A 2 month old boy was taken to the physician to discuss the following birth mark. His mother wanted to know if besides disfiguring, there was any harm in leaving the mark on her son's leg. What, if any, risks are associated with such large nevi?
Large congenital nevi:
"Bathing trunk nevi"
~10% risk of developing melanoma
A woman comes into the dermatologist concerned about the following mark on her arm. She has heard that it could be melanoma. What types of features would the physician look for to be concerned about melanoma?
Rate of conversion to melanoma: < 1 in 200,000 for people < 40, 1 in 33,000 for people > 60 years
UV exposure--> blistering lesions (history of multiple burns in early life)
- One blistering sunburn--> doubles risk
- Intermittent exposure hypothesis (infrequent, heavy sun exposure)
- light skin
- Blond/red hair
- Blue/green eyes
- Prominent freckling
Clark/dysplastic/atypical melanocytic nevi
- Larger than 5 mm with irregular borders
- 10-15% melanoma patients have positive family history
- Younger first-degree relative ex: 40 year old brother (not 85-year old grandmother)
ABCDE of Melanoma:
A: Asymmetry – one half is not identical to the other half
B: Border – irregular, notched, scalloped, ill-defined
C: Color – Varying shades from one area to the next
D: Diameter – > 6 mm or pencil eraser
* Other reasons for changes in mole:
- Hormonal influence
- Natural evolution
Below is a histologic specimen from an atypical colored patch on a woman's arm. What types of changes have occured and what would be visible on the surface?
Melanoma: Atypical distribution of epidermal cells, nuclear and cellular atypia, hyperplastic growth
Light source, magnification, polarization (dermatoscopy- below)
Useful adjunct to H&E diagnosis of melanoma
- Poorly differentiated tumors
- Little or no pigment
- Spindle cell tumors
- + pagetoid spread --> not clearly melanoma
- Most sensitive and specific
- Cellular enlargement
- Nuclear enlargement
- Nuclear pleomorphism
- Hyperchromasia of nuclei
- Nucleolar variability
- Poor circumscription
- Variation in size of nests of melanocytes in the lower epidermis and dermis
- Lack of maturation of nests with descent into the dermis
- Pagetoid spread
A 67 year old woman with a history of repeated sunburns as a child and adolescent comes to her physician because of changes in a mark on her cheek. What is her diagnosis and what caused these changes?
Lentigo maligna melanoma:
Represents up to 15% of cutaneous melanomas
- Diagnosed most frequently in the 7th-8th decade of life
- Arises in a precursor lesion termed lentigo maligna
- 5% of lentigo malignas progress to invasive melanoma
Pathogenesis: cumulative sun exposure
- Found on chronically sun-damaged skin
- Head and neck
- Preference for the nose and cheek
- Slow growing
Appearance: Ill-defined, asymmetric, brown to black macule with color variegation and an irregular border
* Both LM and LMM more difficult to excise because of ill-defined margins
Least association with nevi
- Background: solar elastosis, melanophages, atrophic epidermis with effaced rete-ridges, uneven pigmentation (foci of solar lentigo or solar keratosis frequent), and melanocytic hyperplasia
- Uneven distribution and increase in number of melanocytes in the lower 1/3 epidermis (significant scatter infrequent); at the periphery solitary melanocytes (multinucleation common) frequently predominate over nests making it difficult to assess the boundaries of the neoplasm
- Lentigo maligna melanoma: if melanocytes are found in the dermis
- Atypia ranges from subtle to marked
A man came in for an annual physical and his physician noted a mark on his back (below). The physician asked if he had always had this mark and he denied seeing it before, though he didn't spend much time examining the skin on his back. Why is the physician concerned and what could it be?
Superficial spreading melanoma:
Most common subtype:
- Account for 70% of all melanomas
- Diagnosed most often between the ages of 30 and 50 years
Occurs at any site, most frequently:
- Trunk of men
- Legs of women
- Slowly changing from months-years
- Brown to black macule with color variegation and irregular, notched borders
- Best fits the ABCD criteria
- When enters radial growth phase--> papule or nodule
** Can arise de novo or in a pre-existing nevus
Melanocytes present at all levels of the epidermis:
- “pagetoid” cells in “pagetoid” spread (AKA scatter or buckshot effect)
intraepidermal component is prominent
- “radial horizontal growth phase” neoplastic cells confined to epidermis and papillary dermis
A 68 year old man of Chinese descent comes to his physician for plantar warts on his feet that won't go away. On exam the physician notes the atypical discoloration of the warts and suspects it may be something else. A biopsy is taken. What would you expect to see in the lesion?
