Benign and Pre-Malignant Skin Conditions.
These lesions can be broadly classified according to their tissue of origin:
1.) Epidermis (including melanocyte system).
2.) Epidermal appendages (hair structures, sebaceous glands, apocrine and
* The indications for treatment of these conditions depend on the following factors:
1.) Natural history of the lesion
As the potentiality for malignant transformation of some lesions as cong. Naevus, actinic keratosis, bowen’s tumor and naevus sebaceous of Jadassohn while
others could be destructive by rapid enlargement as keracanthoma.
2.) Lesion Size
Diffuse actinic keratosis is treated by topical 5-fluorouracil then by surgical excision and a large cong. Nevus is treated by expansion and excision.
3.) Functional Disturbances.
As benign lesions may compromise function by size alone.
4.) Anatomic Location and Cosmesis
Some lesions may be treated for cosmetic reasons while others may not be treated or ablated for cosmetic reasons.
5.) Masked Malignancy.
Congenital naevi in scalp are excised because surveillance of this site for cancer development is difficult on the other hand a cutaneous horn although not pre malignant it self but may arise from sq. carcinoma.
* Treatment method is selected based on the following:
1.) Lesion diagnosis and potential for malignant transformation.
2.) Location and size of lesion.
3.) Depth of skin involvement.
- Types of Treatment:
; Topical Medications:
- 5 fluorouracil 2% BID for 4 weeks for diffuse conditions.
- Podophyllin or salicylic acid for verrucae.
- used for histological examination and safe removal of superficial
with minimal scarring.
- used in actinic and seborrheic keratosis and verruca vulgaris.
- It is an excellent treatment for subungual verrucae.
- Liquid Nitrogen is ideal for warts, superficial keratosis and acitinic
- Permanent freeze damage to nerves may happen in fingers and over
- It is limited to clearly benign lesions.
- Rate of delivery of liquid nitrogen can be adjusted by altering the
degree of saturation and the applicator angle.
- It is used with caution in dark skinned patients as hypopigmentation
- Used for small cutaneous lesions and seborrheic keratosis, skin tags,
lentigines and spider neavi.
a) Shave Biopsy.
- Used for seborrheic or actinic keratoses and warts (changes are in
epidermis or papillary dermis.
- Not suitable for neoplasms infilterating dermis or pigmented lesions
with slight suspicion of melanoma.
- It removes the elevated portion of skin in exophytic lesions.
b) Punch Biopsy.
- It could be incisional or excisional.
- Done by circular cutting instrument from 1.5 to 6 mm.
- It should reach subcutaneous fat.
- Not suitable for melanomas.
c) Elliptic incisional / excisional biopsies.
- incisional biopsy with a margin of normal adjacent skin is used for
histological diagnosis in large lesions before definitive treatment.
- excisional biopsy is done in an elliptical fashion along the line of
d) Scissors removal.
- benign pedunculated lesions examples ( acrochordons , polypoid
are readily snipped off with scissors.
e) More complex excisions.
; Moh’s micrographic surgery.
- Used in Bowen’s Lesions to evaluate the surgical margins.
; Tissue expansion.
- Used in treatment of giant congenital naevi or large surface areas
; Facial cosmetic procedures.
- as face lift technique are used in cases of Von Becklinghausen’s
disease ( Neurofibromatosis)
- Epidermal Tumors
; Verruca Vulgaris ( Wart)
- Causes by papovavirus and transmitted by direct contact or
- Mic: hyperkeratosis, acanthosis and parakeratosis.
- Treatment: topical irritants, cryotherapy, excision or laser ablasion. - Since the basal epidermal layer is not invaded, re epithelialization
occur rapidly after curette.
- Subungual warts can be similarly treated after removal of sufficient
overlying nail plate to gain access to the wart.
; Seborrheic Keratosis.
- Seen in old patients.
- Related to sun exposure.
- Covered by greasy scale and appear to have been stuck on surface. - No malignat transformation.
