DERMATOLOGY

C ON T E N T S

Contents ............................................................................................................................... 1
Benign Epidermal Tumours................................................................................................ 2
Seborrhoeic Wart (Basal Cell Papilloma) .......................................................................................................... 2
Skin Tags ......................................................................................................................................................... 2
Epidermal Cysts ............................................................................................................................................... 2
Milium ............................................................................................................................................................. 2
Benign Dermal Tumours..................................................................................................... 3
Dermatofibroma ................................................................................................................................................ 3
Pyogenic Granuloma ......................................................................................................................................... 3
Keloid ............................................................................................................................................................... 3
Campbell de Morgan Spot (Cherry Angioma) ................................................................................................... 3
Lipoma ............................................................................................................................................................. 3
Chondrodermatitis Nodularis ............................................................................................................................ 3
Naevi.................................................................................................................................... 4
Melanocytic Naevi ............................................................................................................................................. 4
Epidermal Naevi .............................................................................................................................................. 4
Connective Tissue Naevi.................................................................................................................................... 4
Differential Diagnosis ....................................................................................................................................... 4
Malignant Melanoma .......................................................................................................... 5
Basal Cell Carcinoma .......................................................................................................... 6
Squamous Cell Carcinoma .................................................................................................. 6
Disorders of Pigmentation .................................................................................................. 7
Urticaria ............................................................................................................................... 8
Leprosy ................................................................................................................................ 9

MICHAEL CHEERAN DAVI D

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DERMATOLOGY

B E N I G N E P I D E R M A L T U M OU R S

SEBORRHOEIC WART (BASAL CELL PAPILLOMA)

Common proliferation of basal keratinocytes; pigmented

Clinical presentation:
Often multiple
Affect elderly or middle-aged
Mostly on trunk and face
Generally round or oval in shape
Start as small papules, often lightly pigmented or yellow
Become darkly pigmented, warty nodules; 1-6 cm in diameter
Have a stuck-on appearance, with keratin plugs and well-defined edges.
Differential Dx:
Actinic keratosis (2 to sun exposure and damage)
Melanocytic naevus
Pigmented basal cell carcinoma
Malignant melanoma
Mx:
Liquid nitrogen cryotherapy
Thicker seborrhoeic warts need curettage, or shave biopsy with cautery.
Histological examination advised if doubts on Dx.
Shows a hyperkeratotic epidermis, thickened by basal cell proliferation, with keratin
cysts.
SKIN TAGS

Pedunculated benign fibro-epithelial polyps; a few millimetres in length

Common in elderly or middle-aged
Common sites: neck, axillae, groin, eyelids
Often found in obese patients

Can be confused with small melanocytic naevi or seborrhoeic warts

Rx for cosmetic purposes cryotherapy or local excision.
EPIDERMAL CYSTS

Usually seen on the scalp, face or trunk

Sometimes incorrectly called sebaceous cysts
Keratin filled and derived from the epidermis
Pilar cyst is derived from the outer root of the hair follicle

Presentation firm, skin coloured, mobile cysts; 1-3 cm in diameter

May be complicated by infection
Rx = excision
MILIUM

Small white keratin cysts (1-2 mm in size)

Around the eyelids and upper cheek; often seen in children
Can be extracted by a sterile needle.
MICHAEL CHEERAN DAVI D

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DERMATOLOGY

B E N I G N D E R M A L T U M OU R S

DERMATOFIBROMA

Common dermal nodules; asymptomatic usually

Caused by a proliferation of fibroblasts, with dermal fibrosis and epidermal hyperplasia
May be 2 to an insect bite or other trauma
Presentation lower legs of young women
Firm, dermal nodules
5-10 mm in diameter
May be pigmented
Enlarge slowly (if at all)
Mx:
May be confused with a melanocytic naevus or a malignant melanoma
Excise lesion if symptomatic or if in doubt.
PYOGENIC GRANULOMA

Rapidly developing bright red or blood-crusted nodule

may be confused with malignant melanoma
it is neither pyogenic nor granulomatous; but is an acquired haemangioma
Presentation:
Develops at a site of trauma (e.g. prick from thorn)
Bright red, or pedunculated nodule bleeds easily
Enlarges rapidly over 2-3 weeks
Is usually seen on a finger; but also occurs on the lip, face and foot
Occurs in young adults or children
Mx = excision; histological analysis to exclude a malignant melanoma.
KELOID

An excessive proliferation of connective

tissue in response to skin trauma
Differs from a hypertrophic scar
because it extends beyond the limit of
the original injury
Presents as protuberant and firm
smooth nodules or plaques
Occur mainly over the upper back,
chest and ear lobes
Develop more commonly in Black
Africans
Have their highest incidence in 2nd to
4th decades
Rx = injection of steroid into keloid.

