Benign skin tumor ( non – vascular )

Benign Skin Tumors
( non – vascular )
Y. RISSIN M.D.

VIRAL TUMORS
VERRUCA VULGARIS
• Small, raised, rough, clearly defined borders
• Most likely on the fingers, hands and arms
• Often appear in clusters around a "mother wart”
• Causes - papilloma virus
• Most common in children & young adults
• Mildly contagious (person to person , area to area)
• Treatment- Chemicals, Cryotherapy,
Electrosurgery, Laser
• Prognosis - spontaneous, recurrence

MOLLUSCUM CONTAGIOSUM
• Molluscum contagiosum virus
• Incubation period averages 2 to 3 months
• Transmission - skin-to-skin, inanimate object
• Sexually transmitted disease in adults
• Treatment - self-resolving, surgically,
chemical, cryotherapy, laser
• Can last from 2 weeks to 4 years
(average 2 years)

TUMORS OF THE
EPIDERMIS
SEBORRHEIC KERATOSIS
(seborrheic wart, senile wart, basal cell papilloma)
• Round/oval, yellow/brown/black slightly elevated,
often waxy surface, rough or wart-like texture
• Origin - unknown, not caused by exposure to
sunlight or viruses
• Light-skinned persons after age 40
• Usually painless & benign, may become irritated
and itch

• Rapid growth - paraneoplastic syn.
• D.D - melanoma
• Treatment- usually is not required, may be removed
surgically, cryotherapy, laser
• Prognosis - benign, usually do not recur after removal

AKTINIC KERATOSIS
(solar/senile keratosis)
• Precancerous lesion caused by sun damage
• Light brown macules, can be slightly elevated,
feel rough, scaly
• If untreated - can turn into cancer
• Biopsy is recommended
• Treatment - 5-FU, surgery, cryotherapy, laser

KERATOACANTHOMA
(molluscum sebaceum)
• Firm nodule, central keratotic plug
• Ears, nose, cheeks, dorsum of the hands
• Benign, develops rapidly, self healing
• Difficult to distinguish from SCC
• Treatment - usually regresses spontaneously
in months, surgical excision is recommended
(scar, rule out SCC)

EPIDERMAL CYSTS
DERMOID CYST
• Congenital hamartoma resulting from the
entrapment of epidermis along the lines of
embryonic fusion
• Lateral ends of the eyebrows, along the
midline in the nasal root, neck, sublingual,
sternal, perineal, scrotal, and sacral areas
• Of variable size
• Treatment - complete excision
• Preoperative CT (midline)

MILIA
(Fullicular infundibular cyst)
• Domed superficial cysts 1-2 mm
• Uniform, pearly-white to yellowish, filled
with keratin
• Occur in all ages
• Primary milia - infants, nose, may be on the
mucosa and palate, (Epstein's pearls)
• Secondary milia - blistering disorders,
dermabrasion

• Primary milia arise in sebaceous glands that are not fully developed
• Secondary milia due to disruption of the sweat duct
• Treatment - no topical or systemic medications have any effect on milia
• Can be safely left alone
• Prognosis: primary milia in infancy tend to spontaneously
disappear within the first few weeks of life. Secondary milia
arising from blisters often do not resolve

ADNEXAL TUMORS
SEBACEOUS TUMORS
Sebaceous Hyperplasia
• Small, round, up to 3 mm, flesh-colored/
white/yellow, often have a central indentation
• Enlarged sebaceous glands on the
forehead/cheeks of the middle-aged/elderly
• Treatment - light cautery, diathermy, laser
• When severe, oral isotretinoin,antiandrogens,
may improve the appearance

Nevus Sebaceus
(organoid nevus)
• Well-circumscribed, verrucose/finely nodular,
orange, raised, irregular, hairless plaque
• Scalp, face, neck
• Present at birth and persists throughout life
• Other tumors tend to arise in these lesions
(basal cell epithelioma 15%- 20%)
• Treatment - excision during childhood

Nevus Verrucosus
• Patchy/linear papillomatous, yellowish-tan
keratotic plaque
• Appears at birth or during childhood
• Treatment - excision with a full thickness of
skin to ensure that they do not recur, vitamin
A analogs (reduce the degree of varicosity)

