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DERMAL AND SUB DERMAL LESIONS Dr M Kanagavel DNB Surgery MRCS Edin Faculty and Consultant Department of General, GI and Minimal Access Surgery (Accredited.

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Presentation on theme: "DERMAL AND SUB DERMAL LESIONS Dr M Kanagavel DNB Surgery MRCS Edin Faculty and Consultant Department of General, GI and Minimal Access Surgery (Accredited."— Presentation transcript:

1 DERMAL AND SUB DERMAL LESIONS Dr M Kanagavel DNB Surgery MRCS Edin Faculty and Consultant Department of General, GI and Minimal Access Surgery (Accredited by The National Board of Examinations) St Isabel Hospital Chennai –

2 This Presentation: Overview of Dermal and Subdermal Lesions Define the Lesion Types: –Benign Nodular Lesions –Papules and Plaques –Pigmented Lesions –Subepidermal Lesions –Benign Dermatoses –Malignant Lesions Surgical Treatment and Biopsy Surveillance and Follow-up

3 The Microscopic Architecture

4 Gross morphologic terms Blister - Nonspecific term for fluid-filled lesion (see vesicle or bulla) Bulla - Fluid-filled lesion >5 mm in greatest dimension Erosion* - Loss of epidermis Excoriation - Lesion of traumatic nature with epidermal loss in a generally linear shape Lichenification * - Grossly thickened, leathery, hyperpigmented skin with hyperkeratosis and deep,

5 Gross morphologic terms Macule - Flat circumscribed area demarcated by color from surrounding tissue Nodule - Solid raised discrete lesion >5 mm in both diameter and depth Onycholysis – Separation of the nail from the nailbed Papule - Solid raised discrete lesion 5 mm Pedunculated - Attached to its base by a stalk- like structure Plaque - Flat but elevated area, usually >5 mm

6 Gross morphologic terms Pustule - Small pus-filled elevated area of the skin with discrete borders Ulceration* - Loss of epidermis with partial-to-complete loss of dermis Seborrheic - Related to excessive secretion of sebum Sebum - Thick, greasy substance secreted by sebaceous glands that consists of fat and cellular debris Sessile - Attached directly to the skin by a broad base; not pedunculated Vesicle - Fluid-filled lesion 5 mm

7 Skin Lesions

8 Histologic definitions Acantholysis - Dissolution of intercellular integrity with fragmentation of epidermis Acanthosis - Hyperplasia of epidermal layer Dyskeratosis - Abnormal keratinization occurring prematurely in cells below the stratum granulosum Erosion* - Loss of epidermis Exocytosis - Infiltration of epidermis by inflammatory cells

9 Histologic Definitions Hyperkeratosis (keratosis) - Thickening of the stratum corneum (the outermost layer of the epidermis) with excess abnormal keratin Lichenification * - Hyperplasia of all compartments of the epidermis with acantholysis and papillomatosis

10 Histologic Definitions Papillomatosis - Hyperplasia of the papillary dermis and lengthening and/or widening of the dermal papillae Parakeratosis - Persistence of the nuclei within the cells of the stratum corneum of the epidermis as seen in psoriasis Spongiosis - Edema limited to the epidermis Ulceration* - Loss of epidermis with variable partial-to-complete loss of dermis

11 Definitions Acral - Related to the extremities and the more distal parts of the body Actinic – Relating to biochemical changes in the skin produced by sunlight energy from both the visible and ultraviolet rays

12 History Duration Mode of Onset Associated Symptoms –Pain Nature Site Time of Onset –Progression –Exact Site

13 History –Systemic Symptoms –Presence of Other lumps –Secondary Changes –Impairment of Function –Recurrence –Body Weight –Personal Hsitory

14 Physical Characteristics Characteristics outside of the lesion Physical characteristics of the lesion Histologic characteristics of the lesion

15 Physical Examination - Inspection Site Size Shape and Extent Surface Edge Number Pulsation Peristalsis Surrounding Structures

16 Examination - Palpation Signs of Inflammation Site Size Shape and Extent Surface Edge Consistency Number Pulsation / fluctuation Fluid Thrill Translucency Cough Impulse Reducibility Compressibility Fixity to Overlying Skin Relation to Surrounding Structures Pressure Effect Examination of nearby joints

17 Examination Auscultation Percussion

18 Characteristics outside the lesion The characteristics outside of the lesion refer to the attributes and condition of the patient beyond the skin lesion itself.

19 Papules and Plaques

20 Acrochordon Soft, common, benign, usually pedunculated neoplasm It is usually skin colored or hyperpigmented, surface nodules or papillomas 2-5 mm in diameter, although larger measure up to 5 cm Neck and the axillae, but any skin fold, including the groin, may be affected.

