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71 Cards in this Set

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Basal Cell Carcinoma
Basal cell carcinoma is a malignant neoplasm arising from the basal cells of the epidermis
Is the most common skin cancer
Caused by ultraviolet light
Rarely metastasizes

Basal cell carcinoma occurs most commonly in sun-exposed skin, particularly on the head and neck in fair individuals.
Diagnosis is confirmed by biopsy
From L to R, the 4 Types of Basal Cell Carcinoma
1. Nodular
2. Superficial
3. Scarring (sclerotic)
4. Pigmented
Therapy for Basal Cell Carcinoma
- Excision
- Curettage and electrodessication
- Mohs micrographic surgery
- Radiation
- Cryosurgery
- 5-Fluorouracil or imiquimod topically for multiple superficial basal cell carcinomas
Actinic (Solar) Keratosis
A precancerous neoplasm confined to the epidermis caused by ultraviolet light
Higher incidence in fair skinned individuals who engage in frequent outdoor activities in warm sunny climates

Actinic Keratosis
A pre-cancerous neoplasm of the epidermis.
The abnormal Keratinocytes are confined to the epidermis.
Solar damage followed by unrepaired or error-prone repair of DNA.

Abnormal replication occurs.
Chronically sun-damaged skin is likely to demonstrate these lesions.
1 per 1,000 go from Actinic Keratosis to squamous cell carcinoma.

Characterized By:
- Reddish poor defined borders.
- Patches, papules with rough yellowish- brown adherent scales.
- Rough texture is more palpable than visible.

Areas typically exposed to the sun:
- Face Neck
- Dorsum of hand Upper back
- Dorsum of forearms Chest

Found on ultraviolet damaged skin that has a yellowish hue, wrinkles, and freckled pigmentation.

- Exam: 1 – 10 mm ill-defined, rough, adherent scaling papules that are often easier felt than seen.
- Thick and indurated actinic keratoses should undergo biopsy to rule out squamous cell carcinoma

- Sunscreen SPF 30
- Wide-brimmed hat, long-sleeved shirt, and pants
- Avoidance of midday sun
- Cryotherapy with liquid nitrogen
- 5-fluorouracil 5% cream bid for 2 – 3 weeks
- Diclofenac 3% gel twice daily for 3 months
- Imiquimod 5% cream twice a week for 16 weeks
Name the 5 Skin Types
Skin types
-Type 1- Always burns never tans.
Type 2- Always burns sometimes tans.
Type 3- Sometimes burns always tans.
Type 4- Never burns always tans
Type 5- Dark complected people
Squamous Cell Carcinoma
Squamous cell carcinoma is a malignant neoplasm of keratinocytes.
It is locally invasive and has the potential to metastasize
Most often found on the head, neck, and arms

Etiology: ultraviolet radiation, x-irradiation, and chemical carcinogens like soot and arsenic
Can develop in sites of chronic injury, burn scars, irradiated sites, erosive discoid lupus erythematosus, osteomyelitis, and on mucous membranes and in areas infected with oncogenic strains of human papillomavirus.

Exam: scaling indurated plaque or nodule that sometimes bleeds or ulcerates occurring most often in sun-exposed skin
The diagnosis is confirmed with a biopsy
Squamous cell carcinoma arising in actinic keratosis has a low metastatic potential.

Therapy for SCC
Excision
Curettage and electrodessication
Mohs micrographic surgery
Radiation
Bowen’s Disease
Bowen’s Disease is squamous cell carcinoma in situ arising in the skin or mucosal surfaces
Erythroplasia of Queyrat
Erythroplasia of Queyrat of the penis resembles Bowen's disease and is probably the same entity. It is a carcinoma in situ that mainly occurs on the glans penis, the prepuce, or the urethral meatus of elderly males.
Leukoplakia
Leukoplakia is a descriptive clinical term, not a definitive diagnosis.
There is always a risk of malignant transformation with time.
Factors that favor or promote malignant transformation include tobacco, alcohol, ultraviolet light, and some human papilloma viruses.
Cutaneous T Cell Lymphoma
Cutaneous T cell lymphoma, also known as mycosis fungoides, is a distinct helper-T cell lymphoma of the skin.
It may eventually invade the lymph nodes, peripheral blood, and internal organs.
Paget’s Disease of the Breast
Paget’s disease of the breast is a rare, distinctive cutaneous presentation of intraductal carcinoma of the breast.
It is most often misdiagnosed as “nipple eczema”
Extramammary Paget’s Disease
Extramammary Paget’s disease is intraepidermal adenocarcinoma involving the anogenital axillary skin.
75% are from adenexal structures
25% are from non-cutaneous adenocarcinomas
Cutaneous Metastasis