Epidermoid cysts
• Dome-shaped, filled with semisolid material
• Trunk, face, neck, scalp
• Most common in adolescents and adults
• Can be injured or infected
• Causes – epidermal cells being trapped in
the dermis (plugged ducts)
• Treatment – removal
• Complications - infection, rupture

HAIR FOLLICLE TUMORS
Pilomatrixoma
• Firm, deep-seated nodule
• Head, neck and upper extremities
• Made up of hair precursor cells
• Treatment - excision

Trichoepithelioma
• Uncommon, arise on the face after puberty
• Single or multiple benign tumors
• Small < 1cm, firm, rounded, shiny, yellow,
pink, brown or bluish
• Both cheeks, eyelids, around the nose
• Gradually increase in number with age

• Treatment - Individual lesions may be removed surgically if
there is any suspicion of malignant change
• Laser & dermabrasion may improve the appearance but partial
destruction of the tumor is usually followed by regrowth

Pilar Cyst
(wens cysts, tricholemmal cysts)
• Resemble epidermoid cysts
• Scalp (90%)
• Contain nonlamellous keratinous
material
• Occurrence of large numbers - look for
Gardner’s syndrome

SWEAT GLAND TUMORS
Syringoma
• Skin-colored/slightly yellow papules, 1–3 mm
• Adenoma of the intraepidermal eccrine duct
• Usually presents as multiple lesions at puberty
• Symmetrically on the eyelids, cheeks, axilla,
umbilicus and pubic area
• Treatment - excision, laser, light
electrodessication

Eccrine Poroma
• Dome-shaped, polypoid/verrrucoid 1-10cm
• Single tumor, sole/sides of the foot
• Usually occurs after the age of 40
• On rare occasions, may develop into a
porocarcinoma or malignant eccrine poroma
• Malignant transformation - ulcers, rapid
growth, multinodular growth, bleeding
• Treatment - excision

Hydradenoma Papilliferum
• Have a tendency to ulcerate
• Can easily be mistaken for a carcinoma
• Treatment - excision

Cylindroma
(turban tumor)
• Round/lobulated, firm, pink nodules
• Solitary & multiple forms
• Multiple lesion occur as an autosomal
dominant inherited
• Solitary - not inherited
• Most common in the scalp
• Treatment – complete excision

DERMAL TUMORS
DERMATOFIBROMA
(histiocytoma, nodulus cutaneus, sclerosing
angioma, lipoidal histiocytoma, fibroma simplex,
fibroma durum)
• A firm, pea-sized, slightly elevated, fleshtoned
to purplish or dusty brown
• The cause is not known
• Common in adults, rarely in children
• Treatment - can be removed completely
(surgically excised), or only the elevated
portion can be removed

SKIN TAGS
(acrochordon, soft fibroma, cutaneous tags)
• Common, occur most often after midlife
• Tiny skin protrusions, may have a small
narrow stalk
• Painless, do not grow or change
• Neck, armpits,trunk, body folds or other
area
• Treatment - not necessary unless the
tags are irritating or are cosmetically
displeasing

TUMOR OF NEURAL TISSUE
GRANULAR CELL MYOBLASTOMA
(granular cell schwannoma)
• It is not clear whether or not it is a true neoplasm,
a developmental anomaly, or a trauma-induced
proliferation
• Widely distributed throughout the body, 50%
occur in the oral cavity
• Malignant variants represent approximately 1%
of all cases
• Usually as a sessile, painless, firm,
immovable nodule < 1.5 cm, smooth surface

• Pallor or a yellowish discoloration
• Treatment - conservative excision
• Recurrence is seen in fewer than 7% of cases even if granular
cells extend beyond the surgical margins of the biopsy sample

NEUROFIBROMA
• Unknown origin, may occur in peripheral
nerve, soft tissue, skin or bone
• Firm, gray-white mass with no capsule
• Vary in size from a few millimeters to 5 cm
• Solitary lesion more common than multiple
• Solitary lesions most commonly present
from age 20 to 30 and often arise as
superficial painless mass in the dermis

