Skin Tumors
Introduction
The great majority of cutaneous tumors are of
little consequence and may never attract the
attention of the patient or his physician
 Genetic and environmental factors play an
important role
 Many skin tumors (e.g. actinic keratoses, basal
cell carcinomas, squamous cell carcinomas and
malignant melanomas) would all become less
common if fair skinned people protected
themselves adequately against sunlight.
 Accurate diagnosis is a must for proper
management of skin tumors. Biopsy as and
when in dilemma is a must.
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Classification

Tumors of skin are broadly classified as Benign,
Premalignant and Malignant
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They may also be classified according to their
origin as:
◦ Epidermal
◦ Appendageal - Pilar(hair), sebaceous and
sweat gland
◦ Melanocytic
◦ Mesodermal origin (vascular and connective
tissue)
Tumors arising from epidermis
Benign
Premalignant
Seborrheic
keratoses
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Leukoplakia
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Epidermal nevi
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Cutaneous horn
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Epithelial cyst
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Bowen’s disease
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Steatocystoma
multiplex
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Paget’s disease
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Keratoacanthoma
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Actinic keratoses
Malignant
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Squamous cell
carcinoma
Tumors of epidermal appendages
Benign
Malignant
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Trichoepithelioma
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Basal cell carcinoma
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Syringoma
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Adnexal carcinoma
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Cylindroma
Tumors arising from Melanocyte
Malignant melanoma
Tumors of mesodermal origin
Connective Tissue
Vascular Tumors
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Dermatofibroma
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Hemangioma
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Acrochordon (skin tag)
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Angiokeratoma
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Keloid
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Glomus tumor
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Neurofibroma
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Kaposi’s sarcoma
Other Cutaneous tumors
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Cutaneous Metastasis
Breast, lungs, colon, kidney, ovary, metastatic
melanoma

Lymphomas and Leukemias
Cutaneous T- cell Lymphomas: Mycosis
fungoides,
Sezary
syndrome
Seborrheic keratoses

Common, benign, persistent, epidermal lesion
appearing as macule or papule, brownish to grey
or black in colour

Greasy surface with plugged horns and a
classical ‘stuck on’ appearance

Seen mainly on the face, trunk and extremities in
adults over 30 years of age, often bilaterally
symmetrical and along skin cleavage lines

Dermatosis papulosa nigra: a variant seen as
heavily pigmented papules on face in Indian skin
Contd…
Seborrheic keratoses

Stucco keratoses: White lesions with a rough
surface and ‘stuck-on’ appearance on the
ankles of elderly; easily lifted off the skin with a
finger nail without causing bleeding

Diagnosis is clinical and biopsy in suspect
cases to rule out malignancy
Treatment

Curettage
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Electrodessication
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Cryotherapy with liquid nitrogen
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Shaving
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Chemical peeling with Trichloroacetic acid(TCA)
Acrochordons (skin tags)

Common benign and fleshy papular
overgrowths occurring in skin folds of obese
middle aged women

Skin-colored or brown, pedunculated or sessile
most often seen in axillae, groins and on neck
and eyelids

Usually asymptomatic, but maybe tender if
irritated by friction, jewellery or clothing
Treatment

Scissors excision with/ without local
anesthesia gives the best cosmetic result

Electrocautery or cryosurgery are other
options
Sebaceous cyst

Firm, subcutaneous, keratin-filled cyst
originating from a hair follicle

Arises spontaneously after puberty; usually
single, on the trunk, neck and post auricular
area
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Fixed to overlying skin by a punctum
representing the follicle

May get infected, rupture and trigger a foreign
body reaction leading to scarring

Can recur post drainage if cyst wall persists
Treatment

Elective surgical excision with the cyst wall to
prevent recurrence and scarring

Inflamed cysts need to be incised and drained
just like an abscess

Recurrent cysts that have previously ruptured
and scarred are best excised with the
surrounding scar after the inflammation
subsides
Keloids
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Benign, cutaneous lesions produced by
overgrowth of dense fibrous tissue
Uncontrolled synthesis and deposition of dermal
collagen
May extend to surrounding skin beyond the site
of injury
Common in young patients, rare in infancy and
old age. Females more predisposed than males.
Trigger factors unknown
May occur de novo but generally occur after
injury, burns, surgery, laser therapy or acne
Contd…
Keloids
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Most frequently on upper back and chest, neck,
shoulders, jaw, ear lobes and legs
These areas exert high tension on healing
wounds
Hereditary predilection (autosomal dominant
and recessive factors) known
Clinical course