(Metastatic Carcinoma of the breast)
Cutaneous metastases occur in 0.7 – 9% of all cancer patients.
Excluding lymphomas, the most common primary site is the breast in women and the lung for men.
The abdominal wall is the most common site for tumors presenting as metastatic disease.
Nevus


Nevus is singular
Nevi is plural

A nevus (mole) is a benign neoplasm of nevus cells which are pigment-forming cells.
Most nevi are acquired between 6 months of age to 35 years of age.

It is common to have darkening in color, itching, and development of new nevi during pregnancy and adolescence.
Otherwise, symptomatic nevi should be regarded suspiciously.

Nevi can be flat or elevated, smooth or verrucoid, polypoid or sessile, pigmented or flesh colored.
Nevi generally have uniform color, surface, and border
The “ugly duckling” mole should be biopsied
Speckled Lentiginous Nevus
Becker’s Nevus
Halo Nevus
Blue Nevus
Atypical (Dysplastic) Nevus
Atypical Mole Syndrome
(Dysplastic Nevus Syndrome,
B-K Mole Syndrome

Atypical mole syndrome consists of multiple clinically atypical nevi, together with an increased risk of melanoma. It occurs as a familial syndrome and also sporadically.
Malignant Melanoma
Malignant melanoma is a cancerous neoplasm of pigment-forming cells, (melanocytes) and nevus cells.
The estimated lifetime risk of developing a malignant melanoma is 1 in 70 and the incidence is increasing.
Prognosis is best predicted by depth of invasion in primary cutaneous melanoma

More than 40,000 new cases are diagnosed yearly in the United States.
Sunlight and heredity may be important factors in it’s etiology.

Keep in mind that in 10% of the cases the general rules do not apply.

Any pigmented lesion or nevus that looks significantly different from an individual’s other nevi, always view as suspicious and biopsy.

Risk factors:
- Sunburns
- Genetics
- A large number of abnormal nevi
Melanoma Signs:
A Asymmetry
B Border irregularity
C Color variegation
D Diameter greater than 6 mm
Superficial Spreading Melanoma
Most common type of melanoma
May occur anywhere on the body, but especially on a man’s back or a woman’s leg.
The lesion is irregular in color and surface and border.
Lentigo Maligna Melanoma
Occurs on sun-exposed skin, especially the head and neck.
It is multicolored and elevated in areas.
The change in size and darkening is insidious over a period of years.
Nodular Melanoma
Rapidly growing, blue-black, smooth or eroded nodule that occurs anywhere on the body.
It has a vertical growth phase resulting in a poor prognosis.
Acral Lentiginous Melanoma
Occurs on the soles, palms, and distal portion of the toes or fingers.
Presents as an irregular, enlarging, dark growth.
Is the most common type of melanoma that occurs in Blacks and Asians.
Therapy of Melanoma

(e,c,r,i)
- Wide excision with margins of normal skin based on the thickness of the melanoma
In situ 0.5 cm margin
< 2 mm thick 1 cm margin
> 2 mm thick 2 cm margin