• Neurofibromas that occur as part of von Recklinghausen's disease are
generally larger and have a 4% chance of malignant transformation
• Treatment, if necessary, is surgical excision

MISCELLANEOUS
LIPOMA
• Made up of fat cells
• Smooth, fluctuant lumps under the skin
• Rarely painful
• Treatment - normally no treatment is required

XANTHELASMA & XANTHOMA
• Common among older adults and persons with
elevated blood lipids
• Xanthelasmas - usually under the skin of the
eyelids near the nose
• Xanthomas - can appear anywhere, commonly
on the elbows, joints, tendons, knees, hands, feet
or buttocks
• Ranging in size from very small to
more than 8 cm
• Treatment - if necessary, is surgical
excision, laser

MUCOUS CYSTS
• Rapid development of soft, rounded
cyst, 2 to 10 mm
• Small, non painful, deposits of fatty
materials under the surface of the skin
• Surface is made up of translucent mucosa
• Most often occurring inside the
lower lip
• Caused by traumatic rupture of the mucus
gland duct with extravasation of
sialomucin into the submucosa
• Treatment - laser, total cyst excision

MYXOID CYSTS
(mucous cyst of finger or toes)
• Cystic lesion (actually a ganglion) over
dorsum of finger near DIP & fingernail
• May or may not be connected to DIP joint by
a synovial stalk
• May be associated with grooving of
fingernail distal to the cyst
• Usually flesh colored and compressible

• Treatments – Cryotherapy, steroid injection, sclerosant
injection, surgical removal
• Unfortunately, mucous cysts often recur,
whatever treatment is used

PIGMENTARY SYSTEM

Melanocytes & Skin Color
• The melanin pigmentary system is
composed of functional units -
epidermal melanin units
• Each unit consists of a
melanocyte that supplies
melanin pigment to a group of
keratinocytes (about 36)
• Pigmentation is determined primarily by
the amount of melanin transferred to the
keratinocytes

• Melanosomes are membrane-bound organelles located in the
cytoplasm of melanocytes and bearing tyrosinase enzyme.
They are responsible for melanin synthesis and pigment
transfer from the melanocyte to the surrounding keratinocytes
• Pigment transfer occurs by keratinocyte
phagocytosis of melanosome
• The differences in racial pigmentation
are not due to differences in the number
of melanocytes, but rather to
differences in melanocyte activity
• Melanin is a brown-black, lightabsorbing
pigment, protecting
the skin against ultraviolet rays

• The melanocyte is a dendritic cell present
in the basal layer of the epidermis
• Melanocytes arise from the neural crest
as melanoblasts and migrate to the
dermis, hair follicles, leptomeninges,
uveal tract and retina
• By the 8th week of intrauterine life,
they start to migrate from the dermis
to the epidermis
• Although full melanocyte migration is normally
completed prior to birth, residual dermal
melanocytes are sometimes left (clinically
appearing as mongoloid spots in the sacral area
of oriental and black infants)

PIGMENTED LESIONS
FRECKLES (ephelides)
• Flat, small brown spot on a sun-exposed area
• Usually multiple in number.
• If a freckle changes significantly, it should
be examined
• Most freckles are medically unimportant
• Cosmetic removal of freckles by laser

LENTIGINES
(Sun spots, age spots, liver spots)
• Flat, brown discolorations of the skin
• Usually occur on the back of the hands,
neck & face of people older than 40 years
• Are caused by exposure sun over years
• Prevention - sunscreen
• Treatment - alpha hydroxy & beta
hydroxy acid gel, retin-A, topical vitamin
C, alpha hydroxyacid peel, Liquid
nitrogen therapy

NEVUS CELL NEVUS
JUNCTIONAL NEVUS
• Usually multiple
• Can occur on any part of the body
• Histologically the nests of melanocytes are
confined to the dermo-epidermal junction

COMPOUND NEVUS
• Common, raised and pigmented mole,
usually dome-shaped papules, may become
pedunculated
• Often present on the face or trunk
• Varies from barely tan to dark brown
• Histologically, the nests of melanocytes are
both at the dermo-epidermal junction and in
the underlying dermis

