1. Identifying skin neoplasms benign vs. malignancy
Yi-Sheng Kam, D.O.
CPT MC USA Dept. of Family Medicine
Eisenhower Army Medical Center

2. Introduction Skin is largest organ system
Skin condition is one of the common complaint to office visit
Understanding from benign to malignant lesion
Incidence of skin cancer is increasing
Lack of evidence to support mass screening

3. History/questions Important question to ask for a new rash/lesion
How long?
Onset, and how is it now different?
Where? Site of onset and where is it now/evolution?
What treatments, and how did it response, this time and previously?
Symptoms with the lesion, such as itching or pain?
Anyone else affected or have a similar history?
Previous rash/lesion and treatment?
Anything new or different with medications, exposures, travel, heat, cold, stress, occupational/recreational or personal care products?
ROS if indicate for systemic disease

4. Describing primary lesions
Macula
Flat, non-palpable e.g Mongolian spots
Papule
Superficial, palpable, solid and less than 0.5cm diameter
Plaques
Plateau like elevation above skin surface occupying large surface, e.g psoriasis
Wheal (urticaria)
Round or flat topped, pale red papule or plaque, change in shape, disappear in 24-48hrs
Nodules and tumors
Palpable, solid, round or ellipsoidal and can involve anywhere of skin (epi/dermis and subcutaneous tissue)
Pustules
Circumscribed, superficial cavity that contains a purulent exudate
Vesicles (<0.5cm) and bulla (>0.5cm)
Circumscribed, elevated, superficial cavity containing fluid
Erosions and ulcers
Ulcer is a skin defect, loss of epidermis and upper papillary layer of the dermis
Erosion only involves epidermis

5. PHYSICAL EXAMINATION 
The most important and useful characteristics on an exam is the type of lesion and distribution of lesions
Type
Flat, elevated or depressed
Color and blanching
Consistency/palpation (soft, firm, hard, fluctuant, hot, cold, mobility, tenderness, depth of lesion)
Distribution
Extent: isolated, localized, regional, generalized, universal
Pattern: symmetrical, exposed areas, sites of pressure, intertriginous area
Shape (round, oval, polygonal, polycyclic, annular, serpiginous, umbilicated)
Arrangement of multiple lesions
Group: Herpetiform, zosteriform, arciform, annular, reticulated, linear, serpiginous
Disseminated: Scattered discrete lesions or diffuse

6. PHYSICAL EXAMINATION ABCDE rule A asymmetry B border C for color
D for diameter (size of a pencil eraser)
E for elevation
Changes; bleeds, fast growing, scaly or crusted growth, sore that won’t heal, itches

7. Basal Cell Carcinoma Basal cell carcinoma
Most common skin neoplasm and low metastatic potential,
Usually located on the face or the backs of the hands
Risk factors includes sun, Caucasians
Six types
Nodular (most common),pigmented, cystic, sclerosing, superficial and nevoid
Low risk if it is less than 1.5 cm in diameter
Prevention
Avoid sun exposure/burn, use sunscreen
Treatment-almost all curable
Surgical, cryotherapy, curettage, laser, referral

8. Actinic keratosis Actinic keratosis (solar keratoses)
Premalignant lesions arising from chronic sun-damaged areas (scalp, face, ears, bald scalp, fair skin)
Most does not progress to squamous cell carcinoma (SCC), 1/1000 but 60% of SCC are from actinic keratosis
Irregular, usually 2-5mm, scaly, flesh color to dark brown, macular or large hyperkeratotic or papule, often multiple lesion
Prevention
Avoid sun exposure/burn, use sunscreen
Treatment-curable
Surgical, liquid nitrogen, topical 5-fluorouracil or imiquimod

9. Squamous Cell Carcinoma
Squamous cell carcinoma (SCC)
Second most common skin cancer
Most common elderly, increase in light skinned, family history
Common on sun expose area
Up to 60% occurs at site of actinic keratosis
Chronic immunosuppression increases SCC (lesser extent BCC), other risk includes chronic inflammation or arsenic exposure
Moderate rapidly growing, nodular or papular, scaling, reddish-brown, pink or flesh colored, plaque, erythematous or eroded
Prevention
Avoid sun exposure/burn, use sunscreen
Treatment-almost all curable
Surgical and referral

10. Malignant Melanoma Most serious form of skin cancer
6 most common cancer in the United States
Prognosis depends on depth of the primary tumor, anatomic location, and presence and extent of metastatic disease
Radial growth phase
Primarily confined to the epidermis and divides into two
Malignant melanoma in situ (MMIS) is proliferation restricted to the epidermis
Microinvasive extend to dermis
Vertical growth phase
Invasive, extending deeply into the dermis
Metastasizes first to the regional lymph nodes and then to secondary sites, most commonly skin, subcutaneous soft tissue and anywhere like lung or brain.