MICHAEL CHEERAN DAVI D

CAMPBELL DE MORGAN SPOT (CHERRY

ANGIOMA)

Benign capillary malformations

Commonly seen as bright-red papules
on the trunk in elderly or middle-aged
Often mistaken for petechiae!
LIPOMA

Benign tumours of fat; soft masses in

subcutaneous tissue
Multiple; found on trunk, neck and
upper extremities
CHONDRODERMATITIS NODULARIS

Small painful nodule on the upper rim

of the helix of the pinna.
Usually in elderly
2 to inflammation in the cartilage, 3
to degenerative in the dermis
Rx = excision
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DERMATOLOGY

NA E V I

MELANOCYTIC NAEVI

A benign proliferation of 1+ normal constituents of the skin = pigmented mole.

Common, usually multiple

Congenital naevi present at birth; protuberant or hairy? Small risk of malignant

Junctional naevi flat macules; round/oval; found on soles, palms or genitalia
Intradermal naevi dome shaped, skin-coloured papules; typically affects the face
Compound naevi pigmented nodules or papules; warty or hairy?

Blue naevi solitary and usually found on hands/feet;

blue colour is an optical illusion caused by pigment deep within the dermis.
Spitz naevi firm, reddish-brown, rounded nodule on the face of a child
Initial rapid growth; dilated dermal vessels
Halo naevi depigmentation where a naevus has involuted (2 immune destruction)
Mostly seen on the trunk
EPIDERMAL NAEVI

Present at birth or develop shortly after

Warty, often pigmented
Frequently linear a few centimetres long
Rx = excision, but recurrence is common
A rare variant on the scalp carries a small risk of malignant (naevus sebaceous)

CONNECTIVE TISSUE NAEVI

Smooth skin-coloured papules composed of coarse collagen, in the dermis

DIFFERENTIAL DIAGNOSIS

Freckle tan-coloured macules on sun-exposed sites

Lentigine sun-exposed sites in elderly, also in Peutz-Jeughers; increased melanocytes
Seborrhoeic wart - stuck-on appearance
Haemangioma vascular, but may show pigmentation
Dermatofibroma elevated, firm and pigmented nodules on the legs (? 2 insect bites)

Pigmented Basal Cell carcinoma often on the face

Pearly edges
Increase in size, and can ulcerate
Malignant Melanoma variable colour and outline
Increase in size
May be inflamed or itchy.

MICHAEL CHEERAN DAVI D

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DERMATOLOGY

M A L I G NA N T M E L A N O M A

Incidence is 10 per 100,000 per year; : is 2:1

Incidence rising by 7% per year, and doubling every decade
Prognosis is related to tumour thickness and staging according to the Breslow Thickness
scale:
The length (mm) between the granular cell layer to the deepest identifiable melanoma
cell.
4 Presentations:
Superficial spreading
50%, predominance
Macular with variable pigmentation
Nodular
25%, predominance
commonest on the trunk
grow rapidly and ulcerate
Lentigo
Developing in long-standing lentigo maligna
15%; lentigo maligna arises in sun-damaged skin (e.g. face of elderly person)
Irregular outline and pigmentation
Acral Lentiginous
10%
Affects palms, soles and nail beds
Often diagnosed late, with a poor prognosis
Risk factors:
Sun exposure
Dysplastic naevus with a FHx of malignant melanoma
Diagnosis:
Size?
Shape?
Colour?
Inflammation?
Crusting ooze/bleed?
Itch?

A asymmetry
B borders
C colour
D diameter

Mx surgical excision
Tumour thickness < 1mm needs a 1cm clearance margin
Tumour thickness > 1mm needs a 2-3 cm clearance, often with a skin graft to close.
Recurrence can be local or via lymphatic/haematogenous spread.
? Prophylactic clearance of local lymph nodes
? -Interferon and dacarbazine vs. thick malignant melanomas.
Avoid burning in the sun; use high strength sun protection.
Report early on, any changes in a mole.

MICHAEL CHEERAN DAVI D

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DERMATOLOGY

BA S A L C E L L C A RC I N O M A

Rodent ulcers typically seen on the face in elderly/middle-aged.

