Theme: Skin disorders

A. Basal cell carcinoma

B. Dermatofibroma
C. Pilar cyst
D. Epidermoid cyst
E. Spitz naevus
F. Seborrhoeic keratosis
G. Atypical naevus
H. Capillary cavernous haemangioma

Please select the most likely underlying nature of the skin lesion described. Each
option may be used once, more than once or not at all.

1. A 70 year old lady presents with a number of skin lesions that she describes as
unsightly. On examination she has a number of raised lesions with a greasy
surface located over her trunk. Apart from having a greasy surface the the
lesions also seem to have scattered keratin plugs located within them.

Seborrhoeic keratosis

Theme from September 2012 Exam

Seborrhoeic keratosis may have a number of appearances. However, the scaly,
think, greasy surface with scattered keratin plugs makes this the most likely
diagnosis.

2. A 28 year old female presents with a small nodule located on the back of her
neck. It is excised for cosmetic reasons and the histology report states that the
lesion consists of a sebum filled lesion surrounded by the outer root sheath of a
hair follicle.

You answered Seborrhoeic keratosis

The correct answer is Pilar cyst

Pilar cysts may contain foul smelling cheesy material and are surrounded by the
outer part of a hair follicle. Because of their histological appearances they are
more correctly termed pilar cysts than sebaceous cysts.

3. A 21 year old lady presents with a nodule on the posterior aspect of her right
calf. It has been present at the site for the past 6 months and occurred at the site
of a previous insect bite. Although the nodule appears small, on palpation it
appears to be nearly twice the size it appears on examination. The overlying
skin is faintly pigmented.
 Dermatofibroma

Dermatofibromas may be pigmented and are often larger than they appear. They
frequently occur at sites of previous trauma.

Benign skin diseases

Seborrhoeic keratosis

 Most commonly arise in patients over the age of 50 years, often idiopathic
 Equal sex incidence and prevalence
 Usually multiple lesions over face and trunk
 Flat, raised, filiform and pedunculated subtypes are recognised
 Variable colours and surface may have greasy scale overlying it
 Treatment options consist of leaving alone or simple shave excision

Melanocytic naevi
Congenital  Typically appear at, or soon after, birth
melanocytic naevi  Usually greater than 1cm diameter
 Increased risk of malignant transformation (increased
risk greatest for large lesions)

Junctional  Circular macules

melanocytic naevi  May have heterogeneous colour even within same lesion
 Most naevi of the palms, soles and mucous membranes
are of this type

Compound naevi  Domed pigmented nodules up to 1cm in diameter

 Arise from junctional naevi, usually have uniform
colour and are smooth

Spitz naevus  Usually develop over a few months in children

 May be pink or red in colour, most common on face and
legs
 May grow up to 1cm and growth can be rapid, this
usually results in excision

Atypical naevus  Atypical melanocytic naevi that may be autosomally

syndrome dominantly inherited
 Some individuals are at increased risk of melanoma
(usually have mutations of CDKN2A gene
 - Many people with atypical naevus syndrome AND a parent
sibling with melanoma will develop melanoma

Epidermoid cysts

 Common and affect face and trunk

 They have a central punctum, they may contain small quantities of sebum
 The cyst lining is either normal epidermis (epidermoid cyst) or outer root
sheath of hair follicle (pilar cyst)

Dermatofibroma

 Solitary dermal nodules

 Usually affect extremities of young adults
 Lesions feel larger than they appear visually
 Histologically they consist of proliferating fibroblasts merging with sparsely
cellular dermal tissues

Painful skin lesions

 Eccrine spiradenoma
 Neuroma
 Glomus tumour
 Leimyoma
 Angiolipoma
 Neurofibroma (rarely painful) and dermatofibroma (rarely painful)

Theme: Skin lesion diagnosis

A. Pyogenic granuloma
B. Amelanotic melanoma
C. Dermatitis herpetiformis
D. Scabies
E. Basal cell carcinoma
F. Squamous cell carcinoma
G. Keratoacanthoma

Please select the most likely underlying diagnosis for the scenario given. Each option
may be used once, more than once or not at all.

4. A 72 year old man presents with a large nodule on his face. It is friable. There is
no regional lymphadenopathy. He is lost to follow up and re-attends several
months later. On this occasion the lesion has been noted to resolve with
scarring.
 Keratoacanthoma

Keratoacanthomas may reach a considerable size prior to sloughing off and

scarring.