- Occur in central areas of body, chest, back, neck, face, scalp and
- Irritation ? ? Keratinization.
- Examples: Dermatosis papulosa nigra in black
- Treatment; Curettage, shave biopsy, cryosurgery.
- Benign, self limited epithelial tumor occurring in sun exposed areas. - Resembles squamous cell carcinoma clinically and histologically. - Central umbilicated portion is filled with keratinous plug which
expelled causing spontaneous resolution in the regressive phase and
lesion heals with a scar.
- Evolution and regression of lesion is related to hair cycle. - Occasionally it has aggressive course with metastasis which cannot
be distinguished from squamous cell carcinoma if the central core is
not included in the biopsy.
- Treatment: a) complete excision if small.
b) spontaneous resolution may yield more favorable results
in widely proliferating lesions.
; Cutaneous Horn.
- Usually are actinic keratoses
- Up to 10% of patients have underlying squamous carcinoma. - Rarely arise from B.C.C.
- N.B. other epidermal lesions maybe sebaceous adenoma or Kaposi’s
; Actinic Keratosis. ( Senile keratosis or solar keratosis)
- Most frequent premalignant cutaneous condition.
- D.D: chronic eczematoid dermatitis, psoriasis, bowen’s disease and
- Squamous cell carcinoma develops in 20% of facial actinic keratosis. - Treatment: surgical excision, liquid nitrogen, superficial curettage,
light electrocautery and topical 5- fluorouracil.
- Lesion resistant to 5- fluorouracil may contain foci of squamous cell
; Bowen’s Disease
- It is considered carcinoma in situ, 10% become invasive after many
- Invasive squamous cell carcinoma arising from Bowen’s disease is
more aggressive than that developing from actinic keratosis and
metastasis occurs in at least ? of patients.
- It is related to old fair complexion, chronic sun exposure and arsenic
- D.D. superficial B.C.C, actinic keratosis, Paget’s disease, psoriasis,
licken simplex chronicus, verrucea, eczematous lesions and chronic
- Treatment: Excision or Moh’s micrographic surgical techniques.
; Erythroplasia of Querat.
- It is Bowen’s disease of the mucous membranes.
- It occurs in glans penis, adjacent mucosa in uncircumcised males and
- Rate of malignant transformation is higher than Bowen’s disease.
- Treatment: excision
; Paget’s disease.
- It is eczematous lesion of nipple, areola, and extra mammary areas as
vulva, scrotum, perianal region and in axilla where apocrine glands
- D.D. Psoriasis, eczema, Bowen’s disease and malignant melanoma.
- Treatments:*In Breast-?excision if no palpable mass.
?similar to breast carcinoma if there is a
*Extramammary? wide excision with careful search of
* Moh’s micrographic surgery may be indicated.
* Prognosis of extramammary pagets is much less favorable
when underlying carcinoma is present.
; Other epidermal Conditions.
These lesions require total excision to provide cure.
; Giant condyloma acuminatum.
- It is fungating growth of uncircumcised prepuce.
- It is locally destructive ?ulceration and urethral fistulas.
- It may transform into verrucous squamous cell carcinoma. ; Epidermodysplasia verruciformis.
- Wart like lesion on the face, neck, hands, feet and trunk. - Caused by human papillom virus( HPV-3, HPV-5)
- Degenerate into squamous cell carcinoma.
- T-cell formation is defective.
- Hereditary disseminated annular plaques with sharply raised horny
- 13% transform into B.C.C.
- Most common is porokeratosis of Mibelli.
; Epithelial Cysts. ( inclusion or keratinous cysts)
- Arise from occluded pilosebaceous follicles.
- Treatment: Complete Excision.
; Pilar Cysts.
- Arise from outer root sheath of hair follicle in scalp. - D.D. epidermal inclusion cysts.
- Treatment: Excision.
- Tiny (1mm to 2mm) epidermal cysts on the face.
- Arise denovo or after burn or dermabrasion.
- Post traumatic milia is self-limited or incision of the top of the lesion
and expressing the contents.
