JC81 (Surgery) - Skin ulcers Flashcards

Question

Describe and name lesion Cause 2 main etiologies and physical difference Tx

Answer 1

Dermoid cyst / Sequestration dermoid Cause: formed by epidermal cells being sequestrated beneath skin Etiologies: 1. Congenital: inclusion of embryonic epithelium at sites of embryonic fusion (midline of scalp, external angle of eye, lower mandible) 2. Acquired: Epithelium driven beneath skin by puncture wound leads to formation of cystic lesions Congenital - soft and may transluminate Acquired - hard and firm Tx: Surgical excision

Answer 2

Seborrheic keratosis Actinic keratosis Keratoacanthoma

Answer 3

Seborrheic keratosis/ Basal cell papilloma/ Senile warts - Brown-black, Raised plateau of hypertrophic greasy skin, - well-demarcated, plaque-like papules, Waxy with papuliferous surface Demographic: elderly >70 Cell of origin: Benign overgrowth of the basal layer of epidermis Dx features: - Can be picked off using blunt forceps - Leser-Trelat sign: acanthosis nigricans + skin tags + senile warts appear with GI/ lung cancer ``` Tx: o Cryotherapy* o Curettage/ shave excision o Electrodesiccation o CO2 laser ablation ```

Answer 4

Actinic keratosis/ Solar keratosis/ Senile keratosis - UV-exposed skin - Dry, scalpy, crusty surface with erythematous base - Early lesions are flat papules - Hyperkeratosis and acanthosis with malignant potention Tx: - Excision - Currettage - Cryosurgery - 5-FU cream

Answer 5

Keratoacanthoma/ Molluscum sebaceum - Dome/ nodular, flesh-colored nodule - Central crater filled with keratin plug Area: Common on the face but can occur anywhere with sebaceous glands/ hair-bearing sun-exposed skin Growth: rapid growth for few weeks, then static and involution Tx: Excisional biopsy (exclude SCC) and Surgical excision

Answer 6

Developmental abnormality with hyperplasia of incompletely differentiated tissue elements Types: - Melanocytic naevus (Moles) - Strawberry naevus (Infantile haemangioma) - Sebaceous naevus

Answer 7

Melanocytic naevi Junctional: in children, flat, dark pigmentation Compound: Young adult, raised, varied pigmentation Intradermal: old age, dome-shaped, flesh-colored Congenital: large, dark, raised, thick, hairy

