Common Cutaneous Lesions

Epidermal Lesions

Seborrheic Keratosis (benign growth that originates in the epidermis)

Description: barnacle-like, light yellow-brown to brown-black, 0.5 – 3.0cm diameter, raised with flat top with verrucous surface and well circumscribed border; occurs often on face, back, chest and arms but can be anywhere, including genitals/legs

Cause: Unknown (genetic tendency) but very common (rare before 30yr); Benign/asymptomatic but can become irritated or inflamed Þ itchy or painful; Exception = sudden appearance or increase in size/# Þ internal malignancy (Leser-Trelat sign), poor prognosis, associated most commonly with adenocarcinoma of stomach

Treatment: remove for comfort and to distinguish from pigmented lesions

Warts (benign epidermal neoplasms)

Individual variation in cell mediated immunity (CMI) Þ variation in susceptibility to, severity of and duration of infection

Cause: Human Papilloma Virus (46 types); some cause benign wart Þ malignant tumor (ie HPV 16 and 18 Þ cervical cancer)

Transmission: Touch; may occur at any age

Common warts (Verrucae Vulgaris) – HPV 1,2,4 and 7; smooth, skin colored papules Þ dome shaped thickened plaques; occur anywhere (most common on hands); thrombosed dilated capillaries (black pinpoints) are diagnostic

Filifom warts: finger-like, skin colored projections commonly around mouth, eyes and nasal alar

Plantar warts (on plantar surfaces) – HPV 1, 2 and 4; occur on points of pressure (callous-like); clusters Þ mosaic wart

Flat warts (Verrucae Plana) – anywhere (mostly on face/hands); skin tone to pale pink; flat, small and numerous (<3mm); tend to spread easily (e.g. line of small warts on lower leg of a woman where she shaved along one initial lesion)

Genital warts (Condyloma Accuminata or venereal warts) – HPV 1, 11, 16, 18; STD with incidence greater than genital herpes; skin colored to pinkish papules; cauliflower appearance (narrow to wide projections upon a broad base) with smooth and moist surface; occur anywhere in male/female genital and perianal regions; may require surgical removal

Molluscum Contagiosum (wart-like but not warts)

Cause: PoxVirus

Transmission: touch, sexual contact; benign but itchy and can spread out of control (very common in children); In children - occurs mostly on face and trunk; In young adults - occurs mostly in genital area due to sexual contact

Description: discrete, dome-shaped, umbillicated skin colored to pearly white papules from 2-7mm; may occur as solitary lesions or be numerous; self-limiting and clear spontaneously

Actinic Keratosis – common, sun induced, premalignant lesions which appears as single or multiple discrete, rough, adherent scaly papules, frequently with inflamed base; begin to develop in middle age and increase in number with age; susceptibility depends on skin type (low) and extent of chronic sun exposure (high); occurs in areas repeatedly exposed to the sun; may disappear spontaneously, but if left untreated, 6-25% of cases transform in Squamous or Basal cell skin cancers

Keratinous Cyst – benign slow growing, discretely circumscribed, intracutaneous or subcutaneous tumors from 3mm to 5cm

Epidermal cyst – appear on any skin surface but mostly above waistline; communicates with skin surface via narrow channel that can fill with white keratin that turns black upon oxidation Þ blackhead appearance; may occur spontaneously or develop in sites following trauma; may result from Garner’s syndrome

Pilar Cyst - Like Epidermal but different keratin, no black head (no communication with surface), and occurs on the scalp

Soft Tissue Lesions

Acrochordon (skin tags) – tiny (<0.5-2cm), skin colored to brown papules that protrude from the skin surface via a narrow stalk; very common (age 20 and increases with age), especially in areas of friction (skin folds - inguinal folds, neck, axillae); asymptomatic (may become irritated or inflamed); unknown cause (apparent genetic component)

Dermatofibroma – 3-10mm, skin colored to red-brown, firm, slightly raised papules; benign; very common, more often women (often legs after trauma; i.e. insect bite; fibrous reaction to trauma); asymptomatic (may become itchy)

Neurofibroma – benign, soft skin colored to reddish papule or nodule composed of proliferating endoneurial and Schwan cells; may become very large and pedunculated (‘Button whole’ sign - invaginate upon finger pressure); solitary NF’s are asymptomatic except for discomfort due to size or location

many NF’s Þ Von Recklinghausens disease (Neurofibromatosis) -genetically determined; Elephant Man’s affliction

Lipoma – benign, solitary, encapsulated subcutaneous tumors from 1-6cm, composed entirely of fat; detectable only with palpation, revealing circumscribed, lobulated, rubbery or compressible subcutaneous nodule; found mostly in upper extremities and trunk; asymptotic unless compressing bone or nerve due to size or location

Hypertrophic scars – firm, thick and inappropriately large but remains within borders of wound site; pink to red due to inflammation; may be itchy; spontaneously regress

Keloids – firm, thick, red and grow beyond borders of wound site; may develop spontaneously but does not to regress spontaneously; may be itchy or painful; found more often in African Americans.

Vascular Lesions – When removing: cut off at base, cauterize, send to pathologist.

Congenital Vascular Lesions

Strawberry Hemangioma: at birth or within first year of life appear as small bruise or telangiectatic macule which grows rapidly for weeks to months into protruberant, compressible, bright red, vascular nodules with well defined borders; spontaneosly involutes by age 3 becoming inappearant by age 9.

Cavernous Hemangioma: same as above but with dermal and subcutaneous component during growth phase.

Salmon Patch: pink to red irregular macule or patch composed of dilated blood vessels; mostly on nape of the neck where they persist, also on face but disappears by age two; most common congenital vascular lesion(40-70% of newborns)

Port Wine Stain: appear at birth as large (10-20cm), flat, irregular, red to purple vascular patches that may cover an entire limb; may form raised papules within them and tend to darken over time; does not spontaneously resolve

Acquired Vascular Lesions

Cherry Angioma: small (0.5-5mm), bright red to purplish vascular papules; form anywhere but mostly on trunk; most common of all vascular lesions; occur in most people, begin around age 30 increasing in # over time; cause is unknown

Pyogenic Granuloma: bright red, dome-shaped, rapidly growing lesion (<1cm) with glistening moist surface and collarette of scale at base; occur anywhere, especially head, neck, arms (especially fingers); very common following trauma, especially in the under 30 crowd; lesions bleed easily and do not spontaneously resolve

Follicular Lesions

Folliculitis

Superficial Folliculitis – erythema or pustules centered around hair follicle (inflammation); painless or mildly tender; heals without scarring; Inflammation caused by infection (most common - staphyloccocus), chemical irritation or physical injury

Deep Folliculitis – more edematous and painful

Furuncle/Carbuncle (abscess or boil) – form of deep folliculitis

tender, deep, firm, red papule that turns into painful firm mass with overlying erythma or inflammation; pus is walled off within lesion; common in friction areas or following trauma; 95% of Furuncles are caused by infection (mostly gm+ staph); normally self limiting but can be recurrent or last years
recurrent furunculosis in a young child could be indicative of an immune defect (ie Job’s syndrome, Chronic granulomatous disease, Chediak-Higashi syndrome and Wiskott Aldrich syndrome)