5. A 22 year old girl is troubled by intensely itchy crops of blisters on her arms
and legs. On examination she is malnourished and she has papulovesicular
eruptions over her elbows and knees.

Dermatitis herpetiformis

Dermatitis herpetiformis is seen in association with coeliac disease.

6. A 30 year old man cuts the corner of his lip whilst shaving. Over the next few
days a large purplish lesion appears at the site which bleeds on contact.

Pyogenic granuloma

Pyogenic granulomas often appear at sites of trauma.

Skin Diseases

Skin lesions may be referred for surgical assessment, but more commonly will come
via a dermatologist for definitive surgical management.

Skin malignancies include basal cell carcinoma, squamous cell carcinoma and
malignant melanoma.

Basal Cell Carcinoma

 Most common form of skin cancer.

 Commonly occur on sun exposed sites apart from the ear.
 Sub types include nodular, morphoeic, superficial and pigmented.
 Typically slow growing with low metastatic potential.
 Standard surgical excision, topical chemotherapy and radiotherapy are all
successful.
 As a minimum a diagnostic punch biopsy should be taken if treatment other
than standard surgical excision is planned.

Squamous Cell Carcinoma

  Again related to sun exposure.
 May arise in pre - existing solar keratoses.
 May metastasise if left.
 Immunosupression (e.g. Following transplant), increases risk.
 Wide local excision is the treatment of choice and where a diagnostic excision
biopsy has demonstrated SCC, repeat surgery to gain adequate margins may
be required.

Malignant Melanoma
The main diagnostic features (major Secondary features (minor criteria)
criteria):
 Diameter >6mm
 Change in size  Inflammation
 Change in shape  Oozing or bleeding
 Change in colour  Altered sensation

Treatment

 Suspicious lesions should undergo excision biopsy. The lesion should be

removed in completely as incision biopsy can make subsequent
histopathological assessment difficult.
 Once the diagnosis is confirmed the pathology report should be reviewed to
determine whether further re-exicision of margins is required (see below):

Margins of excision-Related to Breslow thickness

Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Marsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol
2010 163:238-256.

Further treatments such as sentinel lymph node mapping, isolated limb perfusion and
block dissection of regional lymph node groups should be selectively applied.

Kaposi Sarcoma

 Tumour of vascular and lymphatic endothelium.

 Purple cutaneous nodules.
 Associated with immunosupression.
 Classical form affects elderly males and is slow growing.
 Immunosupression form is much more aggressive and tends to affect those
with HIV related disease.
Non malignant skin disease

Dermatitis Herpetiformis

 Chronic itchy clusters of blisters.

 Linked to underlying gluten enteropathy (coeliac disease).

Dermatofibroma

 Benign lesion.
 Firm elevated nodules.
 Usually history of trauma.
 Lesion consists of histiocytes, blood vessels and fibrotic changes.

Pyogenic granuloma

 Overgrowth of blood vessels.

 Red nodules,
 Usually follow trauma.
 May mimic amelanotic melanoma.

Acanthosis nigricans

 Brown to black, poorly defined, velvety hyperpigmentation of the skin.

 Usually found in body folds such as the posterior and lateral folds of the neck,
the axilla, groin, umbilicus, forehead, and other areas.
 The most common cause of acanthosis nigricans is insulin resistance, which
leads to increased circulating insulin levels. Insulin spillover into the skin
results in its abnormal increase in growth (hyperplasia of the skin).
 In the context of a malignant disease, acanthosis nigricans is a paraneoplastic
syndrome and is then commonly referred to as acanthosis nigricans maligna.
Involvement of mucous membranes is rare and suggests a coexisting
malignant condition

Theme: Management of skin lesions

A. Excision biopsy
B. Excision with 0.5 cm margin
C. Excision with 2 cm margin
D. Shave biopsy and cautery
E. Punch biopsy
F. Excision and full thickness skin graft
G. Discharge
For each skin lesion please select the most appropriate management option. Each
option may be used once, more than once or not at all.

7. A 22 year old women presents with a newly pigmented lesion on her right shin,
it has regular borders and normal appearing dermal appendages, however she
reports a recent increase in size.

