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but, if in doubt, the lesion should be examined histologically.
Seborrheic KeratosesIt is a rare elderly patient who does not have any seborrheic keratoses. These are the unattractive “moles” or “warts”P.269
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that perturb the elderly patient, occasionally become irritated, but are benign (Fig . 26-1 ).
TABLE 26-3 ▪ Classification of Tumors Based on Location
Location Possible Tumor Type
Scalp Seborrheic keratosis
Epidermal cyst (pilar cyst)
Nevus
Actinic keratosis (bald males)
Wart
Trichilemmal cyst
Basal cell carcinoma
Squamous cell carcinoma
Nevus sebaceous
Proliferating trichilemmal tumor
Cylindroma
Syringocystadenoma papilliferum
Seborrheic keratosis
Ear Actinic keratoses
Basal cell carcinoma
Nevus
Squamous cell carcinoma
Keloid
Epidermal cyst
Chondrodermatitis nodularis helicis
Venous lakes (varix)
Gouty tophus
Face Seborrheic keratosis
Sebaceous gland hyperplasia
Actinic keratosis
Lentigo
Milium
Nevi
Basal cell carcinoma
Squamous cell carcinoma
Lentigo maligna melanoma
Flat wart
Trichoepithelioma
Dermatosis papulosa nigra (African American women)
Fibrous papule of the nose
Colloid milium
Dilated pore of Winer
Keratoacanthoma
Pyogenic granuloma
Spitz nevus
Ephelides
Hemangioma
Adenoma sebaceum
Apocrine hydrocystoma
Eccrine hydrocystoma
Trichilemmoma
Trichofolliculoma
Merkel cell carcinoma
Angiosarcoma (elderly men)
Nevus of Ota
Warty dyskeratoma
Atypical fibroxanthoma
Angiolymphoid hyperplasia with eosinophilia
Blue nevus
Pedunculated fibroma
Eyelids Seborrheic keratosisMilium
Syringomas
Basal cell carcinoma
Xanthoma
Pedunculated fibroma
Neck Seborrheic keratosisEpidermal cyst
Keloid
Fordyce’s disease
Lip and mouth LentigoVenous lake (varix)
Mucous retention cyst
Leukoplakia
Pyogenic granuloma
Squamous cell carcinoma
Granular cell tumor (tongue)
Giant cell epulis (gingivae)
Verrucous carcinoma
White sponge nevus
Acral lentiginous melanoma
Pedunculated fibroma
Axilla Epidermal cystMolluscum contagiosum
Lentigo (multiple lentigo in axillae neurofibromatosis called Crowe’s sign)
Seborrheic keratosis
Chest and back AngiomaNevi
Ephelides
Actinic keratosis
Lipoma
Basal cell carcinoma
Epidermal cyst
Keloid
Lentigo
Café-au-lait spot
Squamous cell carcinoma
Melanoma
Hemangioma
Histiocytoma
Steatocystoma multiplex
Eruptive vellus hair cyst
Blue nevus
Nevus of Ito
Becker’s nevus
Pedunculated fibroma
Groin and Seborrheic keratosisMolluscum contagiosum
crural areas Wart
Bowen’s disease
Extramammary Paget disease
Wart
Molluscum contagiosum
Genitalia Squamous intraepithelial lesions
Epidermal cyst
Angiokeratoma (scrotum)
Pearly penile papules (around edge of glans)
Squamous cell carcinoma
Seborrheic keratosis
Erythroplasia of Queyrat
Bowen’s disease
Median raphe cyst of penis
Verrucous carcinoma
Hidradenoma papilliferum (labia majora)
Wart
Hands Seborrheic keratosisActinic keratosis
Lentigo
Myxoid cyst (proximal nail fold)
Squamous cell carcinoma
Glomus tumor (nail bed)
Ganglion
Common blue nevus
Acral lentigines melanoma
Giant cell tumor of tendon sheath
Pyogenic granuloma
Acquired digital fibrokeratoma
Recurrent infantile digital fibroma
Traumatic fibroma
Xanthoma
Dupuytren contracture
Wart
Feet NeviBlue nevus
Acral lentigines melanoma
Seborrheic keratosis
Verrucous carcinoma
Eccrine poroma
Seborrheic keratosis
Lentigo
Arms and legs Wart
Histiocytoma
Actinic keratosis
Squamous cell carcinoma
Melanoma
Lipoma
Xanthoma
Clear cell acanthoma
(legs)
Kaposi’s sarcoma (legs, classic type)
Dermatosis papulosa nigra is a form of seborrheic keratosis of African Americans that occur on the face, mainly in women. These small, black, multiple tumors can be removed, but there is the possibility of causing keloids or hypopigmentation. Stucco keratoses are numerous white 1- to 3-mm seborrheic keratoses mainly over feet, ankles, and lower legs. A very large seborrheic keratosis is sometimes referred to as a melanoacanthoma.
Presentation and CharacteristicsDescriptionThe size of seborrheic keratoses varies up to 3 cm for the largest, but the average diameter is 1 cm. The color may be flesh-colored, tan, brown, or coal black. They are usually oval in shape, elevated, and have a greasy, warty sensation to touch. White, brown, or black pinhead-sized keratotic areas called pseudohorned cysts are commonly seen within this tumor. There is an appearance of being superficial and “stuck on” the skin. Pruritus is common and sudden appearance may occur. Numerous lesions coming on rapidly can be a marker of underlying cancer (sign of Leser-Trélat).DistributionThe lesions appear on the face, neck, scalp, back, and upper chest, and less frequently on arms, legs, and the lower part of the trunk.CourseLesions become darker and enlarge slowly. However, sometimes they can enlarge rapidly and this can be accompanied by bleeding and inflammation, which is very frightening to the patient. Trauma from clothing occasionally results inP.271
infection and bleeding, and this prompts the patient to seek medical care. Any inflammatory dermatitis around these lesions causes them to enlarge temporarily and become more evident, so much so that many patients suddenly note them for the first time. Malignant degeneration of seborrheic keratoses is doubted.
