1. Halo nevus Answer: Halo nevus applies to a nevus that develops an area of surrounding leukoderma which may be followed by gradual depigmentation and ultimate disappearance of the nevus. Common on the posterior trunk, but can occur elsewhere. Clinically may be confused with malignant melanoma. No treatment is needed unless clinical doubt exists as to the nature of the lesion. 2. Nevus araneus Answer: Nevus araneus (spider nevus or spider telangiectasia) contains a central blood vessel that is slightly elevated with fine radiating vessels; occurs in children and adults, most frequently on the face; may arise during pregnancy; benign. Treatment is with laser or excision. 3. Nevus flammeus (neonatorum) Answer: Nevus flammeus (neonatorum) is a congenital vascular malformation; lesions are pink, macular and irregularly outlined; blanch completely with pressure; commonly confused with port wine stains; occurs on nape of neck, eyelids and glabella; almost always vanish within the first year of life. 4. Nevus sebaceous of Jadassohn Answer: Nevus sebaceous of Jadassohn is a plaque-like lesion composed of sebaceous glands, hair structures, skin appendages, squamous epithelium; appears in childhood; it is premalignant (15% become malignant, mostly basal cell carcinomas); treatment is surgical excision. 5. Spitz nevus Answer: Spitz nevus is a small, solitary, dome-shaped lesion that appears on the face in children; benign. 6. Eccrine poroma Answer: Eccrine poroma is a benign tumor of the sweat glands; usually occurs on the palms and soles as a pink pedunculated tumor with a hyperkeratotic periphery; may resemble a pyognenic granuloma without an eroded surface; treatment is excision. 7. Leiomyoma Answer: Benign cutaneous tumors consisting of smooth muscle proliferation are called leiomyomas. Multiple cutaneous leiomyomas occur in widely varying numbers, sometimes diffusely scattered on the trunk, face, or extremities. They tend to increase gradually in number and are usually firm, pale, reddish-brown, intradermal nodules less than 1 cm in size. Frequently they harden and become painful on pressure or application of cold. These multiple lesions are believed to arise from arrectores pilorum muscles. Solitary angioleiomyomas are usually small, encapsulated, subcutaneous nodules less than 2 cm in size, and they are seen mainly on the legs. They may be sensitive to pressure and cold and are believed to arise from venular smooth muscle. A third variety is the solitary genital lesion located in the subcutis on either the scrotum, labia majora, or nipple area. They may reach sizes of up to several centimeters. Solitary tender leiomyomas must be differentiated at times from glomus tumor and eccrine spiradenoma. Excision is the only suitable treatment for symptomatic leiomyomas. There is a fairly high tendency for recurrence. 8. 9. 10. 11. Merkel cell tumor Pilomatricoma Trichoepithelioma Basal cell cancer 12. Syringocystadenoma papilliferum Answer: Syringocystadenoma papilliferum is usually a verrucose lesion that occurs most commonly on or near the scalp. It is a hamartomatous growth that frequently develops within an associated organoid nevus of the nevus sebaceus type. These lesions often begin to develop during childhood and vary in size and appearance. They may be bulbous and exude fluid. Small lesions may be umbilicated and resemble molluscum contagiosum. Foci of basal cell epithelioma occur in about 10% of the lesions. Treatment consists of full-thickness excision of the lesion and any surrounding sebaceous nevus. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Trichilemmoma Actinic keratosis 15. Cylindroma 16. Nevus of Ota 17. Steatoma Blue nevus Hutchinson freckle Mongolian spot Keratoacanthoma Keloid Seborrheic keratosis 24. Intradermal nevus, compound nevus, & junctional nevus Answer: Intradermal nevus (most nevus cells found within the cutis) / Compound nevus (cells in the epidermis as well as a considerable number of nevus cells in the dermis): The cells from the neural crest of the embryo migrate to the skin surface and produce a number of a different types of pigmented nevus cell nevi. There are three major categories of nevus cell nevi: junction, compound and intradermal. They take their names from the microscopic position that most cells occupy in the skin. Flat lesions are likely to be junctional; those that are slightly raised are likely to be compound nevi. Sessile and dome shaped lesions are intradermal nevi in the vast majority of cases. Treatment is surgical excision 25. Cutis aplasia Answer: Cutis aplasia: Congenital absence of epidermis, dermis, and sometimes subcutis, from one or more circumscribed areas. Sixty percent of cases occur in the scalp. Treatment: In infancy, control of secondary infection and good nursing are the only measures available. Later many defects can be satisfactorily corrected with plastic surgery. 