Acral lentiginous melanoma:
5-10% of all melanomas:
- Most common subtype in darker-pigmented individuals
- 60-72% in African Americans
- 29-46% in Asians
Median age of onset being 65 years old
- Most common site is the sole
- Not all palmar or plantar melanomas are ALMs (minority are SSMs or NMs)
- Variegation in color and irregular borders
- May be mistaken for plantar wart or hematoma
More advanced lesion upon diagnosis associated with poorer outcomes
** ALM is not thought to be associated with sun exposure
- within the epidermis, there is marked increase in solitary melanocytes lacking a well-nested pattern with foci of effaced rete-ridges
- there is significant scatter of melanocytes as there are melanocytes at all levels of the epidermis including the cornified layer*
A 58 year old man comes to his physician for what he believes is a bad case of nail fungus. His thumbnail has been cracking and peeling and recently there is some bruising that has developed at the base of the nail, though he can't remember injuring his thumb. What is his possible diagnosis and prognosis?
Variant of ALM:
- Generally arises from the nail matrix
- Most commonly on the great toe or thumb
- A widening, dark, or irregularly pigmented longitudinal nail streak (melanonychia striata)
+/- Nail dystrophy
- Pigmentation of the proximal nail fold
- Poor prognosis, associated with advanced subungual melanoma
A 55 year old man comes to his physician for an annual physical and a skin check. The doctor notes a nodule on the man's shoulder blade (below). What is the physician concerned this could be? What are poor prognostic indicators?
Second most common type of cutaneous melanoma:
- Accounts for 15-30% of all melanomas
- Believed to arise as a de novo vertical growth phase tumor without the pre-existing horizontal growth phase
- Mean age of onset is 53 years
- More common in men
- Occurs most frequently on the trunk
- Blue to black, or pink to red-colored, nodule
* Tend to be diagnosed at a thicker, more advanced stage with an associated poorer prognosis
Neoplastic cells are present in the papillary and reticular dermis with a “vertical growth phase”
“vertical growth phase” defined as aggregations of neoplastic cells in the dermis are larger than those in the epidermis
A 70 year old woman comes to the dermatologist because of a cyst on her forehead that has gotten larger and she wants to have removed. She states it has actually started to hurt as well. What is the dermatologist concerned about and what histologic features may be visible?
Indurated papule, plaque, nodule
Pigmentation absent in at least 40% of cases (i.e. amelanotic)
- Head and neck (53.2%)
- Extremities (26.2%)
- Trunk (20.6%)
Mean age 63 years old
Diagnosis is delayed due to non-specific clinical features
Histopathologically, it may simulate fibrosis/scar or a neural neoplasm leading to misdiagnosis and inappropriate treatment
- intraepidermal component may or may not be present
- interstitial fibrosis and collagenization
- thick lesion usually: mean Breslow depth at dx is 2-6.5mm (red arrow)
- lymphocytic infiltrates often as nodular aggregates (blue arrow)
- elongated, usually basophilic cells, tapered nuclei (black arrow)
- S100+ but other melanocytic markers often negative (HMB45, Melan A/Mart 1, MITF)
- Neurotropism is common
A 14 year old girl is admitted to the hospital with a skin eruption over a large area of her body. A skin biopsy reveals no bacteria. What is a possible diagnosis?
Toxic Epidermal Necrolysis: (could also be staph exfolatoxin, but that only involves subcorneal splitting- this is necrotic)
Involves at least 2 mucous membranes
Eruption involves greater than 30% of a patient’s body surface area
Diagnosis supported by skin biopsy
Poor prognosis, supportive care
Histo: extensive necrosis of epidermis
A 35 year old African American man visits a dermatologist after being unsuccesfully treated with topical antibiotics for a suspected case of folliculitis. What is his diagnosis based on the appearance of his skin and the inability to cure with antibiotics?
Acne keloidalis nuchae: seen in AA
Bands of thick collagen
Chronic inflammatory cells
Hair follicle destruction
A 32 year old woman comes to your office complaining of long-standing painful abscesses in her armpits and along her buttocks and thighs. Her previous physician told her it was due to an infection and lack of proper hygeine. She has been thoroughly cleaning the affected areas and taking antibiotics but the abscesses don't seem to get any better. In fact, they seem to get worse around her menstrual cycle. What is her diagnosis?
Primarily an inflammatory process
Multi-focal and symmetric involving 2 or more locations
Treatment is difficult, significant scar results
* Often confused with infection like Staph abscess or folliculitis
Suppurative, granulomatous inflammation
Fragments of hair shafts
A 50 year old man comes to the physician with a suspected abscess on his chest. He did not cut the skin but the cyst is swelling and red. Antibiotics have helped in the past with the swelling and redness but he wants to get rid of it. What is the diagnosis and treatment?
Firm, mobile nodules, originate from plugged hair follicles
Confused with abscess when inflamed
Antibiotics reduce inflammation, treatment is excision
Cyst lining with granular layer
A man comes into the physician for a new rash all over his body. He states he was feeling fine until about 2 days ago when he developed a sore throat. What is his likely diagnosis, what else may develop on his skin, and what is his treatment?
Caused by Group A Streptococci, erythrogenic exotoxin
Begins 24-48 hours after sore throat
Below: Pastia lines and subsequent desquamation of palms and soles can occur
Diagnosis is strep culture or ASO
Treat with antibiotics
An older man comes to your clinic for a red firm rash that developed on his face after shaving. He had a sore throat for the past two days prior to developing the rash. What is his diagnosis and treatment?
