigra is
- Keloids are common in
- The best treatment for pseudofolliculitis is which of the following?
- Clinical features of psoriasis are the same in fair-skinned and dark-skinned individuals
- CHAPTER 18 Hypersensitivities, Drug Eruptions,
Avoiding allergens and irritants whenever possible is the best treatment for urticaria and other hypersensitivity reactions. The primary biological effects of the immune response are humoral (antibodies) and cellular recognition and elimination of infectious agents and other foreign antigens.
Urticaria, Angioedema, and Anaphylaxis