INTADERMAL NEVUS
• Usually dome-shaped
• Found most often on the scalp, hand,
and neck of adults
• Histologically the nests of melanocytes
are confined to the dermis

BLUE NEVUS
• Variant of a common mole
• Gets its name from the distinct appearance
• Usually present at birth but can develop later
• There are 3 types of blue nevus:
1.Common blue nevus
2.Cellular blue nevus
3.Combined blue nevus – nevomelanocytic
nevus

• Common blue nevus - a small bluish gray papule commonly over
the hands and feet. It develops later in life
• Cellular blue nevus - bigger in size reaching up to 3 cm
• Combined blue nevus and melanocytic nevus - present as bluish
gray nodules or plaques, may be present at birth or later in life
• Treatment - any blue nevus which has not changed recently can
be left alone

HALO NEVUS
(leukoderma acquisitum centrifigum, Nevus of Sutton)
• Pink or brown, surrounded by an area of white
or light skin
• The halo is depigmented skin
• Usually seen in young people
• The mole portion tends to flatten and may
disappear completely
• The white area may stay if the mole disappears,
or the normal skin color may return

• Occurs when the immune cells attack a mole for unknown reasons
• Are sometimes seen in people with vitiligo or may occur in patients
with malignant melanoma
• Atypical moles are more common on people with halo nevi
• Treatment - normally no treatment is required
• A yearly complete skin exam is recommended for those with halo
nevi or a single halo nevus to make sure there are no atypical moles
or malignant melanoma

DYSPLASTIC NEVUS
(atypical nevus, Clark's nevus)
• An acquired mole that may appear as
solitary or multiple lesions
• Usually appear in adolescence on the
back, chest, abdomen, buttocks, scalp.
• Seen in about 4% of the white population
• The tendency to develop dysplastic nevi
is familial

• More than 5 mm in diameter, at least partly flat, has two of the
following three characteristics:
1. Variable coloring
2. Asymmetrical outline
3. Irregular borders
• Someone with a dysplastic nevus is considered to have an
increased lifetime risk for melanoma
• Treatment - routinely evaluation by (once or twice a year)
removing all of these moles is neither practical nor recommended
• Relatives of persons with dysplastic nevi and melanoma
should be examined more frequently

CONGENITAL GIANT (Hairy)
PIGMENTED NEVUS
(bathing trunk nevus)
• Present at birth as large continuous areas
of multiple discrete patches of pigment,
often verrucous, often extremely hairy
• May be associated with abnormalities
(spina bifida, meningocele, other nevi,
neurofibromatosis)
• May eventually develop melanoma
with an incidence of 15%
• Surgical excision is recommended

SPINDEL & EPITHELIOID CELL NEVUS
(spits nevus, benign Juvenile Melanoma)
• Benign, elevated, pink to purplish-red
papule, with a slightly scaly surface
• Usually appears on the face, especially the
cheeks, trunk, and extremities
• Most often occurs before puberty
• Has been mistaken for M.M
• Difficult to distinguish from melanoma
(atypical melanocytes)

OTA’S NEVUS
(oculodermal melanocytosis)
• Hyper pigmentation of certain ocular tissues
and the skin, usually in the territory of the
first and second division of the fifth cranial
nerve, usually unilateral
• Some patients may manifest dermal
involvement alone, others may have only
ocular changes
• Although the condition is congenital, the level
of pigmentation becomes more intense at
puberty and in pregnancy

• Sequelae - glaucoma, malignant melanoma
• M.M can occur at a variety of tissue sites including the uveal tract,
orbit, dura and the central nervous system
• Treatment - Q-switched lasers, liquid nitrogen cryotherapy,
dermabrasion, YAG laser

BACKER’S NEVUS
• Uncommon pigmented smooth muscle
hamartoma
• Develops during adolescence and occurs
primarily in young men
• Hypertrichosis and hyper pigmentation
• Usually unilaterally over the shoulder,
upper arm, and scapula
• Treatment, if necessary, is excision, laser

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