Index

Benign skin diseases

Seborrhoeic keratosis
Most commonly arise in patients over the age of 50 years, often idiopathic
Equal sex incidence and prevalence
Usually multiple lesions over face and trunk
Flat, raised, filiform and pedunculated subtypes are recognised
Variable colours and surface may have greasy scale overlying it
Treatment options consist of leaving alone or simple shave excision

Melanocytic naevi

Congenital Typically appear at, or soon after, birth

melanocytic naevi Usually greater than 1cm diameter
Increased risk of malignant transformation (increased risk greatest
for large lesions)

Junctional Circular macules

melanocytic naevi May have heterogeneous colour even within same lesion
Most naevi of the palms, soles and mucous membranes are of this
type

Compound naevi Domed pigmented nodules up to 1cm in diameter

Arise from junctional naevi, usually have uniform colour and are
smooth

Spitz naevus Usually develop over a few months in children

May be pink or red in colour, most common on face and legs
May grow up to 1cm and growth can be rapid, this usually results in
excision

Atypical naevus Atypical melanocytic naevi that may be autosomally dominantly

syndrome inherited
Some individuals are at increased risk of melanoma (usually have
mutations of CDKN2A gene)
 Many people with atypical naevus syndrome AND a parent sibling
with melanoma will develop melanoma

Epidermoid cysts
Common and affect face and trunk
They have a central punctum, they may contain small quantities of sebum
The cyst lining is either normal epidermis (epidermoid cyst) or outer root sheath of hair follicle
(pilar cyst)

Dermatofibroma
Solitary dermal nodules
Usually affect extremities of young adults
Lesions feel larger than they appear visually
Histologically they consist of proliferating fibroblasts merging with sparsely cellular dermal
tissues

Painful skin lesions

Eccrine spiradenoma
Neuroma
Glomus tumour
Leiomyoma
Angiolipoma
Neurofibroma (rarely painful) and dermatofibroma (rarely painful)
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Treatment of suspicious skin lesions

Skin lesions may be referred to surgeons for treatment or discovered incidentally. The table below
outlines the various therapeutic options:

Method Indication

Tru-cut Most often used for percutaneous sampling of deep seated lesions or used intra
biopsy operatively for visceral lesions

5mm punch Used for diagnostic confirmation of lesions that are suspected to be benign or
biopsy where the definitive management is unlikely to be surgical. Of limited usefulness in
pigmented lesions where they do not include sufficient tissue for accurate diagnosis.
May be used in non melanoma type skin disease to establish diagnosis prior to
more extensive resection.

Wide Where the complete excision of the lesion (with healthy margins) is the main
excision objective. In cosmetically sensitive sites, or where the defect is large, this may need
to be complemented with plastic surgical techniques

Incisional Used mainly for deep seated or extensive lesions where there is diagnostic doubt
biopsy (usually following core or tru-cut biopsy). Used rarely for skin lesions.

Diagnostic Primarily used for lesions that are suspicious for melanoma, the lesion is excised
excision with a rim of normal tissue. Excision of margins may be required subsequently.

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Skin disorders in surgery- malignancy and related lesions

Non melanoma skin cancer (BCC and SCC) are some of the commonest types of human malignancy.
Up to 80% of these are BCC's with approximately 20% comprising SCC's. The incidence of NMSC's
increases with age and whilst there is a female preponderance in those under 40 years of age, in
latter life the sex incidence is roughly equal.
The vast majority of NMSC's are related to UV light exposure. For SCC's the major pattern is in
chronic long term exposure. For BCC's, the pattern of sporadic exposure with episodes of burning is
more important. Organ transplant recipients have a markedly increased incidence of SCC, risk factors
include length of immunosuppression, ethnic origin and associated sunlight exposure. Human
papilloma virus DNA is found in the majority of transplant recipient SCC's. In addition to this
increased risk, transplant recipients are also more likely to develop locoregional recurrences following
treatment.

Actinic keratosis and SCC

Actinic keratosis is viewed as a premalignant lesion because there are atypical keratinocytes present
in the epidermis. In a person with 7 actinic keratosis the risks of subsequent SCC is of the order of
10% at 10 years. The primary lesion is a rough erythematous papule with a white to yellow scale.
Lesions are typically clustered at sites of chronic sun exposure.

Squamous cell carcinoma in situ

Also known as Bowens disease the commonest presentation of in situ SCC is with an erythematous
scaling patch or elevated plaque arising on sun exposed skin in an elderly patient. Lesions may arise
de novo or from pre-existing actinic keratosis.
Pathologically there is full thickness atypia of dermal keratinocytes over a broad zone. Nuclear
pleomorphism, apoptosis and abnormal mitoses are all seen.