; Dermoid Cysts.
- Present since birth along the lines of embryonic fusion. - Treatment: Excision.
- Midline dermoids needs pre-operative CT scan to identify
communication with the central leptomeninges.
- Tumors of epidermal appendages.
- Rare tumors.
- Most benign tumors of this group is not pre malignant except naevus
sebaceous of Jadassohn.
- Treatment: Excision except in trichoepithelioma and syrigoma as
they are numerous.
; Pilar differentiation
; Pilomatricoma or calcifying epithelioma of Malherbe. - Solitary tumor on face, neck or upper extremities of young adults. - Treatment: surgical excision.
- Solitary facial papule or rarely as multiple in Cowden Disease. - It is keratosis on the distal extremities, mucosal papillomas, and
fibromas, and internal organ involvement as thyroid, GIT, ovaries
and breasts with increased incidence of breast cancer. ; Trichoepithelioma
- Solitary or multiple.
- Multiple form is an autosomal dominant concentrating in the
nasolabial folds, forehead, upper lip and eye lids.
- D.D. adenoma sebaceum, syringoma, basal cell nevus syndrome and
- Treatment: removal but it is difficult in multiple lesions.
; Sebaceous Gland Differentiation.
; Nevus sebaceous of Jaddassoh ( organoid naevus). - Present since birth.
- Sites: scalp, face, neck, trunk and limbs.
- In young patients: it is a patch of alopecia with a smooth surface and
yellow brown waxy appearance.
- In puberty: it becomes verrucous with papillomatous projections. - It is hemartomatous conglomerate of large sebaceous glands with
heterotopic apocrine glands and defective hair follicles. - Changes to: apocrine carcinoma or basal cell carcinoma. - Treatment: excision.
; Sebaceous adenoma.
- If associated with tuberous sclerosis ? angiofibromatous
- If multiple and associated with multiple kerato acanthomas ?
Torre’s syndrome with internal malignancies.
; Sweat Gland Differentiation.
- Eccrine hidrocystoma.
- Eccrine spiradenoma
- Eccrine poroma.
- Tumors of Melanocyte System.
(A) Arising from nevus cells.
- Nevi are the most common tumors.
- Most nevi in younger patients are junctional, by adulthood most are
- Compound nevi have nevus cells in both dermoepidermal junction
and the dermis.
- The junctional component may transform into malignant melanoma. - Malignant transformation is suggested by the following:
； Spontaneous ulceration and bleeding.
； Enlargement and darkening.
； Spread of pigment from lesion into surrounding skin.
； Pigmented satellite lesions.
； Inflammatory changes without trauma.
； Pain and itching.
- Treatment: No treatment except for cosmetic purposes ? excision.
If melanoma is suspected ? definitive surgical ablation.
; Halo nevus.
- Depigmented halo surrounding a central nevus usually on the back. - Treatment: complete excision especially when diagnosis is in
; Spindle and epithelioid cell nevus ( benign juvenile melanoma and
- D.D. melanoma.
- Incidence of malignant transformation is like compound nevi. - Treatment: excision.
; Congenital nevus.
- Incidence of malignant transformation 12% to malignant melanoma. - Treatment: total excision in stages with or without expansion.
; Dysplastic Nevus Syndrome
- Multiple a-typical nevi on the upper trunk.
- Charateristic lesion measures approximately 1 cm in diameter with
irregular outline and variegated colorations of brown, black and pink.
- Mic. pic. is characteristic
- Treatment: observation carefully with excision of suspicious lesions.
; Lentigo Maligna ( Hutchison’s melanotic freckle).
- It is melanoma in situ.
- Transformation to melanoma occurs in 30-50 %.
- Treatment: Excision
(B) Arising from melanocytes
; Lentigines ( freckles )
- Benign multiple small flat pigmented lesion result from increased
- Treatment is not necessary or light electrodesiccation of liquid
- Multiple lentigines syndrome (LEOPARD) syndrome is autosomal
dominant with lentigines, ECG conduction defects, occular
hypertelorism, pulmonary stenosis, genital abnormalities, growth
retardation, sensorineural deafness, and café au lait spots.