11. Malignant Melanoma Four types Superficial spreading Irregular border
Most common, may develop anywhere on the body but appears with increased frequency on the upper backs and legs.
Associated with preexisting dysplastic nevus.
Irregular border
Ranging from a few millimeters to several centimeters
Nodular melanoma
Dark brown or reddish brown, dome-shaped, pedunculated or nodular lesion
Lentigo maligna melanoma
Horizontal or radial growth before vertical growth phase
Acral lentiginous melanoma (lease common)
Palmar and plantar , digits and the subungual areas , all ethnic groups
Appears as a dark brown to black, unevenly pigmented patch
Lesion becomes raised or develops ulceration likely invasion to deep tissues

12. Malignant Melanoma Treatment: Referral
Laser or other physical destruction should never be used
Excisional biopsy with a normal skin broader 1 to 2 mm
Follow in 3 months, 6months then yearly

13. Screening yourself Early detection, greater chance of cured
Self exam monthly
Examine entire skin surface from head to soles and palms with full length mirror and hand held mirror

14. UV expsoure
UV light exposure result in DNA damage, particular p53 tumor suppressor gene
UV B radiation 
Primary factor leading to SCC , basal and melanoma
UV A radiation
Associated with increase incidence of SCC, BC and aging
Tanning beds emits UV A
Pass through clouds and car window

15. Sunscreen protection Sunscreen
15-30minutes before exposure, SPF 30 or higher
SPF –sun protection factor
SPF 15 allows 15 times longer in the sun
Re-apply in 2hrs
One teaspoon rule:
face including ear and neck
front body
Back of body
Each arm or leg not covered with clothing
Damage protection 15=92%, 30=97%, 40=97.5%
Physical (barrier) both UVA/UVB -titanium dioxide, zinc oxide, talc
Can stain clothing
Chemical (absorb) suncreens
UV B radiation; para-aminobenzoic acid (PABA), salicylates, camphor derivatives, and cinnamates
UVB and UVA ; Benzophenones
Coppertone “shade” SPF45 sunblock with parsol
Neutrogena Ultra Sheer Dry-Sunblock

16. Benign neoplasms of skin
Nevus (mole)
Benign, can be acquired or sun exposure, peak in early adulthood
Most adult have about 20 nevi
Lesion usually <1cm, pigmented macules, papules or nodules
Evaluation of nevi from junctional (dermal-epidermal junction), compound (involves papillary dermis) and finally dermal nevi (into dermis, grows or remains intradermal).
Congenital nevi are presents at birth, usually not thought to be risk for melanoma .

17. Benign neoplasms of skin
Dysplastic or atypical nevi are pigmented lesions with irregular borders , colors ranging from red to brown to tan or black (less), typically flat but can be raised or palpable if large.
Large number to range to 100 nevi and strong family history of melanoma has high risk of developing to melanoma.
Halo nevi are pigmented nevi with surrounding white halo.
Unknown etiology, likely reactive against melanocytes.
Concern if multiple and adulthood; indicated for thorough skin indication.
Diagnosis clinical appears and dysplastic/atypical is confirmed on histology.
Treatment consist of elliptical entire pigmented excision

18. Benign neoplasms of skin
Acrochordons (skin tags)
Outgrowth of normal skin, usually occur in sites of friction like axilla, neck and inguinal. Increase over time and during pregnancy
Skin-colored, oval or round, pedunculated lesions on narrow stalks
Treatment: Excision, cryosurgery, electrodessication
Cheery Angioma (De Morgan spots)
Mature capillary proliferation, most commonly on trunk and bleed profusely if rupture.
Dome-shaped, cm diameter
Treatment: Cosmetic, shave excision and electrocauterization, laser (expensive)

19. Benign neoplasms of skin
Dermatofibroma
Firm, discrete cm, nontender, hyperpigmented nodules, commonly on lower extremities from repeat trauma.
Lesion dimples when pinched
Treatment
If symptomatic, bleeds, change size or color indicate for shave excision or cryosurgery

20. Benign neoplasms of skin
Lipoma
Most benign neoplasms, is collections of mature fat, occurs anywhere of the body.
Soft, rounded, moveable overlying skin, small but may enlarged >6cm
Treatment: Rapidly enlarging or firm biopsy is indicated. Surgery with removal of fat cells and fibrous capsule for cosmetic, pain or concerns.

21. Benign neoplasms of skin
Epidermal inclusion cyst
Most common cause of cutaneous cysts
Freely movable cyst/nodule, arising from epidermis or epithelium of hair follicle. Rupture is common and contains keratin and lipid.
Treatment: uninfected often resolve by itself and recur. Complete excision best not inflames, waiting for 4-6weeks. Drain and send for culture if infected.
Pyogenic granuloma (granuloma telangiectaticum)
Capillary proliferation, usually from trauma, more frequent during pregnancy at gingiva
Erythematous, dome-shaped papule that bleeds easily develop days to weeks.
Treatment: Cosmetic, bothersome and easily bleeds

22. Benign neoplasms of skin
Seborrheic keratoses
Common epidermal tumors from benign proliferation of immature keratinocytes, usually develop after 50
Sudden appearance of multiple has been associated with GI or lung cancer.
May be inherited AD, few to hundreds, start as macule with 1-3mm tan lesion early but can range from 1-6cm, classically “stuck on”, “greasy”, brown, flat or slightly raised, warty, scaly hyperpigmented lesion
Treatment: Cosmetic, concerns.
Liquid nitrogen but may not respond with thicker lesion.
Snip or shave excision
Electrocautry
Excisional biopsy into subcutaneous fat indicated if suspicion lesion

23. Benign neoplasms of skin
Venous lakes
Dilated capillaries on face, lips and ears of elderly, dark blue to violaceous, asymptomatic, soft papule and bleeds easily follow trauma.
Disappear when compressed and epiluminescence microscopy
Management is cosmetic with electrosurgery or laser, rarely surgical excision.

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