TABLE 26-4 ▪ Classification of Skin Tumors Based on Clinical
Appearance
Appearance Possible Tumor Type
Flat, skin-colored tumors
1. Flat warts (viral)2. Histiocytomas3. Leukoplakia
Flat, pigmented tumors
1. Nevi, usually junctional type2. Lentigo3. Café-au-lait spot4. Histiocytomas5. Mongolian spot6. Melanoma (superficial spreading
type)
Raised, skin-colored tumors
1. Warts (viral)2. Pedunculated fibromas (skin tags)3. Nevi, usually intradermal type4. Cysts5. Lipomas6. Keloids7. Basal cell carcinomas8. Squamous cell carcinoma9. Molluscum contagiosum (viral)10. Xanthogranuloma (yellowish, usually
children)
Raised, brownish tumors
1. Warts (viral)2. Nevi, usually compound type3. Actinic keratoses4. Seborrheic keratoses5. Pedunculated fibromas (skin tags)6. Basal cell epitheliomas7. Squamous cell carcinoma8. Malignant melanoma9. Granuloma pyogenicum10. Keratoacanthomas
Raised, reddish tumors
1. Hemangiomas2. Actinic keratoses3. Granuloma pyogenicum
4. Glomus tumors5. Senile or cherry angiomas
Raised, blackish tumors
1. Seborrheic keratoses2. Nevi3. Granuloma pyogenicum4. Malignant melanomas5. Blue nevi6. Thrombosed angiomas or
hemangiomas
CauseHeredity is the biggest factor, along with old age.
Differential Diagnosis● Actinic keratoses: See Table 26-5 ● Pigmented nevi: Longer duration, smoother surface, softer to
touch; may not be able to differentiate clinically (see later in this chapter)
● Flat warts: In younger patients; acute onset, with rapid development of new lesions, colorless and flat topped without pseudohorned cysts; tiny black thrombosed capillaries may be seen usually smaller; may Koebnerize (see Chap . 23 )
● Malignant melanoma: Less common, usually with rapid growth, indurated; examination histologically with biopsy may be necessary (see later)
TreatmentCase ExampleA 58-year-old woman requests the removal of a warty, tannish, slightly elevated 2- × 2-cm lesion of the right side of her forehead.
1. The lesion should be examined carefully. The diagnosis usually can be made clinically, but if there is any question, a scissors biopsy (see Chap . 2 ) can be performed. It would be ideal if all of these seborrheic keratoses could be examined histologically, but this is not economically feasible or necessary.
2. An adequate form of therapy is curettement, with or without local anesthesia, followed by a light application
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of trichloroacetic acid. The resulting fine atrophic scar will hardly be noticeable in several months.
FIGURE 26-1 ▪ (A) Actinic keratoses in an oil refinery worker. (B) Hyperkeratotic actinic keratoses. (C) Seborrheic keratoses
on back. (D) Pedunculated seborrheic keratosis of eyelid. (Courtesy of Stiefel Laboratories, Inc.)
3. Electrosurgery can be used, but this usually requires anesthesia.
4. Liquid nitrogen freezing therapy works well, if available. It is the therapy of choice of most dermatologists. Do not freeze excessively.
5. Laser therapy has been used recently by some authors.6. Surgical excision is an unnecessary and more expensive form of
removal.SAUER’S NOTES
1. For many benign lesions, it often is best cosmetically to err on the side of surgical undertreatment rather than overtreatment. You can always remove any remaining growth later, but you cannot put back what you took off.
2. Scarring should be kept to a minimum.3. After any surgical procedure, I hand out a “Surgical Notes”
sheet that indicates postoperative care. Skin surgery sites usually heal without any complication. However, there are always questions and concerns from the patient about aftercare.
SURGICAL NOTES FOR THE PATIENT
Minor surgery has been performed for the removal or biopsy of a skin lesion.If liquid nitrogen was used to remove the growth, a blister or peeling at the growth site will develop in 24 hours; if electrosurgery, laser, or burning was used, a crust and scab will form; if a biopsy was made, there will be a crust or suture(s).The sites treated heal better if they are covered with a dressing with Polysporin ointment underneath during the day for 5 to 7 days and left uncovered at night and while bathing. Do not pick at the spot and try to avoid accidentally hitting the area.You can wash over the area lightly.A certain amount of redness and swelling around the surgery site is to be expected. Also you might have a small amount of drainage and crusting. A mild amount of redness and infection can be treated with Polysporin ointment locally three times a day.If more drainage or infection develops, apply a wet dressing with sheeting, or soak the area. Oral antibiotics can be given. Use a solution made with 1 teaspoon of salt to 1 pint of cool water or
Domeboro compresses and apply for 20 minutes three times a day. Make a fresh solution every day.If the infection becomes excessive, call the office or go to a hospital emergency department.If the scab is knocked off prematurely, bleeding may occur. This can be stopped by applying firm pressure with gauze or cotton for 10 minutes by the clock, and then releasing pressure gradually.Depending on the size of the surgery site, healing takes from 1 to 8 weeks. Some scarring or loss of pigment at the surgery site is possible. A few individuals have a tendency to form thick or keloidal scars, which is not predictable.If a biopsy was done, you may receive a separate bill for the pathology study from the laboratory. Call the office in 7 days for this report.Return to the office for further care or follow-up as directed.
Sauer’s Manual of Skin Diseases9th Edition
© 2006 Lippincott Williams & Wilkins