DERMATOLOGYPart 3

Samantha Dye &

Salwa Elmamoun

ANGIOMA (Campbell de Morgan)

• Various kinds

• Collections of aberrant blood vessels within dermis +/or S/C tissue

• In some ‐ developmental defects present from birth

• In others – develop as an adult

• E.g. CAMPBELL DE MORGEN SPOTS

PYOGENIC GRANULOMA

NEUROFIBROMATOSIS• TYPE 1 – Autosomal dominant inheritance, described below

• TYPE 2 – Bilateral 8th nerve tumours, no skin or skeletal lesions, CNS tumours common

•• SKIN LESIONS – Café au lait spots (>5), axillary freckling, subcutaneous

neurofibroma, mollusca fibrosa (pink cutaneous fibromas), plexiform neuroma

• SKELETAL – Kyphoscoliosis

• EYES – Optic Glioma decreases visual acquity, fundal changes, iris nodules

• HEARING – Decreased due to Acoustic Neuroma

• BP – Raised if Renal Artery Stenosis or more rarely Phaechromocytoma

• NEUROLOGICAL COMPLICATIONS – CNS tumours

ERYTHEMA NODOSUM• SITE – typically shins, occasionally thighs

• DESCRIPTION – Tender, red, raised lesions 2‐6 cm in diameter

CAUSES INCLUDE

• Sarcoidosis

• Inflammatory Bowel Disease

• Streptococcal Infection

• Drugs (Sulphonamides, Penicillin, Oral Contraceptive)

• Primary TB

• Pregnancy

• Rheumatic Fever

DERMATITIS HERPETIFORMIS• Pruritus associated with grouped erythematous papules and vesicles

• Sites – Elbows

– Extensor surfaces of forearms

– Knees + shins

– Buttocks

– Shoulders

– Scalp

• Uncommon; associated with Gluten‐sensitive Enteropathy (Coeliac’sDisease)

• Tx ‐ Dapsone

‐ Sulphapyridine

‐ Gluten‐free diet

VITILIGO PITYRIASIS• Can occur anywhere, often on hands face and neck, and dorsum of feet

• Symmetrical patches of depigmentation with hyperpigmented borders

CAUSES

• Associated with organ specific autoimmune disorders– Thyroid disease

– Pernicious anaemia

– Addison’s disease

– Diabetes mellitus

– Alopecia areata

– Chronic active hepatitis

– Primary biliary cirrhosis

– Fibrosing alveolitis

ERYTHEMA MULTIFORME• SITE – limbs and trunk, classically back of hands, forearms, feet and toes

• DESCRIPTION – red papules with central pallor – ‘target lesions’, bullae can develop within the lesions

CAUSES

• Unknown in 50%

• Infection – Herpes simplex, Mycoplasma pneumonia

• Drugs – Sulphonamides, Penicillin

• Connective tissue diseases

• Neoplasia

• Steven Johnson syndrome is a severe form, with widespread bullous eruptions and orogenital ulceration. It is potentially life‐threatening.

URTICARIA• Characterised by the formation of weal swelling of the skin which

disappear leaving no visible sign

• Dermal oedema due to vascular dilatation, often in response to histamine released from mast cells

• Clinical features – the skin itches or stings, weals develop, white at first, then pink with a white rim

Hypertrophic scars + keloids

• Keloid – an overgrowth of fibrous tissue within a scar; often itch

• Suspect in black patients with recent operations

• Follow cuts, ear‐piercing, burns, acne, BCG

• Sites – Chest, upper back, shoulder, pubic region, ear lobes

• DD – any soft tissue tumour

HYPERTROPHIC KELOID

INCIDENCE More common Less common

RACE ASSOCIATION No Yes

EXTENT Confined to scar Into surrounding area

SPONTANEOUS RESOLUTION

Yes – months No

RECURS No Yes

Predisposing factors for skin cancer

• AGE

• SUNLIGHT (UVR)

• IONISING RADIATION

• CHEMICAL IRRITANTS (e.g. Soot, dues, tar)

Basal Cell carcinoma (BCC)• ‘Rodent ulcer’ – small rounded pink pearly edge

• Commonest malignant skin tumour

• Most begin as a nodule, which spreads slowly outwards, usually leaving a central depression (Creates the classical ‘rolled edge’)

• Tumours are usually skin coloures with a translucent look (‘pearly’)

• Telangiectatic vessels on surface are v. characteristic

• An ulcerated lesion with a rolled edge, a pearly glistening pink tinge + telangectasia (new vessels) on surface

BCC cont...