Answer 8

``` Dysplastic naevus with diameter >2mm Family history of skin cancer Previous skin cancer Giant congenital melanocytic naevus (whole trunk black) Age >50 ```

Answer 9

Melanoma BCC Seborrheic keratosis

Answer 10

Dysplastic naevi - Irregular border - Speckled pigmentations Sporadic: a/w caucasians with fair skin with excessive sunlight exposure and freckles Familial: Dysplastic naevus syndrome, high risk of malignant transformation

Answer 11

Dermatofibroma (histiocytoma, sclerosing angioma) * Site: Most commonly located in lower extremities * Size: Usually nodules 0.3 – 1.0 cm but giant lesions > 3 cm have also been described * Color: Hyperpigmented * Consistency: Firm * Associated symptoms: Pruritus * Classically dimple when pitched Cause: History of trauma/ insect bites causing proliferation of fibroblasts, fibrosis and iron pigmentation Tx: o Surgical excision o Cryotherapy with liquid nitrogen

Answer 12

Dermatofibrosarcoma protuberans (DFSP) Painless, indurated plaque with irregular nodules Diffuse, skin-colored Histology: cord/ nests of cells invade into adjacent soft tissue Tx: Wide excisional margin +/- RT

Answer 13

Neurofibroma Origin: neuromesenchymal origin including Schwann cells, perineurial cells, fibroblasts and mast cells Presentation: asymptomatic or Tingling sensation in nerve distribution * Site: Any subcutaneous tissue, common in forearm * Size: Papules or nodules < 2 cm in diameter * Shape: Fusiform or sessile/ pedunculated with long axis lying along the length of limb * Color: Hyperpigmented * Number: Can be solitary but often multiple * Composition: Firm and rubbery Signs: o Tinel sign = Symptoms of pain and paraesthesia can be elicited o Button-hole sign = Applying direct pressure may make some neurofibroma seem to retract into the skin Tx: surgical excision

Answer 14

Neurofibromatosis AD NF-1 and NF-2 mutation Multiple nodules with cafe au lait pigmentation Possible malignant transformation Acoustic neuroma

Answer 15

Content: Matured adipocytes in fibrous capsule Tx: Conservative, excision, liposuction Malignant features: Pain, rapidly enlarging, skin changes, firm consistency

Answer 16

Vascular tumors - Common tumor of infancy, but not present at birth - Rapidly increase in size disproportionate to body size, then involution - e.g. Strawberry naevus Vascular malformation - Present at birth - Grows proportionally to body size - Degenerate or hypertrophy (AVM) - e.g. arteriovenous malformation, AV fistula

Answer 17

Haemangioma/ Strawberry naevus Growth: • Rapid proliferation of blood vessels in the first year of life (followed by) • Gradual regression of vascular component with replacement of fibrofatty tissues Cx: ulceration and permanent disfigurement compromise vital organ function including eyes, CNS and circulatory system ``` Tx: Serial observation (wait for involution) Topical or intralesional corticosteroids Topical β-blockers Pulsed-dye laser (PDL) Excisional surgery ```

Answer 18

Critical compromised blood flow: - Bleeding - Ulceration ``` Mass effect: - Periorbital hemangioma: Upper eyelid affected: >> Stimulus-deprivation amblyopia >> failure to develop binocular vision >> Corneal distortion and astigmatism ``` - Airway hemangioma >> Airway obstruction

Answer 19

• Dermoscopy • Diascopy o Pressing a glass slide onto skin • Wood’s light o Examination of difference in pigmentation

Answer 20

• Serology o Anti-skin antibodies (pemphigoid and pemphigus) o ANA, anti-dsDNA, anti-ENA, anti-Jo1 o Anti-HIV * Skin swab (bacterial/ virus) * Skin scraping (fungus/ scabies mites) • Skin prick test o Type I hypersensitivity reaction o Intradermal injection of common allergens o Allergens in atopic dermatitis • Skin patch test o Type IV hypersensitivity reaction o Allergens in contact dermatitis

Answer 21

Fine needle aspiration (FNA) Core-needle biopsy Incisional biopsy o Gold standard for lesion > 3 cm Excisional biopsy o Gold standard for lesion < 3 cm or for tumours that are probably benign

Answer 22

Viral warts * Site: Common on hands or areas touched by hands including face, arms and knees * Size: < 1 cm in diameter * Shape: Hemispherical papule * Color: Greyish-brown * Surface: Rough and hyperkeratotic * Composition: Firm Cause: human papilloma virus (HPV) infection ``` Types: o Common warts (Verruca vulgaris) o Plantar warts (Verruca plantaris) o Flat warts (Verruca plana) o Periungual warts o Anogenital warts ```

Answer 23

o HPV Type 1 commonly infects the soles of feet causing plantar warts o HPB Type 6 and 11 commonly infects the anogenital region causing anogenital warts Predisposing conditions include eczema (atopic dermatitis) and immunodeficiency (AIDS/ organ transplantation)

Answer 24

Choices of treatment o Topical salicylic acid* (exfoliates affected epidermis and stimulate local immunity) o Cryotherapy with liquid nitrogen* o Surgical excision

Answer 25

Acrochordon (skin tag) - sites of friction particularly the neck, axilla, inframammary and inguinal region - MUST be differentiated from neurofibroma Etiologies: - DM and obesity - Crohn's disease (perianal skin tags) Tx: o Excision under LA o Cryosurgery with liquid nitrogen o Electrodessication

Answer 26

Pyogenic granuloma - Benign vascular tumour of the skin or mucous membranes - Pyogenic: Surface is often infected and ulcerated - Granuloma: Capillary loops grow vigorously and forms a protruding mass of tissue - Rapidly growing lump which bleeds easily and discharges serous and purulent fluid Site: Common on body parts liable to injury such as hands and face Ix: Excisional biopsy Tx: Surgical excision, Curettage/ shave excision, Cryotherapy, Injection sclerotherapy, Electrocauterization

Answer 27