Early stage :
Soft and pink resembling a hypertrophic scar

Late stage :
Firm and white, protuberant and more extensive
than original trauma, with irregular borders
having claw like extensions
Keloids attain a steady state size by gradual
growth and are unlikely to regress on their own
Treatment

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Intra-lesional steroid (ILS) injections :
Triamcinolone acetonide 10-40 mg/ml in
varying dilutions injected every 3-6 weeks till
lesion flattens
Combination of ILS + Hyaluronidase or 5Flurouracil for faster regression of keloids
Surgical excision followed by ILS
Intralesional bleomycin
Cryotherapy with liquid nitrogen + ILS
Constant pressure on the keloid with pressure
garments or silicone elastomer pads for
extensive lesions on extremities
Lasers: CO2 ,Nd: Yag
Neurofibromas
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Solitary tumor occurs occasionally, multiple
neurofibromas are more common
Seen as part of an autosomal dominant
inherited condition - Neurofibromatosis (von
Recklinghausen’s disease)
Neurofibromas are pink or skin colored, soft,
sessile or pedunculated papules or nodules
Plexiform neurofibromas occur along the course
of peripheral nerves creating irregular masses
or tender nodules
Button-hole sign: tumor compressible through a
deficient dermis
May feel ‘knotty’ or ‘wormy
Neurofibromas
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Solitary tumor occurs occasionally, multiple
neurofibromas are more common
Seen as part of an autosomal dominant
inherited condition - Neurofibromatosis (von
Recklinghausen’s disease)
Neurofibromas are pink or skin colored, soft,
sessile or pedunculated papules or nodules
Plexiform neurofibromas occur along the course
of peripheral nerves creating irregular masses
or tender nodules
Button-hole sign: tumor compressible through a
deficient dermis
May feel ‘knotty’ or ‘wormy
Treatment
Excision advised in cases of :
 Cosmetically unacceptable or painful lesions
 Lesions on vital structures
 Lesions suspected of undergoing malignant
change
Hemangiomas
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Benign red, purple or blue vascular neoplasms
occurring within the first year of life; seen in 1-3%
of newborns and 10% of 1 year olds
They exhibit endothelial cell hyperplasia
More likely to be seen in girls and premature
infants; predilection for the head and neck
Can appear at any site including the oral or
genital mucosa
Multiple cutaneous hemangiomas may be
associated with visceral hemangiomas
Contd…
Hemangiomas
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Lesions may ulcerate, bleed and get infected
Hemangiomas near eyes, ears, mouth or viscera
can threaten the function of these organs
Hemangiomas and Portwine stain - common
vascular malformation
Hemangioma (hamartoma)
Portwine stain (vascular esctasia)
Clinical course
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Early hemangiomas may appear flat and pale
white with few telangiectasia and dilated blood
vessels
In growth phase, they are bright red(superficial)
and purple(deep) and feel firm and rubbery
Involuting hemangiomas are slate-gray and
begin to soften
Treatment
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Benign and self- limiting; therefore no treatment
is required in most cases
Parents need to be reassured about the course
of the growth and its subsidence in 5-7 years
Recurrent bleeding, infection, ulceration or
pressure on vital structures need active
treatment
Treatment options: Steroids, sclerotherapy,
embolisation, compression, laser therapy
Actinic keratoses
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Common, persistent keratotic lesions with
malignant potential
Predisposing factors: Cumulative sun exposure,
fair skin (type I and II)
Affect the middle aged and elderly in temperate
climates but younger people in the tropics
Clinical features
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Pink or gray rough scaling macules or papules
in the sun exposed areas; roughness better felt
than seen
10-20% of lesions progress to squamous cell
carcinoma
Diagnosis is clinical but biopsy is warranted
where malignancy is suspected
Treatment
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Cryotherapy with liquid nitrogen or CO2 snow is
simple and effective
Electrodesiccation and curettage for larger
lesions
5- flurouracil (5%) cream and imiquimod (5%)
cream for multiple lesions
Photodynamic therapy
CO2, Er:YAG lasers, dermabrasion
Cutaneous horn
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Hard, yellowish brown, horny outgrowth, often
curved with circumferential ridges
Surrounded by acanthotic collarette
Inflammation and induration beneath indicates
malignant change
Seen on exposed areas specially upper part of
face and ears
Squamous Cell Carcinoma (SCC)
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Invasive, primary skin malignancy arising from
keratinocytes of skin or mucosa
Can be fatal by local spread or metastasis if left
untreated
Sites:
Most commonly seen on head, neck or hands of
elderly patients. Mucosae and mucocutaneous
junction more common in Indians; sun exposed
areas commonly in whites
Predisposing factors
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Skin types I - III, UV exposure, radiation, arsenic
and hydrocarbon, chronic inflammation, burns(
Marjolin’s ulcer)
Spices, spirits, smoking (and chewing tobacco),
syphilis, sharp tooth predispose to oral SCC
Human papilloma virus (HPV) infection is risk
factor for cervical and genito-anal SCCs
May arise de novo or from precursor skin
lesions
Precursor skin lesions
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Lupus vulgaris
Hypertrophic lichen planus
Stasis ulcers
Discoid lupus erythematosus
Sinuses as in chronic osteomyelitis, pilonidal
sinus, hidradenitis suppurativa
Post burns or vaccination scars
Actinic keratosis
Bowen’s disease
Clinical features
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De novo: sharply defined, smooth, dull red, firm,
dome shaped nodule with crusted centre.
Removal of crust shows foul smelling keratin
debris.
Surrounding skin shows signs of photodamage
such as wrinkling and telangiectasia
From prior skin lesions: irregular borders,
induration; bleeding heralds the onset of
malignancy
Regional lymph node enlargement and
metastases to other organs known if left
untreated
Treatment
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Wide local excision with histologic confirmation
of margins
Regional lymph node dissection if involved
Mohs’ micrographic surgery
Radiation therapy or chemotherapy in
inoperable cases
SCCs on lip, scalp and ear - more aggressive
and more likely to metastasize
Ensure regular follow-up to look for recurrence
Basal Cell Carcinoma (BCC)
Synonym : Basalioma, Rodent ulcer
 Most common cutaneous malignancy
 Locally invasive and destructive; usually slow
growing, rarely metastasizes
 Fair skin, sun exposure, ionizing radiation and
age > 40 years are risk factors
 Seen mainly on sun-exposed areas like face,
scalp, ears and neck, less often on trunk and
extremities
Clinical course