Excision biopsy

Likely to be a benign pigmented naevus, radical excision therefore not

warranted.

8. A 58 year old lady presents with changes that are suspicious of lichen sclerosis
of the perineum.

Punch biopsy

This will generate sufficient material for histological assessment.

9. A 73 year old man presents with a 1.5cm ulcerated basal cell carcinoma on his
back.

Excision with 0.5 cm margin

A small lesion such as this is adequately treated by local excision. The British
Association of Dermatology guidelines suggest that excision of conventional
BCC (<2cm) with margins of 3-5mm have locoregional control rates of 85%.
Morpoeic lesions have higher local recurrence rates.

Skin Diseases

Skin lesions may be referred for surgical assessment, but more commonly will come
via a dermatologist for definitive surgical management.

Skin malignancies include basal cell carcinoma, squamous cell carcinoma and
malignant melanoma.

Basal Cell Carcinoma

 Most common form of skin cancer.

 Commonly occur on sun exposed sites apart from the ear.
 Sub types include nodular, morphoeic, superficial and pigmented.
  Typically slow growing with low metastatic potential.
 Standard surgical excision, topical chemotherapy and radiotherapy are all
successful.
 As a minimum a diagnostic punch biopsy should be taken if treatment other
than standard surgical excision is planned.

Squamous Cell Carcinoma

 Again related to sun exposure.

 May arise in pre - existing solar keratoses.
 May metastasise if left.
 Immunosupression (e.g. Following transplant), increases risk.
 Wide local excision is the treatment of choice and where a diagnostic excision
biopsy has demonstrated SCC, repeat surgery to gain adequate margins may
be required.

Malignant Melanoma
The main diagnostic features (major Secondary features (minor criteria)
criteria):
 Diameter >6mm
 Change in size  Inflammation
 Change in shape  Oozing or bleeding
 Change in colour  Altered sensation

Treatment

 Suspicious lesions should undergo excision biopsy. The lesion should be

removed in completely as incision biopsy can make subsequent
histopathological assessment difficult.
 Once the diagnosis is confirmed the pathology report should be reviewed to
determine whether further re-exicision of margins is required (see below):

Margins of excision-Related to Breslow thickness

Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Marsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol
2010 163:238-256.

Further treatments such as sentinel lymph node mapping, isolated limb perfusion and
block dissection of regional lymph node groups should be selectively applied.

Kaposi Sarcoma
  Tumour of vascular and lymphatic endothelium.
 Purple cutaneous nodules.
 Associated with immunosupression.
 Classical form affects elderly males and is slow growing.
 Immunosupression form is much more aggressive and tends to affect those
with HIV related disease.

Non malignant skin disease

Dermatitis Herpetiformis

 Chronic itchy clusters of blisters.

 Linked to underlying gluten enteropathy (coeliac disease).

Dermatofibroma

 Benign lesion.
 Firm elevated nodules.
 Usually history of trauma.
 Lesion consists of histiocytes, blood vessels and fibrotic changes.

Pyogenic granuloma

 Overgrowth of blood vessels.

 Red nodules,
 Usually follow trauma.
 May mimic amelanotic melanoma.

Acanthosis nigricans

 Brown to black, poorly defined, velvety hyperpigmentation of the skin.

 Usually found in body folds such as the posterior and lateral folds of the neck,
the axilla, groin, umbilicus, forehead, and other areas.
 The most common cause of acanthosis nigricans is insulin resistance, which
leads to increased circulating insulin levels. Insulin spillover into the skin
results in its abnormal increase in growth (hyperplasia of the skin).
 In the context of a malignant disease, acanthosis nigricans is a paraneoplastic
syndrome and is then commonly referred to as acanthosis nigricans maligna.
Involvement of mucous membranes is rare and suggests a coexisting
malignant condition

A 29 year old man presents with a lump in his scalp. It is located approximately 4cm
superior to the external occipital protuberance. It feels smooth and slightly fluctuant
and has a centrally located small epithelial defect. What is the most likely underlying
diagnosis?
 A. Cocks peculiar tumour

B. Dermoid cyst

C. Sebaceous cyst

D. Merkel cell tumour

E. Seborrhoeic wart

Sebaceous cysts are most frequently located in the scalp and have an associated
central punctum. They may become infected and develop superficial ulceration in
which case they are known as "Cocks Peculiar Tumour". The presence of a punctum
is highly suggestive of a sebaceous cyst and are not typically found in the other
lesions described.