Arise from basal keratinocytes at the epidermis, in light exposed areas
Grow slowly and destroy local bone, cartilage and soft tissue
Locally invasive, but rarely metastasise.
Causes:
Prolonged UV exposure
Arsenic ingestion (e.g. in tonics)
X-rays
Chronic scarring
Genetic predisposition

Nodular commonest from

Usually starts as a small skincoloured papule
Pearly edges, fine telangectasia and
central crusting
Usually < 1 cm in diameter
Exclude intradermal naevus and
molluscum contagiosum

Cystic tense and translucent

Multi-centric superficial tumours, often multiple, plaque-like and extensive
Frequently pigmented
Exclude discoid eczema and psoriatic plaques.
Morphoeic scarring variant often shows white/yellow morphoea-like plaques
Centrally depressed
Mx:
Excision
Incisional biopsy with radiotherapy, if excision not possible.
Cryotherapy
Regular follow-up, since recurrence is 5% at 5 years.
S Q UA M OU S C E L L C A R C I N OM A

Malignant tumour derived from keratinocytes in an area of damaged skin

> in patients > 55 years; may metastasise.
Malignant keratinoyctes retain the ability to produce keratin
Destroy the dermo-epidermal junction to invade the dermis in an irregular manner.
Keratosis-derived type starts within an actinic papule, which progresses to ulcerate and
form a crust
Nodular dome shaped
More invasive varieties often develop at the edge of pre-existing ulcers and at sites
of radiation damage.
Metastases found in 10%.
Differential: kerato-acanthoma, actinic keratosis, seborrhoeic keratosis.
Mx:
Surgical excision with lymph node examination
Radiotherapy.
MICHAEL CHEERAN DAVI D

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DERMATOLOGY

D I S O R D E R S O F P I G M E N TA T I O N

Vitilgo
Autoimmune disease, associated with pernicious anaemia, thyroid and Addisons
diseases.
Well-defined, depigmented macules
Often symmetrically distributed on the hands, wrists, knees, neck, and mouth.
No good Rx camouflage cosmetics
In dark-skinned individuals, steroids/PUVA/oral psoralens to induce re-pigmentation?
Albinism
Autosomal recessive defect in tyrosinase failure to synthesise melanin
Lack of skin and eye colour
Premature skin photo-ageing, and risk of squamous cell carcinoma.
Mx: strict sun avoidance.
Phenylketonuria
Autosomal recessive deficiency in phenylalanine hydroxylase cannot make tyrosine
Accumulation of phenylalanine leads to mental retardation and choreoathetosis
Impaired melanin fair skin and hair
Atopic eczema is common
Mx = a low phenylalanine diet to prevent early neurological damage.
Freckles & Lentigines
Freckles are light-brown macules which darken on sun exposure; normal melanocytes
Lentigines are also brown macules, but do not darken in the sun; no of melanocytes
Melasma
Patterned, macular, facial pigmentation
Associated with hormonal
e.g. pregnancy (chloasma) or the use of OCP
Avoid sunshine, use SPF, and fade-out cream (over the counter) for 6-8 months.
Peutz-Jeughers Syndrome
Rare autosomal dominant condition
Lentigines around the lips, buccal mucosa and fingers
Associated with small bowel poyps Intersusseption and rare malignant .
Addisons Disease
Autoimmune 1 hypoadrenalism with 2 hyperpituitarism (ACTH)
ACTH synthesised from pro-opiomelanocortin melanogenesis
Generalised pigmentation
Or localised to buccal mucosa, palmar creases, scars, flexures and areas of friction
Drug-induced
Amiodarone
Chloroquine
Chlorpromazine
Psoralens