Nodulo-ulcerative type begins as a flesh
coloured waxy nodule with telangiectasia →
enlarges → central ulceration → deepens →
rolled out, beaded edges → destroys structures
locally as deep as bone or cartilage → aptly
named ‘rodent ulcer’

Rare metastasis (about 10%) but recurrence
known after inadequate treatment
Treatment
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Simple excision with a margin of 2-5 mm is the
treatment of choice.
Mohs’ micrographic surgery for recurrent BCCs
Curettage and cautery, cryotherapy for small
lesions
Radiation therapy, photodynamic therapy and
topical immunomodulators for localised, well
defined growths or for patients refusing surgery
5 year cure rates are almost 90% for primary
and 83% for recurrent BCCs
Malignant melanoma

Increasingly common malignancy of
melanocytes, most often arising in the skin

Potentially curable with early diagnosis and
treatment; late diagnosis carries poor prognosis
Predisposing factors
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Fair skin (Type I & II)
Personal / family history of atypical nevi or
melanoma
Presence of congenital nevi (number is
proportional to risk)
History of frequent sunburn
Clinical course
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30% of melanomas arise in pre-existing nevi
whereas 70% arise de novo
Begins as irregularly pigmented macule or
plaque → change in color, shape and size
Nodular variant → dermal involvement → high
risk of metastasis → poor prognosis
Prognostic factors
ABCDE of melanoma
 Asymmetry
 Border irregularity
 Color variability
 Diameter > 1 cm
 Evolutionary change
Management


Diagnosis :
Biopsy is the most definitive diagnostic tool.
Excision biopsy preferred
Treatment :
Complete excision of the lesion with a free
margin of at least 1cm is the only reliable
therapy
For local, regional or distant metastasis,
options include wide excision, lymph node
resection, chemotherapy and immunotherapy
Thank you