Ganglion cyst Origin: Fluid-filled swelling overlying a joint or tendon sheath Benign lesions usu. painless, but may lead to pain, weakness and loss of function Site: Near joint capsules and tendon sheaths o Dorsal side of the wrist (70%) (most common) o Volar side of the wrist over scaphotrapezoid joint (20%) Tx: - Conservative with either observation or non-surgical treatment such as aspiration - Surgical removal with excision

Answer 28

1. Sloping - Ischemic venous ulcer/ Healing ulcer/ Traumatic ulcer 2. Punched-out - Ischemic ulcer/ Deep trophic ulcer/ Syphilitic ulcer 3. Undermined edge - destroys subcutis quicker than spread - Tuberculous ulcers 4. Rolled edge - central necrosis with fast periphery growth - BCC 5. Everted edge - Fast growing infiltrating cellular disease - Squamous cell carcinoma/ Ulcerated adenocarcinoma

Answer 29

Granulation tissue o Red sheet of delicate capillary loops and fibroblasts covered by a thin layer of fibrin or plasma Dead tissue (i.e. slough) Tumour o Base of a squamous cell carcinoma is the malignant tissue itself o May be slightly vascular or necrotic

Answer 30

Left: Hypertrophic scar - Confined within boundaries of scar - Site: Any location - Develops quickly after injury/ scarring with involution after a year Right: Keloid scar - Extends beyond boundaries of scar - Head and neck, upper check and back - Develops for years after injury/ scarring with no involution

Answer 31

• Infantile hemangioma • Congenital hemangioma  RICH = Rapidly involuting congenital hemangioma  NICH = Non-involuting congenital hemangioma * Pyogenic granuloma * Tufted angioma * Kaposiform hemangioendothelioma

Answer 32

• Capillary malformation o Port-wine stains o Nevus simplex (Macular stain) • Arteriovenous malformation • Lymphatic malformation o Macrocystic lymphatic malformation (Cystic hygroma) o Microcystic lymphatic malformation (Lymphangioma circumscriptum) • Venous malformation

Answer 33

Port-wine stain • Low-flow vascular malformations of dermal capillaries and post-capillary venules Association conditions o Glaucoma o Spinal dysraphism o Soft tissues and bone overgrowth Site: Common on the face, neck, shoulder and buttock • Lesion on the face tends to follow the distribution of trigeminal nerve branches (CN V) • Typically with unilateral or segmental distribution that spares the midline Tx: Pulsed dye laser (PDL) therapy

Answer 34

Macrocystic lymphatic malformation (Cystic hygroma) - Presents at birth as a large poorly delimitated, translucent, soft mass ``` Lymphatic malformations (LM) are benign low-flow vascular lesions composed of dilated lymphatic channels or cysts Caused by failure of lymphatic channel fusion ``` Sites: commonly in cervicofacial region, axilla or lateral chest wall

Answer 35

Macrocystic lymphatic malformation (Cystic hygroma) • Defined as single or multiple cysts each ≥ 2 cm3 Microcystic lymphatic malformation (Lymphangioma circumscriptum) • Defined as single or multiple cysts each < 2 cm3

Answer 36

Non-surgical treatment • Injection sclerotherapy • Radiofrequency ablation (RFA) Surgical treatment • Surgical excision

Answer 37

Angiolipoma - benign tumour of adipocytes typically occurring in adolescents and young adults - Resembles lipoma but are usually painful and tender Lipomas are not painful or tender

Answer 38

Surface: Smooth* or lobulated* Mobility: Mobile in all direction* • Slip sign*: Edge is soft, compressible and thin which might slip away from the examining fingers Tenderness: Non-tender*

Answer 39

Local excision • Linear excision along skin creases • Surgical removal of fat cells and fibrous capsule Liposuction • May be considered in large lipoma

Answer 40

Sebaceous horn • Slow discharge of sebum from wide punctum hardens to form a conical spike Cock’s peculiar tumour • Infection and ulceration of cyst wall leading to an infected, open, granulating, edematous sebaceous cyst

Answer 41

ALL sebaceous cysts are recommended to be excised - Prevent sebaceous cysts from being infected Elliptical incision for sebaceous cyst to include punctum Complete excision of cyst and contents

Answer 42

Location of SCC • Head and neck (55%) • Dorsum of hands and forearms (18%) • Legs (13%) Malignant tumour arising from the epidermis forming the superficial keratinous squamous layer Mode of spread • Local spread: Infiltration into epidermis, dermis, adjacent tissues • Lymphatic spread: Regional lymph nodes is the MOST common site of metastasis • Hematogenous spread

Answer 43

Hair follicle: - Trichofolliculoma, Trichoepithelioma, Trichilemmoma Sebaceous gland: - Sebaceous adenoma Sweat gland - Cylindroma, Syringoma

Answer 44

Bowen’s disease (SCC-in-situ) -“Erythroplasia of Queyrat” when penis is involved ``` Solar keratosis (SCC-in-situ) - multiple erythematous scaly macules or papules on sites of chronic sun exposure ``` Marjolin’s ulcer - long-standing benign ulcers or scars o Commonest ulcer = Venous ulcer o Commonest scar = Burns

Answer 45

Thick, reddish brown, scaly patch with irregular borders Histological: Dysplastic cells confined to basal lamina Tx: Excision, Radiotherapy, Topical 5-FU, Cryotherapy, Photodynamic therapy

Answer 46

Mammary ducts to nipple epidermis Erythema and eczematous lesion of nipple, frequent erosion and ulceration Associated breast CA Ix: Incisional biopsy Tx: Breast CA

Answer 47

SCC BCC Malignant melanoma

Answer 48

RF: - Excessive UV exposure - Carcinogens: RT, Arsenic or chromium - Non healing wounds or unstable scars - Congenital: xeroderma pigmentosa and Albinism - Immunosuppression Classical description - Irregular ulcer with everted edge, exophytic growth - Non-tender Metastasis: Lymphatic preferred, haematogenous Tx: - topical 5-FU, RT - Wide excision, reconstruction - Block LN dissection

Answer 49

