1. SKIN AND SOFT TISSUE CONDITIONS
LESSON 5
SKIN AND SOFT TISSUE CONDITIONS
Inflammatory conditions, Neoplasms, Others

3. OBJECTIVES By the end of this lesson, you should be able to:
Describe rare infections of the skin
Classify neoplasms of the skin
Describe the main types of Benign growths of the skin
Describe the main vascular lesions of the skin
List premalignant lesions of the skin
Describe the major malignancies of the skin – BCC, SCC, MM
Describe cystic lesions of the skin
List other lesions of the skin

4. Rare infections of the skin
Fourniers gangrene
Hydradenitis suppurativa
Lupus Vulgaris

5. Fourniers Gangrene
Neclotising fasciitis (meleney’s streptococcal gangrene)
Causes destructive invasive infection of the skin, subcutaneous tissue and deep fascia with relative sparing of muscle
Caused by either polymicrobial involving anaerobes and facultative species such as coliforms or non gp A strep or monomicrobial due to beta haemolytic strep
Common site is groin, genitalia, lower abdomen
Treatment – Wide excision, antibiotics

6. Hydradenitis suppurativa
Chronic suppurative process caused by apocrine gland hyperplasia
Common in 2nd and 3rd decades of life; F>M
Common site is axillae; also groin and perineum
Due to destruction from keratin plug leading to rupture into dermal and epidemal region and subsequent superinfection
Can present with severe pain
Treatment – metronidazole or erythromycin for long period can be curative
Surgical excision and skingrafting if conservative fails

7. Lupus vulgaris TB of the skin Commonest in 10-25 yr of age
Common site – face, appear as brownish nodes (apple-jelly) followed by ulceration, slow
Blood expressed shows TB tubercles
Mucous membranes of mouth & nose may be affected
Treatment is anti TB or surgical excision if healing delays
Sq cell carcinoma can occur on lupus scars

8. NEOPLASMS Neoplasms are abnormal growths of the skin
They are classified into: -
Benign growths
Premalignant growths
Malignant grwowths

9. Benign Growths Congenital Naevi (birth marks) Keratin Horns
Saborrhoeic Keratosis
Dermatofibroma
Molluscum fibrosum
Pilomatrixoma
Sabeceous adenoma
Cylidroma
Rhinophyma

10. Congenital naevi
Congenital (verrucous, epidermal) naevi are common entities which may single or multiple
They appear at birth or in early childhood
They are warty growth of brownish colour
A bit large horny excrescences may also occur

11. Keratin horn A papilloma with excess keratin formation
Seen in old people
Saborrhoeic keratosis
Also called basal cell papilloma, seborrhoeic wart or senile wart
Caused by overgrowth of epidermal keratinocytes
Usually in large numbers and pigmented
Occur on trunk, face and arms
In middle life or elderly
F=M, usually not seen as a disease and therefore not mentioned. Treatment is by curretage, diathermy or shave excision

12. Dermatofibroma (fibroma)
Also called sclerosing angioma, histiocytoma, fibroma simplex, subepidermal nodular fibrosis
Occurs on the skin as a firm indolent, single or multiple nodules
May follow minor trauma or insect bites which initiate tissue reaction
Usually in extremities
In all age after puberty with M=F
Small, well defined nodule, touching the epidermis
Treatment is by Excision

13. Molluscum fibrosum
Polypoid or filiform soft freshy skin tags that occurs on the neck, trunk or face
Associated with seborrhoeic warts
Frequently pendiculated, round, soft, elastic frequently pigmented lesions
Treatement is by excision or cautery

14. Rhinophyma “Potato nose” This is a glandular form of acne rosascea
The skin of the nose becomes markedly thickened and sabeceous follicles opening are easily seen
Capillaries become dilated and the nose assumes a bluish-red colour
It can rarely be a basal cell carcinoma
Treatment is by surgery to improve the condition