Sebaceous cysts

 Originate from sebaceous glands and contain sebum.

 Location: anywhere but most common scalp, ears, back, face, and upper arm
(not palms of the hands and soles of the feet).
 They will typically contain a punctum.
 Excision of the cyst wall needs to be complete to prevent recurrence.
 A Cock's 'Peculiar' Tumour is a suppurating and ulcerated sebaceous cyst. It
may resemble a squamous cell carcinoma- hence its name.

Theme: Dermatological manifestations of disease

A. Pyoderma gangrenosum
B. Erythroderma
C. Dermatitis herpetiformis
D. Acanthosis nigricans
E. Multiple lipomata
F. Multiple neurofibromata
G. Multiple telangectasia
H. None of the above

Please select the skin disease associated with the condition described. Each option
may be used once, more than once or not at all.

11. A 22 year old man is investigated for weight loss. A duodenal biopsy taken as
part of his investigations shows total villous atrophy and lymphocytic
infiltrate. He has a skin lesion that has small itchy papules.
 You answered Acanthosis nigricans

The correct answer is Dermatitis herpetiformis

Theme from September 2012 Exam

The patient has coeliac disease and this is associated with dermatitis
herpetiformis.

12. A 72 year old man is investigated for weight loss. On examination he is deeply
jaundiced and cachectic. He also has a dark velvety lesion coating his tongue.

You answered Erythroderma

The correct answer is Acanthosis nigricans

Acanthosis nigricans may be associated with GI malignancies such as gastric

and pancreatic cancer.

13. A lesion that may occur in a 32 year old man with long standing Crohns
disease.

Pyoderma gangrenosum

Pyoderma gangrenosum may occur in Crohns disease.

Skin Diseases

Skin lesions may be referred for surgical assessment, but more commonly will come
via a dermatologist for definitive surgical management.

Skin malignancies include basal cell carcinoma, squamous cell carcinoma and
malignant melanoma.

Basal Cell Carcinoma

 Most common form of skin cancer.

 Commonly occur on sun exposed sites apart from the ear.
 Sub types include nodular, morphoeic, superficial and pigmented.
 Typically slow growing with low metastatic potential.
 Standard surgical excision, topical chemotherapy and radiotherapy are all
successful.
  As a minimum a diagnostic punch biopsy should be taken if treatment other
than standard surgical excision is planned.

Squamous Cell Carcinoma

 Again related to sun exposure.

 May arise in pre - existing solar keratoses.
 May metastasise if left.
 Immunosupression (e.g. Following transplant), increases risk.
 Wide local excision is the treatment of choice and where a diagnostic excision
biopsy has demonstrated SCC, repeat surgery to gain adequate margins may
be required.

Malignant Melanoma
The main diagnostic features (major Secondary features (minor criteria)
criteria):
 Diameter >6mm
 Change in size  Inflammation
 Change in shape  Oozing or bleeding
 Change in colour  Altered sensation

Treatment

 Suspicious lesions should undergo excision biopsy. The lesion should be

removed in completely as incision biopsy can make subsequent
histopathological assessment difficult.
 Once the diagnosis is confirmed the pathology report should be reviewed to
determine whether further re-exicision of margins is required (see below):

Margins of excision-Related to Breslow thickness

Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Marsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol
2010 163:238-256.

Further treatments such as sentinel lymph node mapping, isolated limb perfusion and
block dissection of regional lymph node groups should be selectively applied.

Kaposi Sarcoma

 Tumour of vascular and lymphatic endothelium.

 Purple cutaneous nodules.
  Associated with immunosupression.
 Classical form affects elderly males and is slow growing.
 Immunosupression form is much more aggressive and tends to affect those
with HIV related disease.

Non malignant skin disease

Dermatitis Herpetiformis

 Chronic itchy clusters of blisters.

 Linked to underlying gluten enteropathy (coeliac disease).

Dermatofibroma

 Benign lesion.
 Firm elevated nodules.
 Usually history of trauma.
 Lesion consists of histiocytes, blood vessels and fibrotic changes.

Pyogenic granuloma

 Overgrowth of blood vessels.

 Red nodules,
 Usually follow trauma.
 May mimic amelanotic melanoma.

