Benign Neoplasms, Hyperplasias and Pigmentary Disorders - Exam 2

Question 1

How are seborrheic keratosis commonly described?

Answer 1

There can be few or hundreds of these raised, “stuck-on”-appearing papules and plaques with well-defined borders

aka can also look crusty

Question 1

Where on the body are seborrheic keratosis commonly found?

Answer 1

benign neoplasms of the epidermis that typically appear on the chest and the back

very common

Question 2

What am I? How are they inherited?

Answer 2

seborrheic keratosis

autosomal dominat

Question 3

What is the relationship between SKs and age? What do they typically start out as? What happens when SKs get irritated?

Answer 3

SKs tend to increase in incidence and number with increasing age

They may start out as a flat wrinkled plaque with a “postage stamp” appearance

with irritation or trauma: they may become pruritic or painful with associated redness or bleeding

Question 4

A ____ is an inflamed seborrheic keratosis that presents as a pink shiny papule or plaque with an appearance that resembles that of a nodular or cystic basal cell cancer

Answer 4

lichenoid keratosis

Question 5

What is dermatosis papulose nigra?

Answer 5

papular seborrheic keratoses (most often seen as dark brown 1-3 mm papules) on the face of individuals with darker skin phototypes

Question 6

What does a relatively rapid onset of numerous SKs indicate?

Answer 6

may be a cutaneous sign of internal malignancy.

Question 7

**What is the sign of Leser-Trelat?

Answer 7

**Multiple eruptive SKs in association with a visceral cancer

**adenocarcinoma of the gastrointestinal tract

Question 8

Waxy, “stuck-on,” verrucous-appearing papules or plaques
Color is variable and may range from skin-colored, pink, light brown, yellow-brown, and brownish-black to black.
Pigmentation may be variable within a single lesion
Scratching the surface usually shows a scaling, rough appearance
well-circumscribed

What am I?

Answer 8

seborrheic keratosis

Question 9

What is the technical term for a skin tag? Where are the MC locations?

Answer 9

acrochordon

most commonly around the neck or in the axillae

Question 10

How can the classic “stuck-on” appearance of an SK be best appreciated? What does it look like if you removed the coarse, waxy scale? Will SKs continue to keep growing?

Answer 10

transilluminate them

show a raw, moist base

NO! grow rapidly and reach a static size without further growth.

Question 11

Ridges, fissures, white pinpoint milia-like cysts, and comedo-like openings, all better visualized with non-polarized dermoscopy of _____ skin lesion.

Answer 11

Seborrheic keratosis

Question 12

In seborrheic keratosis: the ridges and fissures together form a ____ pattern. Describe the vascular pattern. Will SKs have sharp borders?

Answer 12

cerebriform

The vasculature pattern most commonly demonstrated is looped, or hairpin, vessels

YES! borders are sharply demarcated

Question 13

How are Seborrheic Keratosis dx?

Answer 13

clinical but can bx if concerned for malignancy

Question 14

Sharply demarcated proliferation of monotonous epidermal keratinocytes.
Flat, exophytic or endophytic.
Small keratin-filled cysts (ie, horn cysts) present within the tumor

This is a histopathology report of _____.
Is there any cancerous potential?

Answer 14

Seborrheic Keratosis

no cancerous potential

Question 15

What is the pt education associated with seborrheic keratosis?

Answer 15

Patient reassurance regarding the chronic and benign nature of these lesions is key

only need additional follow up if multiple erupt -> concern for cancer

Question 16

What are the therapy options for SKs in patients who choose to tx them?

Answer 16

Cryosurgery

Curettage and cautery

Chemical peels for small and superficial ones

laser therapy

shave excision can be used for larger lesions

Question 17

What causes melasma? Where is the MC body location?

Answer 17

Acquired light or dark brown pigmentation that occurs in exposed areas by the sun

MC on the face (malar and frontal areas)

Question 18

What are the risk factors for melasma? Who is the MC pt?

Answer 18

Pregnancy (“mask”)
Genetics
Idiopathic
Sun exposure
Ingested contraception
Medications (diphenylhydantoin)

females in hot climates

Question 19

What is the tx for melasma?

Answer 19

Tri-Luma QHS for 6-8 weeks and need to apply GOOD sunscreen

laser

Question 20

What are the components of Tri-Luma? When is it used?

