LESSON 5

SKIN AND SOFT TISSUE CONDITIONS

Inflammatory conditions, Neoplasms, Others

OBJECTIVES

By the end of this lesson, you should be able to:1. Describe rare infections of the skin2. Classify neoplasms of the skin3. Describe the main types of Benign growths of the skin4. Describe the main vascular lesions of the skin5. List premalignant lesions of the skin6. Describe the major malignancies of the skin – BCC, SCC,

MM7. Describe cystic lesions of the skin8. List other lesions of the skin

Rare infections of the skin1. Fourniers gangrene2. Hydradenitis suppurativa3. Lupus Vulgaris

Fourniers Gangrene• Neclotising fasciitis (meleney’s streptococcal

gangrene)• Causes destructive invasive infection of the skin,

subcutaneous tissue and deep fascia with relative sparing of muscle

• Caused by either polymicrobial involving anaerobes and facultative species such as coliforms or non gp A strep or monomicrobial due to beta haemolytic strep

• Common site is groin, genitalia, lower abdomen• Treatment – Wide excision, antibiotics

Hydradenitis suppurativa• Chronic suppurative process caused by apocrine

gland hyperplasia• Common in 2nd and 3rd decades of life; F>M• Common site is axillae; also groin and perineum• Due to destruction from keratin plug leading to

rupture into dermal and epidemal region and subsequent superinfection

• Can present with severe pain• Treatment – metronidazole or erythromycin for

long period can be curative• Surgical excision and skingrafting if conservative

fails

Lupus vulgaris• TB of the skin• Commonest in 10-25 yr of age• Common site – face, appear as brownish nodes

(apple-jelly) followed by ulceration, slow• Blood expressed shows TB tubercles• Mucous membranes of mouth & nose may be

affected• Treatment is anti TB or surgical excision if healing

delays• Sq cell carcinoma can occur on lupus scars

NEOPLASMS

Neoplasms are abnormal growths of the skin

They are classified into: -1.Benign growths2.Premalignant growths3.Malignant grwowths

Benign Growths

1. Congenital Naevi (birth marks)2. Keratin Horns3. Saborrhoeic Keratosis4. Dermatofibroma5. Molluscum fibrosum6. Pilomatrixoma7. Sabeceous adenoma8. Cylidroma9. Rhinophyma

Congenital naevi

• Congenital (verrucous, epidermal) naevi are common entities which may single or multiple

• They appear at birth or in early childhood• They are warty growth of brownish colour• A bit large horny excrescences may also

occur

Keratin horn• A papilloma with excess keratin formation• Seen in old people• Saborrhoeic keratosis• Also called basal cell papilloma, seborrhoeic wart or senile

wart• Caused by overgrowth of epidermal keratinocytes• Usually in large numbers and pigmented• Occur on trunk, face and arms• In middle life or elderly• F=M, usually not seen as a disease and therefore not

mentioned. Treatment is by curretage, diathermy or shave excision

Dermatofibroma (fibroma)• Also called sclerosing angioma, histiocytoma,

fibroma simplex, subepidermal nodular fibrosis• Occurs on the skin as a firm indolent, single or

multiple nodules• May follow minor trauma or insect bites which

initiate tissue reaction• Usually in extremities• In all age after puberty with M=F• Small, well defined nodule, touching the epidermis• Treatment is by Excision

Molluscum fibrosum

• Polypoid or filiform soft freshy skin tags that occurs on the neck, trunk or face

• Associated with seborrhoeic warts• Frequently pendiculated, round, soft,

elastic frequently pigmented lesions• Treatement is by excision or cautery

Rhinophyma

• “Potato nose”• This is a glandular form of acne rosascea• The skin of the nose becomes markedly thickened

and sabeceous follicles opening are easily seen• Capillaries become dilated and the nose assumes a

bluish-red colour• It can rarely be a basal cell carcinoma • Treatment is by surgery to improve the condition