26. Pyoderma gangrenosum Answer: Multiple skin abscesses with necrosis and undermining ulcerations occur in the necrotizing lesion of the skin called pyoderma gangrenosum. It is often associated with ulcerative colitis (50% of patients). It has also been reported to occur in association with other gastrointestinal disorders (diverticulosis, regional enteritis, peptic ulcer disease, hepatitis, and carcinoid tumor) as well as rheumatoid arthritis, pulmonary diseases, and hematologic disorders. No systemic disease is evident in 20% of the patients with pyoderma gangrenosum. No specific organism or combination of organisms has been identified with this disease entity, although frequently Proteus and other gram-negative organisms and beta-hemolytic streptococci have been cultured from these wounds. Systemic and topical antibiotic therapy have been of some use in controlling the active disease process. It appears today that the basic lesion is not a primary infection but may be a necrotizing cutaneous vasculitis with rapidly developing hemorrhagic liquefying tissue necrosis of the skin. It is characterized by ulceration surrounded by bluish hemorrhagic cribriform edges. The course is protracted and in some instances fulminant. Careful control of pathogenic bacteria with culture and sensitivity tests preceding antibiotic therapy, associated with conservative debridement of the necrotic tissues, has been successful in many instances. It appears important to debride only the grossly necrotic tissue and not to incise the adjacent intact tissues, thereby avoiding extension of the disease beyond the operative debridement. Local and systemic steroid therapy immunosuppressives (e.g., azathioprine) and systemic sulfones have been helpful. Caution must be exercised when treating these patients with local injections because of the possibility of local skin trauma, which may induce new pyoderma gangrenosum lesions. 27. Marjolin’s ulcer Answer: Marjolin’s ulcer : Burn scar becomes a carcinoma, usually squamous cell, after about twenty to thirty years. 28. Cutaneous horn Answer: Cutaneous horn: hard, horn-like projection from the skin that may show invasive squamous cell carcinoma at the base of the lesion. A papillomatous proliferation with indistinct solid infiltrating margins and a slowly forming ulcerating center may occur. It bleeds easily. If persistent should be presumed to be squamous cell cancer and excised. 29. Erythroplasia of Queyrat Answer: Erythroplasia of Queyrat: Red patchy lesion which primarily affects the glans penis but may also be found on the penile shaft, vulva, and oral mucosa. It is associated with squamous cell carcinoma either in situ or locally invasive. Treatment is with Grenz ray therapy (low penetration x-rays which are absorbed in the superficial skin) and 5FU or Mohs surgery in difficult cases. 30. Necrobiosis lipoidica diabeticorum Answer: Necrobiosis lipoidica diabeticorum: Characterized by irregular, ovoid plaques with a violaceous, indurated periphery and a yellow central atropic area, this entity is strongly associated with diabetes mellitus. Because of its unknown cause and the fact that many cases occur in nondiabetics, many choose to call it by the shorter necrobiosis lipoidica (or NL). Lesions can start as small, firm , red-brown papules that slowly enlarge and develop the typical violet-brown periphery and yellow-brown center. They often occur on the pretibial area and are usually multiple and bilateral. Ulceration often occurs as a result of minor trauma, however, the ulcers rarely become infected even in diabetics. The prevalence of NL in diabetics is about 3 per 1000 with females outnumbering males 3 to 1. It occurs in patients of any age though it seems to occur at a slightly earlier age in diabetics (average age 30 vs. 41 for nondiabetics). Smoking does not seem to be a risk factor. Almost a fifth of patients will show spontaneous resolution though this may be over a period of up to 30 years. A consistently effective treatment for NL has yet to be found. Control of NL is not related to serum glucose control. Medical treatments have included corticosteroids both topical and intralesional, fibrinolytic agents, and antiplatelet and antithrombotic agents. Ulcerative NL cases usually respond to local wound care but occasionally they require surgical excision. This is usually accomplished by excision to deep fascia or periosteum with split-thickness skin grafting or skin flaps. Patients with NL should be educated to avoid to anterior leg trauma. 