; Blue Nevus
- It results from arrested migration of dermomelanocytes in embryonic
- Treatment: excision
; Nevus of OTA
- It is unilateral proliferation of dermamelanocytes in the distribution
of the first and second branches of the trigeminal nerve. - It is a bluish black discoloration affecting the skin of the eyelid and
adjacent face, forehead, sclera, conjunctiva, tympanum, auditory
canal, and mucous membranes of the nose and mouth.
- Treatment is not needed.
- If it involves the deltoid region it is called the nevus of Ito.
; Mongolian spot
- It is a variably sized bluish black patch over the lower back and
buttocks in infants.
- It regress in early childhood, treatment is not indicated.
- Tumors of mesodermal origin
; Acrochordon (Skin tag)
- Multiple papillomatous lesions that occur in the neck, upper chest
- Symptoms result from irritation or twisting if pedunculated?
- Treatment: tangential scalpel removal or with scissors.
- Common lesion
- Papule or nodule on the extremities.
- Freely movable in relation to S.C. tissue.
- It exhibit depressed central umbilication.
- D.D. malignant melanoma.
- Treatment: excision.
; Dermatofibrosarcoma protuberans
- It is a malignant form of fibrohistiocytic.
- Reccurency is high.
- It arises from dermis of the trunk and proximal extremities with deep
infiltration of S.C. fat and even skeletal muscle.
- Treatment: wide and deep excision with skin grafting.
- It is solitary or multiple (Von Recklinghausen’s disease).
- The peripheral and cranial nerves are involved with café au lait spots.
; Granular cell tumor ( granular cell myoblastoma).
- It is derived from Schwann sheath.
- It occurs in the tongue, over the head and neck region.
- It affects skin and S.C. tissue and deeper tissues like lung, GIT, heart.
- 3% are malignant.
- Treatment: surgical excision.
; Infantile digital fibromatosis.
- It occurs in the hands, and feet.
- They are a-symptomatic but may cause functional impairment and
- 60% experience tumor reccurency after excision.
- They don’t metastasize and occasionally regress spontaneously.
- Treatment: complete excision or observation if it is not metastasizing
or regressing spontaneously.
; Xeroderma Pigmentosum.
- It is a genodermatosis autosomal recessive defect in which the
deoxyribonucleic acid (DNA) repair mechanism for UV light
induced damage is impaired, skin and eyes are intolerant of UV.
- Exaggerated sunburn reaction occurs with intensely pigmented
- Skin thickens, cutaneous and S.C. atrophy occurs.
- Xerodermic idiocy is a severe case with progressive neurologic
- Multiple malignant epithelial tumors and melanomas occur? death.
- No treatment except protective measures against sun and treatment
malignant cutaneous lesions.
; Basal cell nevus syndrome (Gorlin’s syndrome)
- It may become invasive to BCC.
- It occurs throughout the body, jaw cysts with skeletal abnormalities
(eg. bifid ribs, scoliosis, brachymetacarpalism, overdeveloped
supraorbital ridges), broad nasal root, hypertelorism, palmar and
plantar tips, calcification of falx cerebri, mental impairment and
; Other syndromes
- Bazex syndrome (paraneoplastic acrokeratosis).
- Haber’s syndrome.
- Dyskeratosis congenita.
- Rothmund- Thomson syndrome.
-Non- hemangiomatous vascular lesions
; Pyogenic Granuloma
- It is a proliferation of capillaries at the site of trauma.
- Infection may occur.
- Treatment: Excision, electro surgery, CO2 laser, silver nitrate cautery.
- Incomplete removal ? recurrency.
; Glomus Tumor.
- It arises from specialized arteriovenous shunts.
- It is derived from smooth muscle cells.
- It occurs in nail beds and on pulp of the finger tips.
- Treatment: excision of the subungnal lesions and anatomic resulting
of the longitudinal nail bed incision.