Acanthosis nigricans

 Brown to black, poorly defined, velvety hyperpigmentation of the skin.

 Usually found in body folds such as the posterior and lateral folds of the neck,
the axilla, groin, umbilicus, forehead, and other areas.
 The most common cause of acanthosis nigricans is insulin resistance, which
leads to increased circulating insulin levels. Insulin spillover into the skin
results in its abnormal increase in growth (hyperplasia of the skin).
 In the context of a malignant disease, acanthosis nigricans is a paraneoplastic
syndrome and is then commonly referred to as acanthosis nigricans maligna.
Involvement of mucous membranes is rare and suggests a coexisting
malignant condition

Which of the following statements relating to Keloid scars is untrue?

A. They have a predilection for sternal , mandibular

and deltiod area wounds
 B. They are confined to the margins of the original
injury

C. They often recur following excision

D. May occur even after superficial injury

E. They may be treated by injection of triamcinolone

Hypertrophic scars remain
confined to the wound edges.

Keloids (by definition) will tend to extend beyond the margins of the wound and in
wounds of any depth.

Wound healing

Surgical wounds are either incisional or excisional and either clean, clean
contaminated or dirty. Although the stages of wound healing are broadly similar their
contributions will vary according to the wound type.

The main stages of wound healing include:

Haemostasis

 Vasospasm in adjacent vessels, platelet plug formation and generation of

fibrin rich clot.

Inflammation

 Neutrophils migrate into wound (function impaired in diabetes).

 Growth factors released, including basic fibroblast growth factor and vascular
endothelial growth factor.
 Fibroblasts replicate within the adjacent matrix and migrate into wound.
 Macrophages and fibroblasts couple matrix regeneration and clot substitution.

Regeneration

 Platelet derived growth factor and transformation growth factors stimulate

fibroblasts and epithelial cells.
 Fibroblasts produce a collagen network.
 Angiogenesis occurs and wound resembles granulation tissue.

Remodeling

 Longest phase of the healing process and may last up to one year (or longer).
  During this phase fibroblasts become differentiated (myofibroblasts) and these
facilitate wound contraction.
 Collagen fibres are remodeled.
 Microvessels regress leaving a pale scar.

The above description represents an idealised scenario. A number of diseases may

distort this process. It is obvious that one of the key events is the establishing well
vascularised tissue. At a local level angiogenesis occurs, but if arterial inflow and
venous return are compromised then healing may be impaired, or simply nor occur at
all. The results of vascular compromise are all too evidence in those with peripheral
vascular disease or those poorly constructed bowel anastomoses.

Conditions such as jaundice will impair fibroblast synthetic function and overall
immunity with a detrimental effect in most parts of healing.

Problems with scars:

Hypertrophic scars
Excessive amounts of collagen within a scar. Nodules may be present histologically
containing randomly arranged fibrils within and parallel fibres on the surface. The
tissue itself is confined to the extent of the wound itself and is usually the result of a
full thickness dermal injury. They may go on to develop contractures.

Image of hypertrophic scarring. Note that it remains confined to the boundaries of the
original wound:

Image sourced from Wikipedia

Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond
the boundaries of the original injury. They do not contain nodules and may occur
following even trivial injury. They do not regress over time and may recur following
removal.

Image of a keloid scar. Note the extension beyond the boundaries of the original
incision:

Image sourced from Wikipedia

Drugs which impair wound healing:

 Non steroidal anti inflammatory drugs

 Steroids
 Immunosupressive agents
 Anti neoplastic drugs

Closure
Delayed primary closure is the anatomically precise closure that is delayed for a few
days but before granulation tissue becomes macroscopically evident.

Secondary closure refers to either spontaneous closure or to surgical closure after

granulation tissue has formed.
A 72 year old man presents with a lesion on his back. Its appearances are as shown
below:
 Image sourced from Wikipedia
What is the most likely diagnosis?

A. Amelanotic malignant melanoma

B. Squamous cell carcinoma

C. Merkel Cell tumour

D. Basal cell carcinoma

E. None of the above

The lesion has all the characteristic features of a basal cell carcinoma. Including
raised surface and overlying telangectasia. Amelanotic melanomas are rare lesions
and usually have a more ulcerated appearance. Since the question is directed towards
the most likely diagnosis the correct answer is basal cell carcinoma.