31. Bowenoid papulosis Answer: Bowenoid papulosis: Characterized by red-brown to violaceous papules ranging from 2 to 10 mm. The papules may show scaling on the surface, and have been noted to appear on the genitalia of both sexes as well as in other locations. While it is histologically similar to Bowen’s disease (see below), it tends to be non-aggressive in its course and may even spontaneously disappear. It tends to occur in a younger age group (21 to 38 years) and tends to be multicentric within the inguinal and crural areas and genitalia. Human papillomavirus, Type 16 has been found in these lesions which is associated with cervical carcinoma. It is recommended that the lesion should be removed with liquid nitrogen therapy or with electrodesiccation and curettage. 32. Dermatofibroma protuberans Answer: Dermatofibroma, histiocytoma, nodular subepidermal fibrosis, fibroma simplex, sclerosing hemangioma, noduli cutanei, and fibroma durum are various terms that have been applied to a common benign nonencapsulated, reactive, lenticular intradermal nodular lesion composed of proliferating fibrocytes, irregularly arranged bundles of fine collagen fibers, capillary blood vessels, histiocytes, and mononuclear inflammatory cells in varying proportions. At times the histiocytes in the lesions accumulate hemosiderin or become somewhat xanthomatized. The lesions are firm and range in color from pale skin hues through various shades of red, brown, and yellow. They occur most often on the lower extremities but also are seen on the arms and trunk in adults. They rarely exceed 1 cm to 2 cm in size. It is believed that some of these lesions develop at sites of minor trauma, for example, mosquito bites. No treatment is usually needed unless excision becomes warranted for cosmetic or symptomatic reasons. Excision for histologic establishment of the diagnosis may be necessary. Incomplete removal tends to be followed by recurrence. Dermatofibrosarcoma protuberans usually presents as a slowly growing, hard, nodular protuberant mass arising in the dermis, mostly on the trunk and thighs. It may be erythematous or slightly dusky in color and is covered by smooth, shiny epithelium that gives a keloidal appearance. There may be complicating ulceration, infection, and scarring. As this local disorder becomes extensive, it may cause severe pain, contractures, and invalidism. Histologically, there is a characteristic “cartwheel” pattern of the hypercellular fibrous bundles in these nonencapsulated tumors that extend finger-like processes into adjacent subcutis and fascia. Mitotic figures may be numerous. Wide excision, including the deep fascia, is necessary to prevent recurrence. Surgical margins of up to 3 cm have been recommended in the literature. Long-standing, inadequately excised lesions have been known to metastasize 33. Hidradenitis suppurativa Answer: Hidradenitis suppurativa, an inflammatory disease of the apocrine glands, presents most frequently as deep recurrent abscesses in the axillae, which may result in scarred deep sinus tracts, fluctuant draining of abscesses, and excruciating pain with limitation of abduction of the shoulder. Although seen most commonly in young females in the axillae, it also occurs in the groin and perineum and in the areolae. Early acute cases can be treated with local therapy, such as incision and drainage of the abscess, followed by control with long-term antibiotic therapy. However, once the disease entity is established with deep scarring and sinus tracts, the only appropriate therapy is surgical excision of the involved area. These patients are too frequently not offered the alternative of operative management of this disease until an unpleasant, prolonged course of conservative treatment for abscesses and pain has been undertaken. Rarely must patients be convinced of the need for operative interventions, as they have usually suffered extensively with the discomfort and unpleasantness of this disease. Culture of the purulent discharge and appropriate antibiotic therapy for a period of at least 10 days before operative intervention are important. Excision of all of the involved tissue is the ultimate goal of the operative procedure. Primary closure can be accomplished with large defects, but the surgeon must not compromise the excision to accomplish primary closure. Large areas of involvement (8 x 15 cm) can be excised and closed primarily if the wound is closed with heavy retention sutures to approximate the axillary fascia and subcutaneous tissues and if careful subcuticular skin closure is accomplished. When primary closure is not feasible, splitthickness skin grafts and immobilization of the arm with Velpeau’s dressings comprise the next choice. We have not found it necessary to use any type of skin flap to accomplish skin coverage in the axillary vault after excision of hidradenitis suppurativa. Good results