MICHAEL CHEERAN DAVI D

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DERMATOLOGY

U RT I C A R I A

Common eruption of transient pruritic wheals

Associated dermal oedema is usually the result of mast cell degranulation and the release of
vasoactive amines
IgE mediated (type I) hypersensitivity
Complement activation
Direct release of histamine (e.g. opiates and contrast media)
Blocking of prostaglandin pathway (e.g. aspirin and NSAIDs)
A serum histamine releasing factor?
Chronic Idiopathic urticaria:
Itchy pink wheals, anywhere on the skin
Number varies from a few to many, appearing in a day
Angioedema of the lips and tongue can co-exist
? Pharmacological provoking factors.
Spontaneous resolution within a few months
Acute urticaria:
Sudden onset
2 to IgE mediated reaction
Commonly associated with a food allergen (e.g. nuts, egg, prawn) or a drug allergen.
Physical urticaria:
Cold, heat, sun exposure
Dermographism = whealing induced by firm stroking of the skin
Cholinergic urticaria = small intensely itchy papules in response to sweating
Eruptions last from a few minutes to hours.
Hereditary angioedema:
Rare, potentially fatal, autosomal dominant condition.
Can cause respiratory obstruction and/or abdominal pain & vomiting
C1-esterase inhibitor deficiency allows unchecked complement activation
Rx = i.v. FFP vs. acute attacks; anabolic steroids (e.g. Danazol) used to promote hepatic
synthesis of C1-esterase inhibitor.
Urticarial vasculitis
Acute onset with widespread lesions
Persist > 24 hours, and fade leaving purpurea.
Mx:
Conservative (avoidance of allergens)
Desensitisation
Antihistamines: cetirizine (Zirtek), terfenadine (Triludan)
Corticosteroids
Adrenaline vs. anaphylaxis (along with slow i.v. chlorpheniramine/Piriton)
Diet avoid salicylates, azo dyes and benzoic acid preservatives.

MICHAEL CHEERAN DAVI D

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DERMATOLOGY

L E P R OS Y

Also known as Hansens disease chronic disease of peripheral nerves caused by M. leprae
3 cardinal features:
Hypo-pigmented / erythematous, hypo-aesthetic patches
Thickening of peripheral nerves sensory or motor deficits
Acid fast bacilli (AFB) from skin lesions
Incubation for 2-5 years inside histiocytes and schwann cells
Spread by inhalation, direct contact, ingestion and insects.
Classification by degree of immune competence:
Tuberculoid tuberculoid (TT)
greatest cell-mediated immunity
Borderline tuberculoid (BT)
Borderline borderline (BB)
Boderline lepromatous (BL)
Lepromatous lepromatous (LL)
least cell-mediated immunity
TT:
3 patches anaesthetic, well-defined macules or plaques
<3 cm
1 peripheral nerve may be thickened
AFB smear ve; bacterial load
Lepromin test +ve; biopsy shows tuberculoid granuloma
BT:
3-10 patches partially anaesthetic, hypo-pigmented, ill-defined large macules/plaques
Satellite lesions
Asymetrical peripheral nerve thickening
AFB smear 1+
Lepromin test +ve
BB:
AFB smear 2+
Lepromin test +ve or ve
BL:
Tendency towards symmetrical plaques
AFB smear 3+
Lepromin test ve
LL:
Extensive disease symmetrical, numerous macules, nodules, papules
Shiny, infiltrated skin lesions
Nasal involvement epistaxis, septal perforation, collapse of nasal bridge
Pedal oedema
Laryngeal oedema hoarse voice and dyspnoea
Peripheral nerve thickening with glove & stocking anaesthesia and ?motor deficits
Gynaecomastia and testicular atrophy
AFB smear 6+
Lepronin test ve; biopsy shows foam cell granuloma with numerous organisms.

MICHAEL CHEERAN DAVI D

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DERMATOLOGY

Type 1 Lepra reactions: (BT, BB and BL)

Type IV hypersensitivity (delayed)
Erythema, oedema and hyperalgesia in pre-existing skin lesions
Tender and thickening of nerves palsies and sensory deficits
If mild sx Rx = analgesia
Severe sx Rx = 30 40 mg oral prednisolone
Type 2 Lepra reactions: (BL and LL)
Type III hypersensitivity (immune complex deposition)
Triggered by infection, vaccines and stress
Fever
Joint tenderness
Lymphadeopathy
Erythema Nodosum Leprosum over face and extensor surfaces ; not legs
Iritis, Conjunctivitis
Epistaxis, rhinitis
Acute epididymo-orchitis
Laryngeal odema death
Glomerulonephritis
Rx = steroids and thalidomide
Complications:
Nerve palsies ulnar claw hand, carpal tunnel, Bells palsy, foot drop, claw otes
Anaesthetic complications:
Trophic ulcers and osteomyelitis
Distortion of toes
Shortening of foot
Tarsal disintegration
Malignancy
Mx:
Paucibacillary TT/BT = 100mg Dapsone + 600mg Rifampicin for 6 months
2 years of follow-up
Multibacillary BB/BL/LL (or AFB smear +ve)
100mg Dapsone + 600mg Rifampicin + 300mg Clofazimine for 2 years
5 years of follow-up

MICHAEL CHEERAN DAVI D

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