Answer 20

Fluocinolone 0.01%
Hydroquinone 4%
Tretinoin 0.05%

tx for melasma

Question 21

What are the 3 pt education points for melasma?

Answer 21

Avoidance of sun

Sunscreen >30 spf re-apply q 80 min

Remove estrogen exposure

Question 22

What sunscreen ingredients provide the best coverage?

Answer 22

Titanium dioxide and zinc oxide (best coverage)

Question 23

What am I? What is the underlying cause?

Answer 23

solar lentigo

“sun spots”

Localized proliferation of melanocytes resulting from acute or chronic exposure to sunlight

Question 24

How big are the normal solar lentigo? What is the MC age? What skin type?

Answer 24

1-3 cm Onset = >40 years old caucasians: skin type 1 and 2

Question 25

Light yellow, light brown, or dark brown (variegated) Round, oval, with slightly irregular borders and ill defined on sun exposed sites What am I? What is the tx?

Answer 25

Solar Lentigo tx: light cryo or laser therapy

Question 26

Skin colored, brown, round or oval Pedunctulated papiloma What am I? What size? What is the MC patient?

Answer 26

Acrochordon (skin tag) Usually constricted at the base >1mm – 10mm MC in middle aged and elderly obese females in the intertriginous areas

Question 27

What are some common locations for acrochordon? What 2 other conditions are also seen with it?

Answer 27

MC in intertriginous areas Axillae Inframammary Groin Neck Eyelids Seen in Acanthosis Nigricans and Metabolic Syndrome

Question 28

What 2 things cause an increase in acrochordon? What is the tx?

Answer 28

increase in time and during pregnancy tx: Snipping Electrodesiccation Cryo -> need to freeze both sides of the stalk

Question 29

______ is a a collection of keratin and lipid rich debris in an epithelial sac within the dermis. What are the 2 etiologies?

Answer 29

Epidermal Inclusion Cyst 1. plugged pilosebaceous units 2. traumatic implantation of epidermal cells into deeper tissues

Question 30

What is the MC pt type for epidermal inclusion cyst?

Answer 30

males between 30 and 50 years old

Question 31

What am I? What will the pt complain of? What areas of the body are involved?

Answer 31

Epidermal Inclusion Cyst Asymptomatic unless inflamed or infected MC on face, trunk, neck, scrotum

Question 32

flesh colored, round, firm nodules +/- central pore/punctum contents is malodorous “rancid cheese” What am I? How do you dx?

Answer 32

Epidermal Inclusion Cyst can be a clinical dx if textbook presentation C&S if infected

Question 33

When would you need to do imaging or FNA in an epidermal inclusion cyst?

Answer 33

if atypical location (breast, bone)

Question 34

What is the tx for an epidermal inclusion cyst?

Answer 34

no treatment unless cosmetic concern then I&D +/- abx or surgical excision

Question 35

What are the 3 types of surgical excision for an epidermal inclusion cyst? What is the goal? When should it be performed?

Answer 35

punch, minimal incision or elliptical excision technique goal: complete removal of cyst sac when the cyst is NOT inflammed

Question 36

When should you consult general surgery for an epidermal inclusion cyst? Will the cyst remain constant or change?

Answer 36

when the cyst is in an atypical location asymptomatic cysts may wax and wane with periods of inflammation

Question 37

Do epidermal inclusion cyst have the potential to become malignant?

Answer 37

rarely but yes, watch for rapid growth, friability, bleeding

Question 38

______ is a benign collection of fat cells inside thin fibrous capsule. What is the age of onset?

Answer 38

Lipoma Onset MC between 40-60 y/o

Question 39

What is the MC soft tissue tumor? Where are the MC locations?

Answer 39

lipoma trunk, UE

Question 40

soft, painless, slow growing, subcutaneous nodules 1-10 cm in size rubbery on the trunk and UE What am I? How do you dx? What is the tx?

Answer 40

lipoma clinical dx surgical excision

Question 41

What am I? Where are the MC locations? What age range?

Answer 41

venous lake face, lips and ears > 50 years old

Question 42

_____ is a dark blue violaceous, asymptomatic, soft papule resulting from a dilated venule. How many do you typically see at a time? How long do they last?

Answer 42

venous lake Lesions are few in number and remain for years

Question 43

What is the underlying cause of a venous lake?