Clinical images are not currently part of the MRCS Part A

Skin Diseases

Skin lesions may be referred for surgical assessment, but more commonly will come
via a dermatologist for definitive surgical management.

Skin malignancies include basal cell carcinoma, squamous cell carcinoma and
malignant melanoma.

Basal Cell Carcinoma

 Most common form of skin cancer.

 Commonly occur on sun exposed sites apart from the ear.
 Sub types include nodular, morphoeic, superficial and pigmented.
  Typically slow growing with low metastatic potential.
 Standard surgical excision, topical chemotherapy and radiotherapy are all
successful.
 As a minimum a diagnostic punch biopsy should be taken if treatment other
than standard surgical excision is planned.

Squamous Cell Carcinoma

 Again related to sun exposure.

 May arise in pre - existing solar keratoses.
 May metastasise if left.
 Immunosupression (e.g. Following transplant), increases risk.
 Wide local excision is the treatment of choice and where a diagnostic excision
biopsy has demonstrated SCC, repeat surgery to gain adequate margins may
be required.

Malignant Melanoma
The main diagnostic features (major Secondary features (minor criteria)
criteria):
 Diameter >6mm
 Change in size  Inflammation
 Change in shape  Oozing or bleeding
 Change in colour  Altered sensation

Treatment

 Suspicious lesions should undergo excision biopsy. The lesion should be

removed in completely as incision biopsy can make subsequent
histopathological assessment difficult.
 Once the diagnosis is confirmed the pathology report should be reviewed to
determine whether further re-exicision of margins is required (see below):

Margins of excision-Related to Breslow thickness

Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Marsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol
2010 163:238-256.

Further treatments such as sentinel lymph node mapping, isolated limb perfusion and
block dissection of regional lymph node groups should be selectively applied.

Kaposi Sarcoma
  Tumour of vascular and lymphatic endothelium.
 Purple cutaneous nodules.
 Associated with immunosupression.
 Classical form affects elderly males and is slow growing.
 Immunosupression form is much more aggressive and tends to affect those
with HIV related disease.

Non malignant skin disease

Dermatitis Herpetiformis

 Chronic itchy clusters of blisters.

 Linked to underlying gluten enteropathy (coeliac disease).

Dermatofibroma

 Benign lesion.
 Firm elevated nodules.
 Usually history of trauma.
 Lesion consists of histiocytes, blood vessels and fibrotic changes.

Pyogenic granuloma

 Overgrowth of blood vessels.

 Red nodules,
 Usually follow trauma.
 May mimic amelanotic melanoma.

Acanthosis nigricans

 Brown to black, poorly defined, velvety hyperpigmentation of the skin.

 Usually found in body folds such as the posterior and lateral folds of the neck,
the axilla, groin, umbilicus, forehead, and other areas.
 The most common cause of acanthosis nigricans is insulin resistance, which
leads to increased circulating insulin levels. Insulin spillover into the skin
results in its abnormal increase in growth (hyperplasia of the skin).
 In the context of a malignant disease, acanthosis nigricans is a paraneoplastic
syndrome and is then commonly referred to as acanthosis nigricans maligna.
Involvement of mucous membranes is rare and suggests a coexisting
malignant condition

heme: Management of skin diseases

A. Excision biopsy
B. Excision with 1 cm margin
C. Excision with 5 cm margin
D. Shave biopsy and cautery
E. Punch biopsy
F. Excision and full thickness skin graft
G. Discharge

For each scenario please select the most appropriate management option. Each option
may be used once, more than once or not at all.

16. A 89 year old women presents with long standing seborrhoeic warts of her
abdominal wall , they have caused troublesome itching.

You answered Excision biopsy

The correct answer is Shave biopsy and cautery

These lesions are often extensive and superficial. Shave excision will suffice,
material must be sent for histology.

17. A 22 year old man has an excision biopsy of a pigmented lesion from his back,
histology shows a 1mm depth nodular melanoma, all resection margins are
clear of tumour and the nearest is 0.5cm.

Excision with 1 cm margin

This man will require re-excision of margins so that a 1cm margin around the
lesion is achieved. This can usually be achieved without skin grafting.

18. A 73 year old lady presents to the breast clinic with a weeping crusty skin
lesion of the left nipple. There are no masses to feel in the breast itself and
imaging is normal.