Vascular lesions• Structural and morphological anomalies due to

faulty embryological morphogenesis• Present at birth, grows with the child and does not

regress• Can lead to underlying soft tissue or bone

hypertrophy• They are grouped into:1.High-flow – arterial malformations, AV

malformations2.Low-flow – lymphatics, venous, capillary, combined3.Ectasias – Telengenctasia ( spider naevi)

Miscallaneus vascular lesions

• Pyogenic granuloma – arise from minor trauma, acquired, vascular lesion of the skin and mucus membrane. Look like haemagiomas

• Macular stains – salmon patch, present at birth over the fore head in the midline and over the occiput; disappear by age 1 yr

Benign Pigmented lesions1. Simple melanocytic tumour • Derived from neurocrest cells• Increased melanocytes from benign pigment naevi

which include• Lentigo – in basal cell layer of epidermis• Junctional naevi – localized aggregations projecting

into the dermal• Dermal naevi – entirely within the dermis• Compound naevi – features of both junctional and

dermis naevi

Café au lait spots

• Light brown flat macules that are of often apparent at birth

• Solitary lesion or increased numbers in syndromes such as neurofibromatosis and albrights syndrome

Premalignant lesions

• Actinic Keratosis• Bowen’s disease• Erthyroplastic of Querat ( Bowen’s disease of

the grans penis)• Radiodermatitis• Chronic scars• Sabeceous epidermal naevus• Porokeratosi

Actinic Keratosis

• Also known as senile keratosis, solar keratosis• Formed by areas of epidermal dysplasia giving rise

to cutanous scaling usually observed in sun-exposed fair skin

• Potentially malignant• Solitary lesion should be excised• Multiple lesions might clear with 5-fluorouracil

Bowen’s disease• Intraepidermal squamous cell carcinoma that

is potentially malignant and appears as a persistent, progressive flat red scaly or crusted plaque

• Mostly found in the elderly• Triggered by solar radiation• Untreated, 3-5% will develop invasive

squamous cell carcinoma• Treatment is by complete excision

Erythroplasia of Querat

• Bowen’s disease of the penis• Occurs usually in uncircumcised males• Radiodermatitis• Due to excessive exposure to X-ray irradiations• Presents with early erythema which progresses

to desquamation and pigmentation• Eventually leads to squamous cell carcinoma

Chronic scars

• Carcinoma develops in a chronic scar• Referred to as Majolin’s ulcer• Grows slowly, relatively avascular• Painless since the scar contains no nerves• No secondary lymph nodes deposit until it

spreads to normal tissue

Sabeceus Epidermal naevus

• Frequently affecting the scalp• Initially appears as a raised papular yellow

areas developing into a papillomatous area as the child matures

• 10% developes into basal cell carcinoma• Treatment is complete excision

Porokeratosis

• Characterized by annular plaques with horny borders

• 13% may transform into basal cell carcinoma

Malignant Lesions

1. Basal cell carcinoma2. Squamous cell carcinoma3. Virrucous carcinoma4. Kerato acanthoma5. Malignant melanoma

Basal cell carcinoma (rodent’s ulcer)• Commonest kind of skin cancer• Commonly affects ages 40-79yr• >50% affects males• 85% affects neck region• Arises from pluripotent basal layer of dermis and

hair follicles• Metastasis is rare• Presents as spots which do not heal• Has nodular appearance with rolled edges

BCC cont…• Classified into: -

1. Nodular – 50-54%2. Superficial – 9-11%3. Cystic - 4-8%4. Pigmented – 6%5. Morpheic – 2%Treatment of choice is by surgical excision (85-95%

success)Other modes of treatment are Electrodessication and

curretage(85-100% success, radiotherapy (92% success since BCC is very radiosensitive

Squamous cell carcinoma (SCC)• Arises from areas with premalignant lesions or

chronic irritation• More inflammatory and indurated than BCC• Squamous layer of the skin is involved in

development of cancer• Related to radiation with UV light• Follows chronically ulcerated lesions and scars• Metastasis is mainly via lymphatic to regional nodes• Treatment of choice is surgical excision.• Radiotherapy can be used for large unresectable

tumours

Verrucous carcinoma

• These are well differentiated SCC which invade locally but rarely metastasize

• Commonly occurs in palms of the hands and the soles of the feet where they are referred to as carcinoma ciniculatum