Answer 43

Dilated cavity is lined with a single layer of flattened endothelial cells filled with red blood cells and surrounded by thin wall of fibrous tissue

Question 44

How will the venous lake change when compressed? How will it appear with diascopy?

Answer 44

When you press down on a venous lake, you'll see the bluish-purple color lighten or disappear as the blood drains out, and the lesion will flatten or become less noticeable ^same way to say lighten with diascopy

Question 45

What are the tx options for a venous lake? Do you have to tx them?

Answer 45

Cosmetic reasons only: Electrosurgery Laser Surgical excision

Question 46

______ pruritic, raised, well-circumscribed areas of erythema and edema

Answer 46

urticaria

Question 47

What is the pathogenesis of urticaria? What is the underlined phrase?

Answer 47

mast cells and basophils release vasoactive substances (histamine, leukotriene C4, prostaglandins) resulting in *extravasation of fluid into the dermis*

Question 48

What are the 5 different types of urticaria?

Answer 48

type I allergic IgE response complement-mediated physical mediated autoimmune idiopathic

Question 49

What type of urticaria? foods, meds, insect bite/sting, latex, contact allergen

Answer 49

type I allergic IgE response

Question 50

What type of urticaria? infectious, serum sickness, transfusion reaction

Answer 50

complement-mediated,

Question 51

What type of urticaria? pressure urticaria, cold urticaria, cholinergic urticaria

Answer 51

physical mediated

Question 52

What type of urticaria? SLE, RA, thyroid autoimmune d/o

Answer 52

autoimmune

Question 53

What are the 2 different timeframes for urticaria?

Answer 53

acute: less than 6 weeks: think infection or allergy chronic: recurrent, most days of the week, > 6 wks: think physical or autoimmune

Question 54

raised, erythematous-pink-skin colored wheals with central pallor shape and size change rapidly +/- dermatographism What am I? **When should the lesions resolve?

Answer 54

urticaria **resolves within 24 hours

Question 55

What is the management for acute urticaria?

Answer 55

emergency department eval triple regimen therapy: H1 + H2 + steroid is often recommended

Question 56

loratadine(Claritin) desloratadine(Clarinex) fexofenadine(Allegra) cetirizine(Zyrtec)

Answer 56

Second gen. antihistamines (first line): What are the first line agents in the H1 antihistamine drug class?

Question 57

diphenhydramine (Benadryl) hydroxyzine (Vistaril)

Answer 57

What are the 2nd line agents in the H1 antihistamines? first gen antihistamines- H1

Question 58

cimetidine(Tagamet) famotidine(Pepcid) ranitidine(Zantac)

Answer 58

What are the medications in the H2- antihistamine drug class?

Question 59

____ MOA stabilize mast cell membrane, inhibits further histamine release

Answer 59

steroids prednisone

Question 60

What is the management of chronic urticaria?

Answer 60

antihistamines prn refer to dermatology for further evaluation/management identify and avoid cause

Question 61

_____ is a rapidly developing vascular lesion usually following minor trauma. How common is it?

Answer 61

pyogenic granuloma very common to have 1

Question 62

Smooth +/- crusts +/- erosions Bright red Dusky red Violaceous Brown-black papule Erodes Vascular bleeds spontaneously What am I? What is the rx?

Answer 62

pyogenic granuloma sx excision Electrodesiccation and Curettage

Question 63

What am I? What can it be mistaken for?

Answer 63

Pyogenic Granuloma amelanotic nodular melanoma

Question 64

____ is the MC tumor in babies. What is it composed of? What is it NOT?

Answer 64

amelanotic nodular melanoma endothelil hyperplasia NOT a vascular malformation

Question 65

When does a hemangioma start to form? MC in males or females? Where are the 2 MC locations?

Answer 65

Starts 2-4 weeks of age more common in females MC on head and neck

Question 66

What are the 4 types of hemangiomas?

Answer 66

simple deep multiple congenital

Question 67

When does a simple hemangioma resolve?

Answer 67

Resolve on own by year 5-10

Question 68

What is a deep hemangioma?

Answer 68

Lower dermis and subq fat / bluish w/ telangiectasias

Question 69

What size are multiple hemangiomas typically?

Answer 69

Small <2mm papules (entire body)

Question 70

What is a congenital hemangioma?