- Chemotherapy if metastatic
- Radiation for brain or bone mets
- Immunotherapy – interferon, interleukin
Melanoma Mimics, From L to R
1. Hemangioma
2. Nevus
3. Seborrheic Keratosis
4. Dermatofibroma
Congenital Melanocytic Nevi, from the L
3rd is Large Congenital Hairy Nevus
4th is Giant Congenital Nevus (Bathing Trunk Nevus)
1% of newborns have congenital nevi.
Large congenital nevi (greater than 20 cm across or covering 5% of body area) have a 6-12% chance of developing into a malignant melanoma.
Small congenital nevi do not need to be removed.
Hemangioma
A benign proliferation of blood vessels in the dermis and subcutaneous tissue resulting in a red, blue, or purple papule or nodule.
There is no need to treat unless it is ulcerated or compromising normal function
Port Wine Stain
Salmon Patch,
Stork bite,
Nevus Flammeus
Cherry Angioma
Cherry angioma is a distinct, benign vascular neoplasm found in nearly all people older than 30 years of age.
They increase in number with age.
Lesions are asymptomatic
Angiokeratoma
Angiokeratomas are scaly papules, colored red – purple, formed by dilation of superficial blood vessels and epidermal thickening.
They can appear on the scrotum and vulva.
They appear in mid-life and persist indefinitely.
Lymphangioma Circumscripta
Lymphangioma circumscripta is a lymphatic malformation consisting of small
(1-5 mm) discrete, clear to blood-tinged papules that look like vesicles (frog spawn)
Venous Lake
A venous lake is a dilated vein that occurs on sun-damaged skin and appears as a small blanchable dark blue-to-purple papule
They completely blanch with diascopy (pressure)
Pyogenic Granuloma
Pyogenic granuloma is a hemangioma with an unknown cause.
They can occur at sites of injury and during pregnancy, thus trauma and hormones may play a role.
They appear as yellow to deep red, glistening, dome-shaped to polypoid papules 3 – 10 mm.
They grow rapidly and bleed profusely when traumatized.
Kaposi's Sarcoma
Kaposi’s sarcoma is a malignant vascular tumor derived from endothelial cells.
Manifested by multiple purple macules, plaques, or nodules
Types
AIDS associated Kaposi
Classic in elderly Mediterranean men
Lymphadenopathic in young men in equatorial Africa
Associated with immunosuppressive therapy
Kaposi's Sarcoma
Kaposi’s sarcoma is a malignant vascular tumor derived from endothelial cells.
Manifested by multiple purple macules, plaques, or nodules
Types
AIDS associated Kaposi
Classic in elderly Mediterranean men
Lymphadenopathic in young men in equatorial Africa
Associated with immunosuppressive therapy

Anti-retroviral therapy for AIDS patients
Radiation therapy
Excision
Interferon alpha (intralesional or systemic)
Chemotherapy (intralesional or systemic)
Decrease the dose of immunosuppressive therapy in transplant patients

Pathogenensis
Human herpesvirus type 8
Telangiectasias
Telangiectasias are common asymptomatic, dilatations of capillaries, venules and arterioles.
A spider angioma is an asymptomatic blanchable pink papule due to a central dilated arteriole and very fine radial branches.
Androgenic Alopecia,

Male Pattern Baldness
Androgenetic alopecia is premature loss of hair of the central scalp.
Androgens in genetically predisposed men lead to this phenomenon
It can begin any time after puberty and usually is fully expressed by the time the man is in his 40s.

It begins with bitemporal thinning that then progresses to an M-shaped recession. Then there is loss of hair focally in the crown of the scalp, which extends to total hair loss in the central scalp.
Treatment for Androgenetic alopecia

Minoxidil (Rogaine) solution or foam bid

Finasteride (Propecia) 1 mg daily

Hair Transplant

Hair weaves or wigs
Androgenetic Alopecia in Women,
Female Pattern Hair Loss
Terminal hairs are replaced by miniaturized hairs in genetically predisposed women on the central top of the scalp with retention of the normal hairline.
Women rarely become completely bald.
Widening of the part is often the earliest visible change.
Telogen Effluvium
Telogen effluvium is a non-scarring, non-inflammatory, diffuse hair loss which is typically sudden in onset and occurs 3 – 5 months after a systemic stress, such as childbirth, a severe medical illness, surgery, high fever, crash dieting, and occasionally in response to medication.

In telogen effluvium, gentle pulling of the hair (hair-pull test) pulls out more than 3 telogen hairs consistently from different scalp areas

Laboratory Testing
- Thyroid function tests
- Iron studies
Course
- usually self-limited and reversible after correcting the underlying problem
Therapy
- reassurance
Alopecia Areata
Alopecia areata is a non-scarring hair loss, typically of rapid onset in a sharply defined, usually round or oval area.
It is likely to be due to an immunologic phenomenon.
Exclamation point hairs that are 2 – 3 mm long and tapered at the base may be seen !!!!!

The scalp, eyebrows, eyelashes, and beard may be affected
Patients may have other disorders like thyroid disease, pernicious anemia, Addison’s disease, vitiligo, lupus erythematosus, ulcerative colitis, diabetes mellitus, and Down syndrome.