• Clinical Variants of BCC

BCC cont...• Frequent PC – contact bleeding

• Mets v. rare but local invasion is destructive ( can spread along bony passages to skull)

• DD ‐ Naevi

‐ Inflammatory (if superficial BCC)

‐ Melanoma (if heavily pigmented)

• Tx ‐ Excision (with margins), biopsy + Radiotherapy

‐ Curettage or Cryotherapy (for superficial tumours)

‐ Microscopically controlled surgery’ (for morphoeic tumours)

SOLAR KERATOSIS

• Areas of Dysplastic Squamous Epithelium without invasion

• Have low‐grade malignant potential – unstable epithelium

• Red, scaly patches that characteristically wax + wane with time

• Can get 100’s of lesions in heavily sun‐exposed areas

• Sites – Light‐exposed areas e.g. Face, forearms, dorsa of hands, lower legs + bald scalp

• DD – Lentigo Maligna (if pigmented)

• Tx ‐ Cryotherapy (best for small numbers of lesions) ‐ Topical anti‐mitotic agent 5‐fluorouracil (For large areas on face +

scalp)‐ Do nothing in very elderly

Squamous Cell Carcinoma (SCC)

SCC in situ (Bowen’s Disease)

• Solitary patch of red, scaly skin; although multiple areas may occur

• Similar changes in one nipple ? Paget’s Disease

• Tx ‐ Curettage or Cryotherapy

‐ Radiotherapy (if very large areas)

SCC cont...Invasive SCC• A cutaneous ulcer that is classically irregular, raised +

everted, with a red‐brown colour, due to vascularity

• Locally invasive + may metastasise to regional LN + beyond esp. Lip, mouth + genitalia)

• Clinical features – may be v. varied:1. A keratotic lump2. A rapidly growing polypoid mass3. A cutaneous ulcer

SCC cont...• SCC is often surrounded by actinic keratoses

• Sites ‐ sun‐exposed sites

‐ mouth + lips

‐ genitalia

• DD – Keratotic lesions may closely resemble hypertrophic actinickeratoses

• Tx ‐ Biopsy of any suspicious lesion

‐ Definitive Tx is by Surgical removal or Radiotherapy

LENTIGO MALIGNA• A patch of malignant melanocytes, in sun damaged skin, which proliferate

radically along the dermoepidermal junction, often for many years

• Invasive component may develop at any time

TREATMENT– Biopsy is essential

– Excision preferred as it reduces the recurrence when compared toCryotherapy

– In elderly do nothing

MALIGNANT MELANOMA

FEATURES SUGGESTING MALIGNANCY IN A PIGMENTED NAEVUS

• Itchy

• Colour change

• Increase in size

• Ulceration

• Bleeding

• Halo of pigmentation

• Satellite lesions

• Enlarged local lymph nodes

• Distant spread

The most dangerous of the malignant skin tumours

Typically affecting younger patients then SCC and BCC

DIAGNOSIS AND PROGNOSIS

• Related to Breslow thickness

• If tumour < 1.5mm at 1st excision 5 year survival is 90%

• If tumour > 3.5mm at 1st excision 5 year survival is 40%

TREATMENT

• Excision and biopsy to confirm diagnosis

• Aim to eradicate by wide local excision and nodes

• Cytotoxic drugs and radiotherapy for palliation

PREVENTION

• Avoid sunburn

• Avoid midday sun (between 11am and 3pm)

• Or wear adequate clothes and sunblock

MANAGEMENT OF MALIGNANT MELANOMA

DERMAL MALIGNANT TUMOURS

• Malignant sarcomas may develop in skin

• Indolent, slow‐growing nodules, which become fixed to deeper tissues

KAPOSI’S SARCOMA• Type of Dermal Malignant Tumour – vascular

• Classically in Ashkenazi Jews + Northern Italians

• More aggressive in Africans + AIDS patients

• Purpilish plaques + nodules

• Tx ‐ Biopsy

‐ Symptomatic Tx with radiotherapy

LYMPHOMAS• TYPE OF DERMAL MALIGNANT TUMOUR

• May be secondary, for example in Non‐Hodgkins B cell lymphoma

• Or Primary especilly in CUTANEOUS T CELL LYMPHOMA (‘MycosisFungoides’)

• Variable in size, some areas remain unchanged or grow slowly for years

• Red, well circumscribed, scaly plaques and tumours eventually develop

• DD – Eczema and Psoriasis

• Tx – biopsy is essential, definitive treatment varies with the stage but includes Radiotherpay, PUV and Chemotherapy

DERMATOMYOSITIS

• Vasculitis associated with malignancy

• FEATURES:– Heliotrope erythema – red, purple

– Peri‐orbital oedema

– Erythema on dorsum of hands

– Linear erythema on dorsa of fingers

– Erythematous papules over knuckles

– Prominant ragged cuticles + dilated capillaries in proximal nail folds

– Erythema over hands + knees

With thanks to the authors and publishers:

Robin Graham‐Brown, Tony Burns. Lecture Notes on Dermatology, 7th Ed. UK: Blackwell Publishing Ltd, 1996 – (Images from pages 26, 30, 40, 57, 80, 90, 120, 123, 126, 127,133, 135, 136, 138, 139, 153, 154, 162, 197, 201, plus purple tables and boxes from pages 130, 140, 137, 138, 140, 203)

JAA Hunter, JA Savin, MV Dahl. Clinical Dermatology, 2nd Ed. UK: Blackwell Publishing Ltd, 1996 – (Images from pages 68, 110, 152, 153, 157, 160,162, 173, 174, 179,180, 198, 199, 221, 222, 223, 227, 230, 232, 242, 243, 130)

All images are copyright and reproduced by kind permission of the authors and publishers