You answered Shave biopsy and cautery

The correct answer is Punch biopsy

This is likely to represent Pagets disease of the nipple and is best diagnosed on
punch biopsy.

Skin Diseases

Skin lesions may be referred for surgical assessment, but more commonly will come
via a dermatologist for definitive surgical management.

Skin malignancies include basal cell carcinoma, squamous cell carcinoma and
malignant melanoma.

Basal Cell Carcinoma

 Most common form of skin cancer.

 Commonly occur on sun exposed sites apart from the ear.
 Sub types include nodular, morphoeic, superficial and pigmented.
 Typically slow growing with low metastatic potential.
 Standard surgical excision, topical chemotherapy and radiotherapy are all
successful.
 As a minimum a diagnostic punch biopsy should be taken if treatment other
than standard surgical excision is planned.

Squamous Cell Carcinoma

 Again related to sun exposure.

 May arise in pre - existing solar keratoses.
 May metastasise if left.
 Immunosupression (e.g. Following transplant), increases risk.
 Wide local excision is the treatment of choice and where a diagnostic excision
biopsy has demonstrated SCC, repeat surgery to gain adequate margins may
be required.

Malignant Melanoma
The main diagnostic features (major Secondary features (minor criteria)
criteria):
 Diameter >6mm
 Change in size  Inflammation
 Change in shape  Oozing or bleeding
 Change in colour  Altered sensation

Treatment

 Suspicious lesions should undergo excision biopsy. The lesion should be

removed in completely as incision biopsy can make subsequent
histopathological assessment difficult.
 Once the diagnosis is confirmed the pathology report should be reviewed to
determine whether further re-exicision of margins is required (see below):

Margins of excision-Related to Breslow thickness

Lesions 0-1mm thick 1cm
Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features)
Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features)
Lesions >4 mm thick 3cm
Marsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol
2010 163:238-256.

Further treatments such as sentinel lymph node mapping, isolated limb perfusion and
block dissection of regional lymph node groups should be selectively applied.

Kaposi Sarcoma

 Tumour of vascular and lymphatic endothelium.

 Purple cutaneous nodules.
 Associated with immunosupression.
 Classical form affects elderly males and is slow growing.
 Immunosupression form is much more aggressive and tends to affect those
with HIV related disease.

Non malignant skin disease

Dermatitis Herpetiformis

 Chronic itchy clusters of blisters.

 Linked to underlying gluten enteropathy (coeliac disease).

Dermatofibroma

 Benign lesion.
 Firm elevated nodules.
 Usually history of trauma.
 Lesion consists of histiocytes, blood vessels and fibrotic changes.

Pyogenic granuloma

 Overgrowth of blood vessels.

 Red nodules,
 Usually follow trauma.
 May mimic amelanotic melanoma.

Acanthosis nigricans

 Brown to black, poorly defined, velvety hyperpigmentation of the skin.

 Usually found in body folds such as the posterior and lateral folds of the neck,
the axilla, groin, umbilicus, forehead, and other areas.
  The most common cause of acanthosis nigricans is insulin resistance, which
leads to increased circulating insulin levels. Insulin spillover into the skin
results in its abnormal increase in growth (hyperplasia of the skin).
 In the context of a malignant disease, acanthosis nigricans is a paraneoplastic
syndrome and is then commonly referred to as acanthosis nigricans maligna.
Involvement of mucous membranes is rare and suggests a coexisting
malignant condition

hich of the following statements relating to sebaceous cysts is false?

A. When infected are also known as Cocks peculiar tumour

B. Typically contain pus

C. Are usually associated with a central punctum

D. Most commonly occur on the scalp

E. They will typically have a cyst wall

Sebaceous cysts usually contain sebum, pus is only present in infected sebaceous
cysts which should then be treated by surgical incision and drainage.

Sebaceous cysts

 Originate from sebaceous glands and contain sebum.

 Location: anywhere but most common scalp, ears, back, face, and upper arm
(not palms of the hands and soles of the feet).
 They will typically contain a punctum.
 Excision of the cyst wall needs to be complete to prevent recurrence.
 A Cock's 'Peculiar' Tumour is a suppurating and ulcerated sebaceous cyst. It
may resemble a squamous cell carcinoma- hence its name.