``` Pigmented (common in HK) Nodular/ Ulcerative Superficial Cystic Morpheaform (Sclerosing) ``` Rarely spread by LN or blood (c.f. SCC)

Answer 50

Non-modifiable factors • Aging • White ethnicity • Family history of BCC ``` Modifiable factors • UV light exposure (most important) • Arsenic exposure • Ionizing radiation • Immunosuppression • Medical conditions o Gorlin’s syndrome (Basal cell nevus syndrome) o Xeroderma pigmentosum (XP) ```

Answer 51

Site: Most common on the face (70%) Shape: Nodule/ Pigmented nodule/ Ulcer/ Deep eroding ulcer (rodent ulcer) * Edge: Rolled edge. Pearly-white edge and well-defined (characteristic)* Tenderness: Non-tender* Attached to overlying skin* Freely mobile over deep structures*

Answer 52

``` Chemotherapy • Topical 5-FU • Topical Imiquimod Photodynamic therapy Radiotherapy ``` Surgical treatment • Surgical excision*** • Electrodessication and curettage (ED&C) • Mohs micrographic surgery (MMS)

Answer 53

Origin: Melanocytes in basal epidermis Areas: - UV-exposed area - Mucous lining, choroid of eye, meninges, soft tissue Metastatic: LN and hematogenous

Answer 54

Superficial spreading (Most common): from pre-existing pigmented nevus Nodular melanoma (most aggressive) Lentigo maligna melanoma (least aggressive) Acral lentiginous melanoma: on palms and soles Subungal melanoma

Answer 55

Breslow scale (thickness and survival) Clark's level of invasion (skin histological layer and survival) Both correlate with LN metastases and survival Thinner lesion = better prognosis

Answer 56

Increase in size, shape or thickness Changes in surface • Loss of normal skin markings (creases) over the mole • Becomes rough and scaly Changes in color • Darker as malignant melanocytes produce more melanin Itchiness Bleeding • Late and slight sign • Overlying epithelium becomes anoxic as tumour cells multiply Evidence of local or distant spread • Spread diffusely to surrounding skin to produce a brown halo around the primary lesion

Answer 57

• Asymmetry o If a lesion is bisected then one half is not identical to the other half • Border irregularities • Color variegation o Presence of multiple shades of red, blue, black, gray or white • Diameter ≥ 6 mm • Evolution (Enlarging/ Elevation) o Lesion that is changing in size, shape, color or a new lesion

Answer 58

excisional biopsy: Full-thickness excisional biopsy of suspicious lesions with 1 – 3 mm margin of normal skin Sentinel lymph node biopsy (SLNB) • Lymphatic mapping with SLNB for prognosis and staging

Answer 59

``` Checkpoint inhibitors* • CTLA-4 inhibitor • Anti-programmed cell death 1 (PD-1) antibodies Cytokines • Interferon-α (IFN-α) • Interleukin-2 (IL-2) Intralesional BCG therapy ``` Surgery: Surgical resection with adequate margin ± BLock Lymph node dissection

Answer 60

``` Benign: Stable in size No ulceration or bleed Well-demarcated border Flat No enlarged regional LN No satellite lesions ``` Malignant = opposite of everything

JC81 (Surgery) - Skin ulcers Flashcards

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