PIGMENTED SKIN

LESIONS Richard Shellenberger, DO, FACP

IT’S NOT A SPIDER BITE

PART 2

No financial disclosures

Not Spider Bites!

Not in Michigan!

“Spiders do not bite”

• Chris Buddle – Arthropodologist – McGill University,

Montreal, Canada

• Never been bitten in 20 yrs of handling spiders

• “Have to work hard to get a spider to bite you”

Why dermatology? Important in IM

• “I have no special talents. I am only passionately curious”

Albert Einstein

• “Develop a passion for learning. If you do; you will never

cease to grow.”

Anthony J D’Angelo

• “There is no passion to be found in playing small – in

settling for a life that is less than the one you are capable

of living.”

Nelson Mandela

Goals

• Improve comfort with office dermatology

• Learn to identify and risk stratify pigmented lesions

• Excise suspicious lesions or call someone who can!

• Skin cancer prevention and awareness

• (please read my commentary in JFMPC)

Acrodhordon (skin tag)

Outgrowths in middle aged and elderly, F > M

• Pedunculated lesions - narrow stalks

• 25% of adults with familial tendency

• Friction areas – Neck, axilla, breasts are more

common with obesity

• Treatment : Excision or liquid nitrogen PRN

Cherry Angioma

• Capillary proliferations in middle aged – elderly

• On trunk

• Bleed!

• Can be confused with amelanotic or nodular melanoma

• Electrocauterize or excise

Dermatofibroma

• Fibroblastic proliferation

• Firm, hyperpigmented, dome shaped nodules on leg

• Dimple sign when pinched

• Nodular BSC are waxy and have telangectasias

• Remove only if change

Pyogenic Granuloma

• Not an infection……or spider bite!

• Rapidly developing hemangioma – capillary

proliferation

• Site of trauma

• Erythematous, dome shaped, bleed easily

• Isolated lesions on fingers, lips trunk or toes

• Excision and ablate the base

Epidermoid Inclusion Cyst

• Traumatic implantation of epidermis

• Accumulation of keratin

• Enclosed in stratified epithelium

• Lipoma

• Excise or inject with steroids

Seborrheic Keratosis (SK)

• Develop after 50

• “Stuck on” appearance

• “Warty”, well circumscribed, scaly hyperpigmented lesions

• Trunk, face, and upper extremities

• Horny cysts and dark keratin plugs

Solar lentigo

• Proliferation of normal melanocytes

• Flat, oval, evenly pigmented (café au lait)

• Sun exposure

• Face, hands, arms, shoulders, and back

• Lentigo maligna

• variable pigment and irregular borders

• Lentigo maligna melanoma : raised nodule

Actinic Keratosis (AK)

• Rough appearing, scaly, erythematous papules

• Sun exposed areas of middle-aged with fair skin

• Michigan sailors and farmers (never in golfers!)

• Sandpaper

• Premalignant (~1/1000 > SCC)

• Treatment with cryotherapy

Nevus

• Melanocytic nevus

• Benign proliferation melanocytes in childhood

• Number peaks in early adulthood

• Types of nevi

• Junctional Nevi

• Flat pigmented macules on acral surfaces

• Melanocytes in dermal epidermal junction

Nevus

• Compound nevi

• Melanocytes in dermal-epidermal junction as

well as dermis

• Congenital Nevi

• Present at birth

• Giant congenital pigmented hairy nevus

• 20 cm diameter

• 3-6% may develop into melanoma

Becker’s Nevus

• Benign Hamartoma

• Adolescent

• M/F = 5:1

• Shoulder and trunk

• Tan - brown

Dysplastic Nevus Is it cancer?

- Asymmetry

- Borders – irregular

- Color – dark or variegated

- Diameter – size > 5 mm

- Evolving - any changes

Dysplastic Nevus

• Slightly elevated

• Central Papule surrounded by a Pigmented Macule

• Most commonly on trunk and back – same as melanoma

Dysplastic Nevus

• Epidemiology

• 7-16 % prevalence

• May evolve from normal appearing nevi

• May develop after age 30

• Sun exposure theorized:

• Intermittently sun exposed areas (trunk)

• History of sunburn

• Sun-sensitive skin types

Dysplastic nevus (DN)

• Clinical Significance (RISK OF MELANOMA)

• 15 X age-adjusted incidence of melanoma

• But only 1 in 10,000 DN per year progress to melanoma.

• Risk of melanoma = # of DN (10 DN = 12 x risk)

• First degree relatives should be screened for melanoma

Dysplastic Nevus and Melanoma

• 200 fold increase in melanoma if 2 family members with

melanoma

• Melanoma can arises contiguous to DN

• Histology of dysplasia NOT predictive of Melanoma

• # of DN most predictive

• ? evidence for clinical atypia being predictive

Dysplastic Nevi

• Controversial

• Sunscreen and avoiding sun exposure

• Not shown to decrease the development of DN

• Dermoscope

• Excision with 1-2 mm margin to r/o melanoma.

• Excision of dysplastic nevi does not reduce the risk of melanoma.