Tx for Alopecia Areata:

1. Steroids
- Topical
- Intralesional injections
- Systemic - prednisone
2. Anthralin
3. Squaric acid

Shallow pitting occurs in the nails of some patients with alopecia areata
Trichotillomania
Trichotillomania is the recurrent pulling of one’s hair that results in significant hair loss.
The urge to pull hair is overwhelming; after hair pulling, anxiety is relieve temporarily.
A history of emotional problems may be elicited often with difficulty

Several short broken hairs of varying lengths are randomly distributed in the involved site. Hair that grows beyond 0.5 – 1 cm can be grasped by small fingers and extracted.

Physical exam – irregular, patchy areas of hair loss with numerous twisted and broken hairs and perifollicular hemorrhage.

Several short hairs are randomly distributed in the involved site.

Therapy for Trichotillomania
- Emotional support
- Behavioral counseling
- Psychiatric medications
Ridging and Bending
Parallel elevated nail ridges are a common aging change. This change does not indicate any deficiency.
Onycholysis
Onycholysis is the separation of the nail from the nail bed.
Separation begins at the distal end and slowly progresses proximally.
The non-adherent portion of the nail is white, yellow, or green tinged.

Causes include psoriasis, trauma to long nails, Candida or Pseudomonas infections, internal drugs, contact with chemicals, maceration from prolonged immersion, and allergic contact dermatitis (like to nail hardener or adhesives).
Treatment: trim the nails, keep them dry, and avoid exposure to contact irritants.
Habit-tic Deformity
Biting or picking a section of the proximal nail fold is a common habit.
Habit tic deformity usually appears as a sharply defined band of rippling down the center of the nail plate.
Psoriasis
Nail involvement commonly occurs in patients with psoriasis
Fingernails may be unsightly and toenail deformity may be painful
Look elsewhere on the body for evidence of psoriasis

Psoriatic nails may have
Pits
Onycholysis – separation of the nail plate from the nail bed
Oil stain appearance - the accumulation of scale and serum under the nail produces a yellow-brown stain under the nail
Scaling debris under the nail and thickening.

Alteration of the nail plate
Acute Paronychia
- Bacterial infection of the proximal and lateral nail fold causes the rapid onset of pain and swelling.
- Trauma and manipulation is the cause or it may occur spontaneously.
- Pus accumulates behind the cuticle or deeper in the lateral nail folds.

Tx: incision and drainage and anti-Staph antibiotics.
Chronic Paronychia
Chronic paronychia is usually caused by Candida albicans and sometimes by bacteria.
Characterized by loss of the cuticle, slight tenderness, swelling, erythema, and sometimes, separation of the nail fold from the plate

Can occur in children who suck their thumbs and in adults who do wet work – bartenders, janitors, housekeepers, healthcare workers, and diabetics
Treatment – avoid trauma, water, and irritants. Apply topical anti-yeast preparations and topical steroids.
Pseudomonas Infection
Pseudomonas can colonize the space between the nail and the nail plate imparting a green-black color to the nail plate.

Tx: trim the unattached nail. Apply medication that fights the bacteria such as vinegar, diluted bleach or thymol.
Hangnail
Triangular strips of skin may separate from the lateral nail folds, particularly during winter months.
Tx:
Separated skin should be cut before extension occurs.
Moisturize
Avoid water immersion
Ingrown Nail
Definition – ingrown nail occurs when the lateral portion of the nail plate grows into the lateral nail fold resulting in an inflammatory response, pain and swelling.