have also been reported with excision without closure, allowing the wound to heal by secondary intention. When the disease has extended beyond the axilla onto the chest wall or the upper arm, it is preferable to excise the involved areas entirely and apply split-thickness skin grafts. It has been our practice to undertake the excision and grafting on one axilla at a time so that the patient is not totally disabled during the healing period. When the surgeon can clearly excise and close the wounds primarily, it is feasible to undertake correction of the disease in both axillae with one operative procedure. Good healing and lack of wound infection are usual when all the diseased tissue is properly excised. If the scarred sinuses or involved glands are not completely excised, delayed wound healing and infection are common. Because these patients have had limited abduction of the shoulder for long periods before the operative intervention, the need for exercises to abduct the arm must be stressed and the patients followed until full abduction is accomplished. 34. Xeroderma pigmentosum Answer: Xeroderma pigmentosum: a rare, systemic genetic disease transmitted by a sex-linked recessive gene. It is characterized by extreme sensitivity to sunlight from an early age. Associated metabolic abnormalities include elevation of serum copper and gamma globulin levels, increased excretion of urinary amino acids and decreased excretion of 17-ketosteroids and 17hydroxycorticosteroids. Beginning in early childhood, affected individuals show an unusual sensitivity to sun exposure with diffuse freckling initially followed by progressive drying and thinning of the skin. Keratoses later appear and by early adulthood, malignant changes in the skin occur in the form of basal cell carcinoma, squamous cell carcinoma, or melanoma. Most individuals eventually die from metastatic skin cancer, though a few cases of long-term survival have been reported. Increased survival has been reported by following a strict management regime consisting of absolute protection from sun exposure, frequent and regular skin observation, and early aggressive treatment of skin tumors as they occur. 35. Nodular fasciitis Answer: Nodular fasciitis is a benign proliferation of fibroblasts and myofibroblasts in the subcutaneous tissues. The lesions are generally small and solitary, arising commonly in the upper extremities of adults and in the head and neck region of infants and children. A history of trauma may precede these reactive lesions, but their cause is unknown. The rapid growth, abundant cellularity, and mitotic activity frequently cause these lesions to be misdiagnosed as sarcomas. Local excision is the treatment of choice for these generally nonrecurring lesions. 36. Bowen’s disease Answer: Bowen’s disease is predominantly a disease of the elderly, with a mean age at diagnosis in the sixth decade. Most often the lesion appears as a scaly, crusted, fissured, erythematous plaque. The histopathology of Bowen’s disease is that of squamous cell carcinoma in situ and is histologically indistinguishable from erythroplasia of Queyrat or bowenoid papulosis. Surgical excision is the therapy of choice for Bowen’s disease lesions. 37. Kaposi's sarcoma Answer: Kaposi's sarcoma is a vascular malignancy that can be HIV related or not. The non-HIV related kind occurs in the elderly of Mediterranean ancestry. The HIV-related kind is the leading cause of morbidity among 25-30% of AIDS patients and is by far the most common AIDS-associated malignancy. Since this is an aggressive tumor the treatment is usually not surgical and radiation therapy may be used for palliation 38. Sebaceous carcinoma Answer: Sebaceous carcinoma, or meibomian gland carcinoma, is a malignant tumor derived from the adnexal epithelium of sebaceous glands. It may arise in ocular or extraocular sites. Regardless of location the tumor is aggressive and has a tendency to recur locally after surgical excision. Wide margins of 5-6 mm are advocated. 39. Leiomyosarcoma Answer: Leiomyosarcoma is a rare malignant soft tissue sarcoma. Superficial leiomyosarcomas may occur anywhere in the body, but there is a predilection for the extremities and especially the thighs. At presentation, the lesion characteristically is a solitary, wellcircumscribed nodule of the skin. Wide local excision is the treatment of choice. 40. Xanthelasma Answer: Xanthelasma refers to xanthomas that occur in the eyelids. Xanthomas are lipid accumulations in tissues in association with large foam cells. Xanthelasma are usually plaque-like, yellow lesions, which are often found near the inner canthus. Treatment consists of surgical excision or CO2 laser. Whatever method is used, they can be frustrating because they are prone to recur.