• Pt with multiple DN need increased surveillance

Halo Nevi

• Pigmented nevi with surrounding white halo due to

lymphocytes

• Mostly in adolescents

• Think melanoma when seen in adults and Excise them!

Halo Nevus

Skin Cancer

• Sunlight

• Pop quiz

• A farmer with lifelong sun exposure in his arms is most likely to get

what type of skin cancer?

• A. Melanoma

• B. Non-melanoma

• Lifetime risk all skin cancers is 1:5

• Melanoma is 2.4%

Sun Exposure

Melanomas arise in areas susceptible to sunburn

- Dark skin or those who tan easily are at lower risk of melanoma

- Intermittent exposure and sunburn in adolescence or childhood = risk

• Key #: 5 or more sunburns = 2x risk of melanoma

Sun Exposure

• Nonmelanoma skin cancer is associated with cumulative

sun exposure

• Melanoma = sporadic exposure except for head and neck

• Back and trunk in men

• Legs in women

• SUNBURNS = BAD

Skin Types

• Type I

• White skin, blue or hazel eyes

• Always burns and never tan

• Type II

• Fair Skin, blue eyes

• Burns easily – tans poorly

Skin Type

• Type III

• Dark white skin

• Tans after burning

• Type IV

• Light brown skin

• Minimal burning, tans easily

Skin Types

• Type V

• Brown Skin

• Rarely burns, tans easily

• Type VI

• Dark Brown Skin

• Never burns, tans easily

Nonmelanoma Skin Cancer

• Basal Cell Skin Cancer

• 60% of primary skin cancers

• Slow-growing locally invasive

• Recurrence after excision increases risk of metastasis

• Most common on face

Basal Cell Carcinoma

• Appearance

• First round oval

• Extends circumferentially

• Raised edges

• Shiny, pearly or translucent

Basal Cell Carcinoma

• Growing edges irregular and shape is uneven

• Central atrophy

• Hollow covered by vessels and ulceration

• Base invades underlying tissues

Squamous Cell Carcinoma

20 % of all cases of skin cancer

• Risks:

• Sun exposure

• Ionizing radiation

• Organic trivalent arsenic compounds

• Pipe smoking

• HPV

Squamous Cell Carcinoma

• Appearance

• Redness, slight scaling and fissuring initially

• Appears dry and may bleed when scratched

• Spreads laterally from edges and may heap up irregularly

• Centers may be atrophic and ulcerated

Keratacathoma

• Can be confused with SCC

• Occurs at trauma sites, esp immunocompromised

• Skin colored or pink initially and become dome shaped with rapid growth

• Matures to volcano shaped with protruding masses of keratin resembling lava.

• Will regress spontaneously!

Malignant Melanoma

• 1% of skin cancers but majority of deaths

• 76,000 annual cases in US (~10,000 deaths)

• #5 prevalence

• One of 3 cancers with mortality not decreasing in men

• Survival increasing – early diagnosis important

• 98% 5 yr survival if no LN involvement

• 63% if LN involvement

• 16% if organ involvement

Melanoma

•3X increase in incidence since 1975

• Lifetime risk in US 1:40 (2.4%) – mostly

whites

• 1:35 for men

• 1: 54 for women

• Yearly rate in Michigan > Texas and Florida

Melanoma

• Mortality increasing

• Only melanoma of top 7 US cancers increasing

• 31% have organ involvement at dx

• Mortality linked

• Thickness at time of dx

• Regional spread

• Physicians find melanoma earlier

• LOOK!

• Excisional Biopsy! – Early diagnosis!

Melanoma

• Screening, Counseling, Prevention

• Primary care can make a difference

• ABCDE’s

• Itching or bleeding – excise it!

• When in doubt – Take it Out

Superficial Spreading Melanoma

• Most common type of melanoma

• Dark brown or black

• Slowly spreading irregular outline

• Vertical growth late

Nodular Melanoma

• Shiny black dome – looks bad!!

• Grows vertically at the start and is more likely to

metastasize as grows more quickly

• Little or no lateral extension

Nodular Melanoma

Lentigo Maligna Melanoma

• Occurs in pre-existing lentigo maligna

• Appearance of nodules heralds change to invasive lesion

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fwww.myskincancercentre.com.au%2Flentigomaligna-melanoma%2F&ei=NLIaVba3LYeyogTfyYKIAw&bvm=bv.89381419,d.cGU&psig=AFQjCNE7oDg_CaFT3JAw5hDDoj0IMOvLzA&ust=1427899304084631

Acral Lentiginous Melanoma

• Palms, soles of feet, under nails, mucosa

• Least common melanoma

• Dark-skinned patients will get this type

Eponym for subungal melanoma?

Amelanotic melanoma

• Diagnosed later and prognosis worse

because lack of pigment

• Keys:

• sun exposure with sunburns

• moles that change: itch and bleed

• These moles need to come out!

Skin cancer prevention

• Avoid sunburns

• Sunscreen

• Tanning beds

• Hats and sunshirts

• Skin exam and biopsy!

Key points

• Look carefully at the skin

• Ask about sunburns, FH of melanoma and mole changes

• Biopsy or fond someone to biopsy

• Early detection can be lifesaving; esp in melanoma

• Avoid sunburns and counsel on protection