Invasive SCC
The commonest clinical presentation of SCC is with an erythematous keratotic papule or nodule on a
background of sun exposure. Ulceration may occur and both exophytic and endophytic areas may be
seen. Regional lymphadenopathy may be present.
Pathologically there is downward proliferation of malignant cells and invasion of the basement
membrane. Poorly differentiated lesions may show perineural invasion and require
immunohistochemistry with S100 to distinguish them from melanomas (which stain strongly positive
with this marker).
Basal cell carcinoma

Nodular BCC Commonest variant (60%)

Raised translucent papule
Usually affect the face
Large nodular BCC's are locally destructive

Superficial BCC Usually appears as superficial erythematous macule affecting the trunk
Younger age at presentation (mean 57)
May show areas of spontaneous regression
Horizontal growth pattern predominates
High recurrence rate (due to sub clinical lateral spread)

Morpheaform BCC Macroscopically resembles flat, slightly atrophic lesion or plaque

without well defined borders
Tumour has sub clinical lateral spread which increases recurrence rates

Cystic BCC Often have clear or blue - grey appearance

Cystic degeneration may not be clinically obvious and tumour may
resemble nodular BCC

Basosquamous Atypical BCC

carcinoma Basaloid histological BCC features with eosinophillic squamoid features
of SCC
Biologically more aggressive and are more locally destructive
Rare lesion accounts for 1% of all non melanoma skin cancers
Metastatic disease may occur in 9-10% of cases and resemble an SCC

Keratoacanthoma
Dome shaped erythematous lesions that develop over a period of days and grow rapidly. They often
contain a central pit of keratin. They then begin to necrose and slough off. They are generally benign
lesions although some do view them as precursors of malignancy. They may be treated by curettage
and cautery. If there is diagnostic doubt (they can mimic malignancy) then formal excision biopsy is
warranted.

Pyogenic granuloma
These present as friable overgrowths of granulation at sites of minor trauma. They may be ulcerated
and bleeding on contact is common. They may be treated with curretage and cautery, formal excision
may be used if there is diagnostic doubt.
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Sebaceous cysts

Originate from sebaceous glands and contain sebum.

Location: anywhere but most common scalp, ears, back, face, and upper arm (not palms of the
hands and soles of the feet).
They will typically contain a punctum.
Excision of the cyst wall needs to be complete to prevent recurrence.
A Cock's 'Peculiar' Tumour is a suppurating and ulcerated sebaceous cyst. It may resemble a
squamous cell carcinoma- hence its name.

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Skin Diseases

Skin lesions may be referred for surgical assessment, but more commonly will come via a
dermatologist for definitive surgical management.

Skin malignancies include basal cell carcinoma, squamous cell carcinoma and malignant melanoma.

Basal Cell Carcinoma

Most common form of skin cancer.
Commonly occur on sun exposed sites apart from the ear.
Sub types include nodular, morphoeic, superficial and pigmented.
Typically slow growing with low metastatic potential.
Standard surgical excision, topical chemotherapy and radiotherapy are all successful.
As a minimum a diagnostic punch biopsy should be taken if treatment other than standard
surgical excision is planned.

Squamous Cell Carcinoma

Again related to sun exposure.
May arise in pre - existing solar keratoses.
May metastasize if left.
Immunosupression (e.g. following transplant), increases risk.
Wide local excision is the treatment of choice and where a diagnostic excision biopsy has
demonstrated SCC, repeat surgery to gain adequate margins may be required.

Malignant Melanoma

The main diagnostic features (major criteria): Secondary features (minor criteria)
Change in size Diameter >6mm
Change in shape Inflammation
Change in colour Oozing or bleeding
Altered sensation

Treatment
 Suspicious lesions should undergo excision biopsy. The lesion should be removed completely as
incision biopsy can make subsequent histopathological assessment difficult.
Once the diagnosis is confirmed the pathology report should be reviewed to determine whether
further re-excision of margins is required (see below):

Margins of excision-Related to Breslow thickness

Lesions 0-1mm thick 1cm

Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)

Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)

Lesions >4 mm thick 3cm

Marsden J et al. Revised UK guidelines for management of Melanoma. Br J Dermatol 2010 163:238-
256.

Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block
dissection of regional lymph node groups should be selectively applied.

Kaposi Sarcoma
Tumour of vascular and lymphatic endothelium.
Purple cutaneous nodules.
Associated with immuno supression.
Classical form affects elderly males and is slow growing.
Immunosupression form is much more aggressive and tends to affect those with HIV related
disease.

Non malignant skin disease

Dermatitis Herpetiformis
Chronic itchy clusters of blisters.
Linked to underlying gluten enteropathy (coeliac disease).

Dermatofibroma
Benign lesion.
Firm elevated nodules.
Usually history of trauma.
Lesion consists of histiocytes, blood vessels and fibrotic changes.
Pyogenic granuloma
Overgrowth of blood vessels.
Red nodules.
Usually follow trauma.
May mimic amelanotic melanoma.

Acanthosis nigricans
Brown to black, poorly defined, velvety hyperpigmentation of the skin.
Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin,
umbilicus, forehead, and other areas.
The most common cause of acanthosis nigricans is insulin resistance, which leads to increased
circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth
(hyperplasia of the skin).
In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is
then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes
is rare and suggests a coexisting malignant condition.
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