15. Vascular lesions
Structural and morphological anomalies due to faulty embryological morphogenesis
Present at birth, grows with the child and does not regress
Can lead to underlying soft tissue or bone hypertrophy
They are grouped into:
High-flow – arterial malformations, AV malformations
Low-flow – lymphatics, venous, capillary, combined
Ectasias – Telengenctasia ( spider naevi)

16. Miscallaneus vascular lesions
Pyogenic granuloma – arise from minor trauma, acquired, vascular lesion of the skin and mucus membrane. Look like haemagiomas
Macular stains – salmon patch, present at birth over the fore head in the midline and over the occiput; disappear by age 1 yr

17. Benign Pigmented lesions
1. Simple melanocytic tumour
Derived from neurocrest cells
Increased melanocytes from benign pigment naevi which include
Lentigo – in basal cell layer of epidermis
Junctional naevi – localized aggregations projecting into the dermal
Dermal naevi – entirely within the dermis
Compound naevi – features of both junctional and dermis naevi

18. Café au lait spots
Light brown flat macules that are of often apparent at birth
Solitary lesion or increased numbers in syndromes such as neurofibromatosis and albrights syndrome

19. Premalignant lesions Actinic Keratosis Bowen’s disease
Erthyroplastic of Querat ( Bowen’s disease of the grans penis)
Radiodermatitis
Chronic scars
Sabeceous epidermal naevus
Porokeratosi

20. Actinic Keratosis Also known as senile keratosis, solar keratosis
Formed by areas of epidermal dysplasia giving rise to cutanous scaling usually observed in sun-exposed fair skin
Potentially malignant
Solitary lesion should be excised
Multiple lesions might clear with 5-fluorouracil

21. Bowen’s disease
Intraepidermal squamous cell carcinoma that is potentially malignant and appears as a persistent, progressive flat red scaly or crusted plaque
Mostly found in the elderly
Triggered by solar radiation
Untreated, 3-5% will develop invasive squamous cell carcinoma
Treatment is by complete excision

22. Erythroplasia of Querat
Bowen’s disease of the penis
Occurs usually in uncircumcised males
Radiodermatitis
Due to excessive exposure to X-ray irradiations
Presents with early erythema which progresses to desquamation and pigmentation
Eventually leads to squamous cell carcinoma

23. Chronic scars Carcinoma develops in a chronic scar
Referred to as Majolin’s ulcer
Grows slowly, relatively avascular
Painless since the scar contains no nerves
No secondary lymph nodes deposit until it spreads to normal tissue

24. Sabeceus Epidermal naevus
Frequently affecting the scalp
Initially appears as a raised papular yellow areas developing into a papillomatous area as the child matures
10% developes into basal cell carcinoma
Treatment is complete excision

25. Porokeratosis Characterized by annular plaques with horny borders
13% may transform into basal cell carcinoma

26. Malignant Lesions Basal cell carcinoma Squamous cell carcinoma
Virrucous carcinoma
Kerato acanthoma
Malignant melanoma

27. Basal cell carcinoma (rodent’s ulcer)
Commonest kind of skin cancer
Commonly affects ages 40-79yr
>50% affects males
85% affects neck region
Arises from pluripotent basal layer of dermis and hair follicles
Metastasis is rare
Presents as spots which do not heal
Has nodular appearance with rolled edges

28. BCC cont… Classified into: - Nodular – 50-54% Superficial – 9-11%
Cystic - 4-8%
Pigmented – 6%
Morpheic – 2%
Treatment of choice is by surgical excision (85-95% success)
Other modes of treatment are Electrodessication and curretage(85-100% success, radiotherapy (92% success since BCC is very radiosensitive

29. Squamous cell carcinoma (SCC)
Arises from areas with premalignant lesions or chronic irritation
More inflammatory and indurated than BCC
Squamous layer of the skin is involved in development of cancer
Related to radiation with UV light
Follows chronically ulcerated lesions and scars
Metastasis is mainly via lymphatic to regional nodes
Treatment of choice is surgical excision.
Radiotherapy can be used for large unresectable tumours

30. Verrucous carcinoma
These are well differentiated SCC which invade locally but rarely metastasize
Commonly occurs in palms of the hands and the soles of the feet where they are referred to as carcinoma ciniculatum