Answer 70

Present at birth Purplish/telangiectasia/large veins

Question 71

**Why are deep and multiple hemangiomas a problem? What diagnostic tests should you order?

Answer 71

OBSTRUCT VITAL FUNCTIONS!!! VISION LARYNX NOSE MOUTH MRI TO EVAL DOPPLER AND ARTERIOGRAPHY TO SEE BLOOD FLOW

Question 72

What is the tx for hemangioma? What is the first line tx?

Answer 72

**Propranolol** first line refer to cardiology to monitor prednisone 2-3mg daily for 6-12 weeks can also do laser surgical options, topical timolol

Question 73

______ is a depigmenting disorder characterized by a patchy absence of melanocytes. What is the underlying cause?

Answer 73

vitiligo a depigmenting disorder characterized by a patchy absence of melanocytes

Question 74

What is the onset of vitiligo? What races does it affect?

Answer 74

½ of all cases begins between 10-30 years of age affects all races!! but reported and treated more frequently in races of darker skin complexion

Question 75

__% of vitiligo patients have a first degree relative with vitiligo. How is it transmitted?

Answer 75

> 30 likely a polygenic transmission

Question 76

What are the 3 theories about the mechanism of destruction of melanocytes in vitiligo?

Answer 76

autoimmune neurogenic self-destruction

Question 77

pathogenesis of vitiligo: _______ Selected melanocytes are destroyed by certain lymphocytes that have been activated for unknown reasons.

Answer 77

autoimmune

Question 78

pathogenesis of vitiligo: _______ Interaction of the melanocytes and nerve cells

Answer 78

neurogenic

Question 79

pathogenesis of vitiligo: _______ Melanocytes are destroyed by toxic substances formed as part of normal melanin biosynthesis

Answer 79

self-destruction

Question 80

individual “chalk” white macules with sharp margins Painless and without pruritus Often seen first in sun-exposed areas What am I? How large are the macules?

Answer 80

vitiligo 5 mm to 5 cm or larger

Question 81

What is the Koebner phenomenon?

Answer 81

May report new vitiligo macules in areas of recent trauma

Question 82

in vitiligo, may see loss of color to _____, _____, and _____ overlying areas of depigmented skin

Answer 82

mucosal membranes, retina or hair

Question 83

What are the 4 presentation types of vitiligo? Which one is MC?

Answer 83

generalized**- MC segmental localized Vitiligo Universalis

Question 84

Type of vitiligo presentation: ______ Symmetrical with widespread distribution. “Lip-tip” pattern involves skin around mouth, fingers and toes, as well as nipples and genitalia

Answer 84

generalized- MC

Question 85

Type of vitiligo presentation: ______ Only one side or part of body in one band that do not extend beyond the initial one-sided region. Younger age, taking 1-2 years to progress, then stops

Answer 85

segmental

Question 86

Type of vitiligo presentation: ______ Focal to only 1-3 macules in a single sight

Answer 86

localized

Question 87

Type of vitiligo presentation: ______ Confluence of macules resulting in only a few pigmented areas.

Answer 87

Vitiligo Universalis aka mostly depigmented

Question 88

What type of vitiligo is one sided and common in younger pts?

Answer 88

segmental

Question 89

How do you dx vitiligo? What will a skin bx show?

Answer 89

clinical dx normal skin with lack of melanocytes

Question 90

What is the pt education for vitiligo?

Answer 90

NO CURE!! ⅓ of patients may report a few areas of spontaneous repigmentation sunburn precautions!! SPF >30 recommended

Question 91

What are some tx options for vitiligo?

Answer 91

Topical Glucocorticoids: Intermittent application of high potency steroid for single or few macules, but if no response in 2 months, discontinue Topical Photochemotherapy: topical 8-methoxypsoralen (8-MOP) and UVA

Question 92

If no response, when should a pt stop applying high potency steroids for vitiligo?

Answer 92

but if no response in 2 months, discontinue

Question 93

What are the 2 components of systemic photochemotherapy in vitiligo? When is it used?

Answer 93

Oral 8-MOP and UVA therapy Treatment for 1 year with poor results for “lip-tip” distribution. Genitals shielded and not treated

Question 94

What is the tx of choice for vitiligo in kiddos older than 6?

Answer 94

Narrow-band UVB

Question 95

______ is also done in the management of refractory vitiligo and involves small skin grafts taken from normally pigmented skin

Answer 95

Minigrafting