21 Keratoacanthoma They are hemispheric shaped with a keratin- filled crater and overhanging edges

22 Pyogenic Granuloma is a rapidly proliferating solitary lesion of mostly disorganized vascular growth known for its bleeding tendencies. Also known as a cutaneous ectasia, it is commonly associated with minor previous trauma to the area

23 Sebaceous Horn – Cornu cutaneum is a skin lesion made of compacted keratin that forms an exophytic conical projection Actinic keratoses, Seborrheic keratoses, benign verrucae, inverted follicular keratoses, and sqaumous cell carcinoma

24 Keloid fibrotic, papular lesions that usually occur as an aberrant healing response to cutaneous injuries, such as acne, trauma, surgery, and piercing earlobes, chest, lower legs, upper back, and jaw line. unlike hypertrophic scars, grow beyond the borders of the original scar. pruritus, pain, and, occasionally, a burning sensation.

25 Seborrhiec keratosis greasy appearance and prevalence in regions of the body with a high concentration of sebaceous glands (ie, face, shoulder, chest, back).

26 Subepidermal Lesions

27 Sebaceous Cyst Blocked Sweat Gland Punctum Skin at the summit not pinchable

28 Dermoid Cyst

29 Retention Cyst

30 Lipoma


32 Neurofibroma

33 Pyogenic Granuloma

34 Traumatic Hematoma Implantation Dermoid

35 Inflammatory Erysipelas Cellulitis

36 Abscess Pyogenic Pyemic Cold

37 Furuncle Carbuncle Carbuncle

38 Moles Hairy Mole Non Hairy Mole Blue Naevus Junctional Naevus Compound Naevus Juvenile Mole Hutchisons Freckle (Lentigo)

39 Melanocytic Naevus

40 Neoplasm - Malignant Basal Sell Ca – Rodent ulcer

41 Wart Overgrowth of Skin with hyperkeratosis

42 Callosity / Corn

43 Bowens Disease Velvetty, flat lesions Clear margin Premalignant Ca in situ

44 Vascular Lesions Hemangiomas, Kaposiform hemangioendothelioma (KHE), Tufted angiomas (TA), Pyogenic granulomas, Hemangiopericytomas, and other rare lesions.

45 Vascular Tumor/Infantile HemangiomaVascular Malformations Proliferative 30% visible at birth 70% become apparent during first few weeks of life Female to male ratio 3:1 Rapid postnatal growth followed by slow involution Endothelial cell proliferation Increased mast cells No coagulation abnormalities High percentage respond dramatically to corticosteroid treatment in 2 to 3 weeks Immunopositive for biologic markers (including GLUT1)

46 Hemangiomas

47 Vascular Malformations Congenital malformations of capillaries, veins, lymphatic vessels, or arteries. They may also exist as a combination of different types of vessels (eg, the arteriovenous malformation).

48 Classification These malformations may further be –High-flow –Low-flow lesions based on the vessel type.

49 Lymphatic Classification The lymphatic lesions may be further divided into macrocystic and microcystic based on the size of the cystic components within the lesion.

50 Vascular Malformations Vascular malformations are congenital, meaning that they are present at birth. Most are diagnosed during infancy, although some are noticed later in childhood. In the case of a lymphatic malformation that presents after viral upper respiratory infection.

51 Vascular Malformation Congenital abnormality with proportional growth No gender predilection May expand secondary to sepsis, trauma, or hormonal changes Normal endothelial cell turnover Normal mast cell count Do not involute Localized consumptive coagulopathy possible Low-flow: phleboliths, ectatic channels High-flow: enlarged, tortuous vessels with arteriovenous shunting No response to corticosteroids or antiangiogenic agents Immunonegative for hemangioma biologic markers

52 Venous Malformations Composed of ectatic, poorly organized venous channels that have normal endothelium and lack the normal smooth muscle architecture that usually surrounds veins. Malformations are low- flow lesions.

53 Lymphatic Malformations Present at birth and lined by nonproliferating endothelium. They may occur anywhere in the body, although the head and neck region is most commonly affected. Lymphatic malformations are low-flow lesions and may exist as combinations of lymphatic and venous vessels, in which case they are termed venous- lymphatic malformations

54 Arteriovenous malformations Arteriovenous malformations (AVMs) are high-flow lesions that allow shunting of blood from the arterial system directly into the venous system. It is thought that they are residual from failure of primitive vascular communications to obliterate. In addition, these lesions share the ability with other vascular malformations to expand rapidly with infection, trauma, or hormonal disturbance.

55 Investigations General Specific FNA Exfoliative Cytology Skin Testing Ultrasound CT Biopsy –Drill / Punch –Incisional –Excisional –Punch

56 Planning Excision




60 Vascular Lesions

61 Welcome to 5 th ISABEL SURGICAL REVISION COURSE th Sunday 2013 St Isabel Hospital Auditorium in alliance with ASI – Chennai City Section

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