31. Malignant Melanoma
This a pigmented malignant tumour arising from epidermal melanocytes
Described by Hippocrates in 5th century BC
1/3 to ½ develop in premalignant lesions or areas of chronic irritation
It has no sex predilection
Commonest site is the sole of the foot
May also occur in the eye, mucocutaneus junctions
Risk factors – albinism, tropical climate, life style, poor socioeconomic status, Xeroderma pigmentosa, Hutchinson’s freckles

32. Malignant melanoma cont…
4 parameters of histological grading
Depth
Ulceration
Mitotic rate
Regression

33. Malignant melanoma cont….
Clinical features
Clinically presents in 5 types
Superficial spreading – commonest 64%
Nodular – most malignant – 12-25%, in young
Acral-lentiginous
Amelanotic – occurs in palms, sores and subungual regions – worst prognosis, may be pinkish or hypopigmente, may present with regional lymph nodes
Lentigo maligna – least common 7-15%

34. Malignant melanoma cont…
Unknown before puberty
Development of malignancy in a mole should be suspected if the following signs occur: -
Major signs – Change in size, shape or colour
Minor signs –inflammation, crusting or bleeding, sensory change eg itch, diameter >5mm
Spread is via: -
Local spread
Lymphatics – by embolism or permeation
Haematogenous spread – to lung, liver, brain, skin, small intestines – secondary sites deposits are back in colour

35. Malignant Melanoma cont….
Treatment
Treatment of choice is surgical – wide excision with a margin of normal tissue of 1-2cm – do not excise beyond the deep fascia
Regional node dissection of involved – diagnosis by FNAC recommended
Malignant Melanomas in children are very rare

36. Other malignancies affecting the skin
Dermatofibroma protuberans
Kaposis sarcoma
Angiosarcoma
Lymphagiosarcoma
Primary cutaneous malignant lymphoma
Merkes cell tumour
Metastatic malignant tumours

37. Other lesions of the skin
Cysts
Epidermoid cysts (sebaceous cyst)
Pilar cyst
Implantation dermoid cyst
Callosity
Corn
Warts
Venereal warts and moist warts

38. Epidermal Cysts (sebaceous cysts)
Cysts containing keratin and its breakdown products surrounded by a wall of stratified sq keratinized epithelium
Have a punctum
Inherited in autosomal dominant fashion
Common sites – face, neck, shoulder and chest
Can be solitary but often are multiple
Suppuration may occur if superinfected
May form “sebaceous horn” if content slowly leaks
Treatment – Excision but when inflammed – I&D
May recur if not completely excised

39. Implantation Dermoids
Pilar cysts
Multiple lumps in the scalp
Have no punctum
Histologically – similar to external root of the hair follicle
Implantation Dermoids
From deep implantation of a fragment of dermis by penetrating injury
Traumatic inclusion cysts may appear on the palmar surface of the hand, buttock or knees

40. Callosity
Localized thickened or hardened patches of hyperkeratinized skin. Acquired, superficial, circumscribed yellowish-white lesions
Occurs at pressure areas or friction areas of the hands, feet. Not painful. Require no treatment
Corn
Horny induration of the curticle with a hard center caused by undue pressure. Chiefly found on the toes and feet.
Treatment is by surgical excision or application of abrasive chemical e.g. 50% podophyllin

41. Venereal Warts and Moist wart
A viral induced tumour that undergoes spontaneous resolution. Contangious, usually in immunosuppressed patient
Tends to affect areas of trauma e.g beard, genitalia, hands, feet
Have no 100% cure – Curretage, diathermy, or 50% podophyllin can be used
Venereal Warts and Moist wart
Referred to as papillomata accuminata
Warty papillomatous lesions occuring at most areas of the genitalia

42. Conclusion Rare infections of the skin Neoplasms of the skin Benign
Vascular lesions
Premalignant
Malignant – BCC, SCC, MM
Cysts
Other lesions

43. 4/14/2017