Benign Neoplasms and Hyperplasias

 Seborrheic Keratosis
 Keratocanthoma
 Nevi
 Port-wine stain
 Angioma/Hemangioma
 Telangectasia
 Dermatofibroma
 Keloids
 Acrochordon
 Cysts
 Lipoma

Seborrheic Keratosis

Pathophysiology

 Clonal expansion of mutated epidermal keratinocyte

 >80% have one mutation in an oncogene
 Mutations in the fibroblast growth factor receptor 3 (FGFR3), PIK3CA, KRAS, EGFR

Etiology

 Autosomal dominant mode of inheritance

 UV radiation exposure
 HPV

Epidemiology

 Most common benign skin tumor

 Epidermal tumor
 >50 years old
 Fair complexion

Prognosis

 Benign
 Secondary tumors
 Can become irritated, itch, grow, bleed

Clinical Features

 Small papule or plaque

 Well-demarcated
 Dull, verrucous (velvety/warty)
  Stuck-on appearance
 Pale brown with pink tones, dark brown, black, grey

Examination

 Hand lens – horn cysts or dark keratin plugs

 Dermatoscope – multiple milia cysts, comedome openings, fissures, ridges
 Biopsy – if there is concern for malignancy
 Histology – well-demarcated proliferation of keratinocytes

Differential Diagnosis

 Acrochordon
 Verruca vulgaris
 Epidermal nevi
 Melanocytic nevi
 Basal cell carcinoma
 Squamous cell carcinoma
 Melanoma

Treatment

 If symptomatic or causing cosmetic concerns

 Cryotherapy
 Curettage/shave excision
 Electrodesiccation

Consultation

 None
Keratoacanthoma
Pathophysiology

 Poorly understood
 Most likely derived from follicular infundibulum

Etiology

 Cause remains unclear

 UV radiation
 Exposure to pitch, tar, cigarette smoke
 Trauma
 HPV
 Genetic factors
 Immunocompromised

Epidemiology

 Cutaneous tumor
 Fair complexion
 Male to female, 2:1
 All age groups, increases with age
o Rare under 20 years old

Prognosis

 Rarely progresses to metastatic carcinoma

 Excellent following excisional surgery

Clinical Features

 Rapid growth over a few weeks to months, spontaneous resolution in 4-6 months
 Solitary lesion
 Begin as firm, round, skin-colored/red papules
  Progress to come-shaped nodules with a smooth shiny surface
 Central ulceration or keratin plug
Examination

 Shave biopsy – indistinguishable from SCC

 Excisional or deep incisional biopsy
 Histology – well-differentiated squamous epithelium, mild degree of pleomorphism

Differential Diagnosis

 Actinic keratosis
 Cutaneous horn
 Squamous cell carcinoma
 Molluscum contagiosum

Treatment

 Surgical excision
 Laser therapy
 Cryotherapy
 Systemic retinoids
 Intralesional Methotrexate, 5-fluorouracil, Bleomycin, Prednisone

Consultation

 Dermatologist – exclude SCC

Nevi
 Very common
 Congenital
o born with them
o Vary in color, shape, consistency
 Common
o Smooth, round
o One color, pink, brown, tan
o flat or dome shaped
 Dysplastic/Atypical
o Bening but resemble melanoma
o Higher risk of developing melanoma
 Blue
o Congenital or acquired
o Blue-grey or blue-black
o Flat or domed
o More common in Asian descent
Port-wine stain
Pathophysiology
 Abnormal morphogenesis
 Ectatic papillary dermal capillaries and postcapillary venules
 Superficial
 Neural role in development and progression

Etiology
 Congenital malformation of the superficial dermal blood vessels
 Idiopathic
Epidemiology
 Most common vascular malformation
 Present at birth and grows
 More common in Caucasian than African Americans

Prognosis
 No increase in mortality

Clinical Features
 Flat, well-circumscribed patch
 Pink, red, purple
 Color mar darken with crying or fever
 Unilateral
 May evolve into a raised plaque

Examination
 CT or MRI if it involves the upper facial dermis
 Ophthalmology evaluation if it involves CN V1 and CN V2 or eyelid
 Histology – ectasia and erythrocytes

Differential Diagnosis
 Hemangioma
 Coats disease
 Cobb Syndrome

Treatment
 Tattoo with skin colored pigment
 Cosmetic cover-up
 Flashlamp pumped pulsed-dye laser

Consultation
 Dermatologist – early intervention
 Opthalmologist – exclude glaucoma
 Neurologist – Sturge-Weber syndrome

Associated syndromes
 Sturge-Weber
 o triad of capillary malformations involving the upper facial dermis, the ipsilateral
leptomeninges, and the ipsilateral cerebral cortex
o facial skin supplied by the ophthalmic branch (CN V1) of the trigeminal nerve must be
involved
o Complications include glaucoma, seizures, hemiplegia, mental retardation, cerebral
calcifications, subdural hemorrhage, and an increased prevalence of underlying soft
tissue hypertrophy
 Klippel-Trenaunay
o triad of capillary malformation, congenital varicose veins, and hypertrophy of
underlying tissues, particularly skeletal overgrowth
o Complications include varicose veins with venous thrombosis and pulmonary embolism;
bleeding from varices, the rectum, or the bladder; skin ulceration; increased sweating
overlying the capillary malformation; leg circumference or length discrepancy with
resultant scoliosis; edema; and recurrent infections