Malignant Melanoma• This a pigmented malignant tumour arising from

epidermal melanocytes• Described by Hippocrates in 5th century BC• 1/3 to ½ develop in premalignant lesions or areas of

chronic irritation• It has no sex predilection• Commonest site is the sole of the foot• May also occur in the eye, mucocutaneus junctions• Risk factors – albinism, tropical climate, life style,

poor socioeconomic status, Xeroderma pigmentosa, Hutchinson’s freckles

Malignant melanoma cont…

4 parameters of histological grading1. Depth2. Ulceration3. Mitotic rate4. Regression

Malignant melanoma cont….• Clinical features• Clinically presents in 5 types

1. Superficial spreading – commonest 64%2. Nodular – most malignant – 12-25%, in young3. Acral-lentiginous 4. Amelanotic – occurs in palms, sores and

subungual regions – worst prognosis, may be pinkish or hypopigmente, may present with regional lymph nodes

5. Lentigo maligna – least common 7-15%

Malignant melanoma cont…• Unknown before puberty• Development of malignancy in a mole should be

suspected if the following signs occur: -– Major signs – Change in size, shape or colour– Minor signs –inflammation, crusting or bleeding, sensory

change eg itch, diameter >5mm

• Spread is via: -– Local spread– Lymphatics – by embolism or permeation– Haematogenous spread – to lung, liver, brain, skin, small

intestines – secondary sites deposits are back in colour

Malignant Melanoma cont….

Treatment• Treatment of choice is surgical – wide excision

with a margin of normal tissue of 1-2cm – do not excise beyond the deep fascia

• Regional node dissection of involved – diagnosis by FNAC recommended

• Malignant Melanomas in children are very rare

Other malignancies affecting the skin

• Dermatofibroma protuberans• Kaposis sarcoma• Angiosarcoma• Lymphagiosarcoma• Primary cutaneous malignant lymphoma• Merkes cell tumour• Metastatic malignant tumours

Other lesions of the skin

• Cysts

–Epidermoid cysts (sebaceous cyst)–Pilar cyst–Implantation dermoid cyst

• Callosity• Corn• Warts• Venereal warts and moist warts

Epidermal Cysts (sebaceous cysts)• Cysts containing keratin and its breakdown

products surrounded by a wall of stratified sq keratinized epithelium

• Have a punctum • Inherited in autosomal dominant fashion• Common sites – face, neck, shoulder and chest• Can be solitary but often are multiple• Suppuration may occur if superinfected• May form “sebaceous horn” if content slowly leaks• Treatment – Excision but when inflammed – I&D• May recur if not completely excised

Pilar cysts• Multiple lumps in the scalp• Have no punctum • Histologically – similar to external root of the hair

follicle

Implantation Dermoids• From deep implantation of a fragment of dermis

by penetrating injury• Traumatic inclusion cysts may appear on the

palmar surface of the hand, buttock or knees

Callosity• Localized thickened or hardened patches of

hyperkeratinized skin. Acquired, superficial, circumscribed yellowish-white lesions

• Occurs at pressure areas or friction areas of the hands, feet. Not painful. Require no treatment

Corn• Horny induration of the curticle with a hard center

caused by undue pressure. Chiefly found on the toes and feet.

• Treatment is by surgical excision or application of abrasive chemical e.g. 50% podophyllin

Wart• A viral induced tumour that undergoes

spontaneous resolution. Contangious, usually in immunosuppressed patient

• Tends to affect areas of trauma e.g beard, genitalia, hands, feet

• Have no 100% cure – Curretage, diathermy, or 50% podophyllin can be used

Venereal Warts and Moist wart• Referred to as papillomata accuminata • Warty papillomatous lesions occuring at most areas

of the genitalia

ConclusionRare infections of the skinNeoplasms of the skinBenignVascular lesionsPremalignantMalignant – BCC, SCC, MMCystsOther lesions

04/18/23