Caused by Group A streptococcus
Infection of superficial dermal lymphatics often from lacerations
Erythematous, brawny plaque on face or legs
Diagnosis is clinical
Treat with oral antibiotics
A 75 year old woman is being treated for arthritis by her physician who notes the following on her skin. She feels fine except for her knee pain which prevents her from walking very much (she is largely confined to a chair within her home. What is her diagnosis, what caused it, and what is the treatment?
Stasis dermatitis: can be confused by staph or s. pyogenes cellulitis.
Caused by venous stasis
Erythema or even yellow-brown plaques with lichenification
Diagnosis is often clinical
Treatment is compression and topical steroids
A 25 year old woman returns from a hiking trip in the Adirondaks with the following on her arm. What is her diagnosis and what changes are seen in her skin?
Caused by Borrelia burgdorferi
Begins 3-32 days after bite as a papule and becomes annular
25-50% of patients develop multiple lesions
EM fades on its own
Diagnosis is clinical
Treatment is with doxycycline
Superficial and deep perivascular mixed cells infiltrated
Plasma cells are often present
A 50 year old man, recently returned from a trip to Morrocco, comes to his physician for treatment of a foul-smelling ulcer on his penis. There is no lymphadenopathy. What is his diagnosis?
Front: Granuloma inguinale:
2-3 weeks post infection
beefy red, foul-smelling ulcer without lymphadenopathy
Below: Lymphogranuloma venereum (LGV):
3-30 days post-infection
Begins as a painless erosion
Erosion heals, leading to massive, fluctuant LAD
The following histological specimen was obtained from the fingertip of a 12 year old girl. What is her diagnosis?
Dilated blood vessels
What is the diagnosis of the rash on the face of this man? IS it viral or bacterial?
HSV: herpetic sycosis (front), herpes gladiatorum (below)
The following is a skin biopsy from a vesicle on the face of an 18 year old boy 3 days after acquiring an upper respiratory tract infection. Based on the histology, what infection does he have?
Herpes simplex virus:
Epidermal necrosis with vesicle
Enlarged, multinucleated keratinocytes with margination, and steel-grey nuclei
A 25 year old man comes to the physician with an itchy rash on his body that resembles chicken pox, but he's sure he had chicken pox when he was 5 years old. What might his diagnosis be?
Pityriasis lichenoides et verioliformis (PLEVA):
Appears very similar to varicella
Much longer time frame
Diagnose with skin biopsy
No great treatment, light therapy, antibiotics, or immune-suppressants
Ulceration of epidermis
Dense interface dermatitis
A 22 year old man is checked into the hospital after developing the following rash. He had a URI and sinus infection a couple of weeks ago that was treated with amoxicillin. Based on his appearance, what might be going on?
HHV4 EBV eruption (morbilliform)
Occurs 7-10 days after treatment with amoxicillin, ampicillin
A baby was born with severe eye problems and the following marks on his skin. What is his diagnosis?
HHV5 CMV baby:
In adults, infection similar to EBV
“Blueberry muffin baby”
In AIDS can be devastating
Can also co-infect with HSV
Treatment is gangciclovir
What HHV infection is apparent on the skin of this baby? What is the disease commonly known as?
A 25 year old man comes into the physician with a papery, scaly rash all over his body. He has been feeling a bit feverish and sore recently but didn't seek medical attention until this rash appeared. What is his diagnosis?
Pityriasis Rosea HHV 6 and 7:
20% have mild flu-like symptoms
Begins with 2-10cm oval, scaling patch
Followed by smaller oval patches with cigarette-paper scale along skin tension lines on trunk
Diagnosis is clinical
Treatment with topical steroids
Focal parakeratosis and spongiosis
A mother brings her newborn son into the physician because of some little pimples around his chest and underarm. What is his diagnosis and treatment?
Common in kids, resolve on their own
Can be STD in adults; giant molluscum seen in AIDS
Histo: Henderson-Patterson bodies
A man comes into the physician freaking out that he has a flesh-eating bacteria. Based on the appearance of his arm below, what might his diagnosis be?
Dermatophyte invades and ruptures the hair follicle
Most commonly T. rubrum
Treat with oral antifungals
A 60 year old man is concerned he may have a fungal infection (based on the appearance below) but his histologic exam reveals no organisms. What is his likely diagnosis and treatment?
Commonly found on the extremities
Round, erythematous plaques with scale
Pathology shows spongiotic dermatitis
Treat with topical steroids
A 24 year old woman has been using topical antifungals in an effort to treat what she thought was a foot fungus (tinea pedis) but she hasn't been able to make it go away. What is her diagnosis based on the gross appearance and the excessive keratinization seen on histology?
Multiple presentations: dry, scaling patches, verrucous plaques, or pustules
Diagnosis by skin biopsy
Treatment with topical steroids, PUVA, immune supressants