Nevus flammeus (Stork-bite)

  1/3 of infants
 Can regress spontaneously

Cherry Angioma/Hemangioma
Pathophysiology
 Proliferation of dilated venules

Etiology
 Unknown

Epidemiology
 Frequency increases with age

Prognosis
 Benign
 When present at birth they usually resolve by age 5

Clinical Features
 ranging from a small red macule to a larger dome-topped or polypoid papule

Examination
 Histology – ranging from a small red macule to a larger dome-topped or polypoid papule

Differential Diagnosis
 Angiokeratoma
 Milia
 Insect bites

Treatment
  Shave biopsy
 Electrodesiccation
 Laser ablation
 Cryotherapy

Consultation
 Dermatologist - if multiple appear in a short period of time

Telangiectasia
Pathophysiology
 Broken capillaries in skin

Etiology
 Can be associated with rosacea
Treatment
 Laser
 Electrodessication

Dermatofibrosis
Pathophysiology
 Benign fibrous papule

Etiology
 Unknown
 Possible reactive

Epidemiology
  More common in female than males

Prognosis
 Benign

Clinical Features
 Pink, tan, brown, gray
 Nodule or papule

Examination
 Dimple sign
o Lateral compression causes dimple
 Histology – whirling fascicles of spindle cell proliferation with excessive collage deposition in the
dermis

Treatment
 Liquid nitrogen may flatten it
 Surgical removal is unnecessary
Keloids
Pathophysiology
 Excessive proliferation of tissue

Epidemiology
 More common in females
 More common in individuals with darker pigmentation
 Average age of onset 10-30 years old

Clinical Features
 Abnormal proliferation of scar tissue
 Grows beyond original margins of the scar

Examination
 Soft and doughy or rubbery and hard
 Histology
o Keloidal hyalinized collagen
 o Tongue-like advancing edge underneath normal-appearing epidermis and papillary
dermis
o Horizontal cellular fibrous bands in the upper reticular dermis
o Prominent fascia-like fibrous bands

Treatment
 Occlusive dressing
 Compression
 Corticosteroid injection
 Surgical excision
 Cryotherapy
 Laser therapy

Acrochordon (skin tags)

 small, soft, common, benign, pedunculated neoplasm
 Neck, axillae, skin folds
Pathophysiology
 Obesity
 HTN
 HLD
 Insulin resistance

Etiology
 Frequent irritation
 HPV

Epidemiology
 All races, equal among male and females
 Increase in frequnecy through the fifth decade of life

Prognosis
 Benign

Clinical Features/Examination
 Small, furrowed papules of approximately 1-2 mm in width and height, located mostly on the
neck and the axillae
 Single or multiple filiform lesions of approximately 2 mm in width and 5 mm in length occurring
elsewhere on the body
 Large, pedunculated tumor or nevoid, baglike, soft fibromas that occur on the lower part of the
trunk
 Histology – rarely BCC or SCC

Differential Diagnosis
 Pedunculated seborrheic keratosis
 Nodular polypoid melanoma

Treatment
 Scissors
 Electrodessication
 Cryotherapy
Epidermoid cysts
 Cystic enclosure within the epidermis, filled with keratin
 Not an infection but can become inflammed

Epidemiology
 Adult life
 Male:Female 2:1

Prognosis
 Prognosis is good if early surgical excision

Clinical Features
 flesh–colored to yellowish, adherent, firm, round nodules of variable size.
 A central pore or punctum may be present.
 Keratinous contents are soft, cheese-like and malodorous.

Treatment
 I&D
  Treat with oral abx if inflamed prior to excision

Consultation
 Dermatologist/General Surgeon

Mucocele
 A cyst in the lip may be due to occlusion of the salivary duct
 It is a soft to firm firm, 5–15 mm diameter, semi-translucent nodule.
Ganglion cyst
 Most often involves scapholunate joint of dorsal wrist

Epidemiology
 These arise in young to middle-aged adults
 They are 3 times more common in women than in men

Clinical Features
 The cyst is a unilocular of multilocular firm swelling 2–4 cm in diameter that transilluminates
 Cyst contents are mainly hyaluranic acid, a golden-colored goo

Lipoma
 Most common soft tissue tumor
 Slow growing, benign fatty tumor

Pathophysiology
 Can be subcutaneous, duodenal, colon, esophagus, stomach

Etiology
 Trauma
  Genetic, rearrangement of chromosome 12

Prognosis
 Excellent when removed

Clinical Features/Examination
 Soft, fluctuant, lobulated
 “slippage sign” - slip from under your finger

Differential Diagnosis
 Hibernoma
 Liposarcoma

Treatment
 Removal for cosmetic reasons

Consultation
 Dermatologist/General Surgery/Plastic Surgery