Therapy
Good fitting shoes
Trim nail plate straight across
Topical antiseptics
Cotton pledget insertion
Nail avulsion with matrix destruction
Subungual Hematoma
Trauma to the nail plate may cause immediate bleeding and pain.
As pictured, the blood has lysed but the staining will persist until the nail grows out.
Nail Hypertrophy
Gross thickening of the nail plate may occur with tight fitting shoes or other forms of chronic trauma.
White Spots or Bands aka Leukonychia
common
probably result from low grade trauma
Distal Plate Splitting
Brittle nails and splitting are found in 20% of adults.
Nails – like the skin – dry in the winter. Repeated water immersion encourages the process. Vinyl gloves protect during wet work.
Beau's Lines
Beau’s lines are traverse depression or ridges of all the nails that appear at the base of the lunula weeks after a stressful event that temporarily interrupted nail formation.
They develop in response to high fevers, scarlet fever, hand foot and mouth disease, in many other diseases, and in patients taking chemo.
Digital Mucous Cysts
Digital mucous cysts are focal collections of mucin lacking a cystic lining.
Dome-shaped, pink-white structures occur on the dorsal surface of the distal phalanx of middle-aged and elderly people.
A clear, sometimes blood-tinged, viscous, jellylike substance exudes when the cyst is incised.
Nevus
A nevus in the nail matrix can produce a brown pigmented band.
Brown bands are common in black people, but are rare in white people and should prompt a biopsy
Melanoma

Hutchinson's sign
Hutchinson’s sign is the extension of brown-black nail pigmentation onto the nail folds. It is an important indicator of melanoma.
Fungal Nail Infections

on the Left - Distal subungual onychomycosis
in the Middle - White superficial onychomycosis
top Right - Proximal subungual onychomycosis (HIV)
lower Right - Dx made w/ potassium hydroxide (KOH)
Distal subungual onychomycosis is the most common pattern. Fungi invade the distal area of the nail bed. The distal plate turns yellow or white as hyperkeratotic debris accumulates causing the nail to rise and separate from the underlying bed.

White superficial onychomycosis is caused by the surface invasion of the nail plate by fungus. The nail surface is soft, dry, and powdery and can easily be scraped away. The nail plate is not thickened and remains adherent to the nail bed.

Proximal subungual onychomycosis
Infection of the proximal nail plate from below
Is a marker of HIV infection

Diagnosis is made with a potassium hydroxide (KOH) preparation or fungal culture. Biopsy can also establish the diagnosis
Treatment: oral Terbinafine (Lamisil) and Itraconazole (Sporanox)
Erythema Toxicum Neonatorum
- Common benign transient pustular eruption seen in the newborn period.
- Unknown cause.
- Lesions appear as blotchy macules that develop into superficial pink papules and pustules, taking on a “flea-bitten” appearance.
- Resolves within 3 weeks without adverse sequelae.
Erythema Toxicum Neonatorum
- Common benign transient pustular eruption seen in the newborn period.
- Unknown cause.
- Lesions appear as blotchy macules that develop into superficial pink papules and pustules, taking on a “flea-bitten” appearance.
- Resolves within 3 weeks without adverse sequelae.
Miliaria
Miliaria is the term describing clear to red papules that result from obstruction of the eccrine sweat duct.
Miliaria is very common in newborns and infants who are “bundled” or placed in warm environments.
Miliaria
Miliaria is the term describing clear to red papules that result from obstruction of the eccrine sweat duct.
Miliaria is very common in newborns and infants who are “bundled” or placed in warm environments.
Cutis Marmorata
Cutis marmorata is a transient benign blanching mottled or lace-like erythema of the skin on the trunk and extremities that resolves with rewarming.

It is thought to be due to an exaggerated vasomotor response to decreased core body temperature.
Cutis Marmorata
Cutis marmorata is a transient benign blanching mottled or lace-like erythema of the skin on the trunk and extremities that resolves with rewarming.

It is thought to be due to an exaggerated vasomotor response to decreased core body temperature.
Cutis Marmorata
Cutis marmorata is a transient benign blanching mottled or lace-like erythema of the skin on the trunk and extremities that resolves with rewarming.

It is thought to be due to an exaggerated vasomotor response to decreased core body temperature.
Cutis Marmorata
Cutis marmorata is a transient benign blanching mottled or lace-like erythema of the skin on the trunk and extremities that resolves with rewarming.

It is thought to be due to an exaggerated vasomotor response to decreased core body temperature.
Cutis Marmorata
Cutis marmorata is a transient benign blanching mottled or lace-like erythema of the skin on the trunk and extremities that resolves with rewarming.

It is thought to be due to an exaggerated vasomotor response to decreased core body temperature.
Cutis Marmorata
Cutis marmorata is a transient benign blanching mottled or lace-like erythema of the skin on the trunk and extremities that resolves with rewarming.

It is thought to be due to an exaggerated vasomotor response to decreased core body temperature.