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Mohs Surgery

1 What is Mohs surgery? Mohs micrographic surgery is a surgical technique used to remove skin cancer. During Mohs surgery, the dermatologist acts as both the surgeon and the pathologist. The goals of Mohs surgery are to completely remove the skin cancer and to maximize conservation of normal tissue, resulting in high cure rates, optimal cosmesis, and preservation of function. Mohs surgery is recommended as first-line…

Cryosurgery

1 What is cryosurgery? Cryosurgery is the controlled application of low temperatures to cause tissue damage. It can be used to treat both benign and malignant skin conditions. With cryosurgery, the degree of tissue damage is controlled in order to destroy the target lesion with minimal damage to normal surrounding tissue. Gage AA. History of cryosurgery. Semin Surg Oncol. 1998;14:99–109. Korpan N. Atlas of cryosurgery .…

Fundamentals of Cutaneous Surgery

1 How does one define dermatologic surgery? Dermatologic surgery describes procedures involving the skin and/or its appendages. Although many specialties may perform dermatologic surgery, dermatologists receive specific training in treating the skin both medically and surgically. Some dermatologists undergo additional fellowship training in micrographic surgery and dermatologic oncology (MSDO). In this fellowship, a dermatologist focuses on skin tumor extirpation using the Mohs micrographic surgery technique (see…

Topical Steroids

Key Points: Topical Steroids 1. Approximately 2% total body surface area (TBSA) requires one fingertip unit (FTU) or 0.5 g of topical steroid medication. One percent of the patient's TBSA can be estimated as one palmar surface, including the fingers. Approximately 15 g is required to apply a topical medication to all of the skin from the neck down, one time. 2. Provide written instructions and…

Sunscreens and Prevention of Skin Cancer

1 List some important facts about skin cancer About 90% of nonmelanoma skin cancers are related to ultraviolet (UV) radiation from the sun. More than 5.4 million cases of nonmelanoma skin cancer were treated in over 3.3 million people in the United States during 2012, the most recent year for which data is available. Basal cell carcinoma, a form of nonmelanoma skin cancer, if the commonest…

Cutaneous Metastases

1 How often do internal malignancies metastasize to the skin? Cutaneous metastases from internal malignancies are uncommon, with a reported incidence that varies from less than 1% to over 10%. The largest autopsy study including 7500 patients with internal malignancies demonstrated cutaneous metastases in 9% of patients. Most cases occur late in the course of disease, but cutaneous metastasis may also be the initial presentation of…

Uncommon Malignant Tumors of the Skin

Atypical fibroxanthoma/pleomorphic dermal sarcoma 1 What is an atypical fibroxanthoma (AFX) and what is it relationship to pleomorphic dermal sarcoma (PDS)? AFX is a malignant neoplasm that occurs chiefly in the elderly, upon sun-damaged skin. These tumors are usually well circumscribed, grow rapidly, and demonstrate an exophytic architecture but are otherwise indistinct ( Fig. 46.1 A,B ). AFX does not invade the deep soft tissue, and…

Leukemic and Lymphomatous Infiltrates of the Skin

1 Define lymphoma A lymphoma is a malignancy of the immune system that is characterized by an abnormal proliferation of lymphocytes. Lymphoma can arise in either B cells or T cells or natural killer lymphocytes. Lymphomas can be divided into two categories: Hodgkin's and non–Hodgkin's lymphomas (NHLs). NHLs are a heterogeneous group of malignancies. Within NHLs, there can be aggressive (fast-growing) or indolent (slow-growing) types. Indolent…

Melanoma

1 What is melanoma? Cutaneous melanoma is a malignant tumor of skin melanocytes. Other, less common sites of melanoma that are not considered “cutaneous” include melanoma of the eye, brain, oral mucosa, nasopharyngeal area, nail bed, and anal area. 2 How common is melanoma in the United States? For 2019, the American Cancer Society estimates that in the United States, about 96,500 new melanomas will be…

Common Cutaneous Malignancies

1 How are skin cancers classified? Primary cutaneous cancers are classified on the basis of their cell of origin within the skin ( Table 43.1 ). Skin cancers are most commonly derived from keratinocytes (e.g., squamous cell carcinoma [SCC], basal cell carcinoma [BCC]) or melanocytes (e.g., melanoma), which are normal components of the epidermis. Less commonly, they arise from other cells within the epidermis, dermis, or…

Fibrous Tumors of the Skin

1 What are tumors of fibrous tissue? Tumors of fibrous tissue (“soft tissue tumors”) are typically mesenchymal tumors composed of fibroblasts and variants of fibroblasts. Fibroblasts produce the structural components of the dermis, including collagen, elastin, and ground substance (dermal mucin). Some tumors are composed of myofibroblasts, which are specialized fibroblasts with contractile properties afforded by cytoplasmic actin filamets. Other specialized fibroblasts demonstrate histiocytic properties and…

Vascular and Lymphatic Neoplasms

Key Points 1. Infantile hemangiomas undergo an initial rapid proliferation for several months before subsequently “leveling off” then eventually involuting, a process that may take years to complete. 2. Topical timolol gel-forming solution has been a breakthrough therapeutic option for infantile hemangiomas, performing as well as oral propranolol for smaller, thinner lesions with a lower risk of systemic adverse effects. 3. Clinicians should evaluate patients for…

Benign Melanocytic Tumors

1 What is a mole? A mole is a small burrowing mammal belonging to the family Talpidae. It is also a term commonly used to describe a melanocytic nevus. 2 What is a nevus? Derived from the Latin term meaning “spot” or “blemish,” nevus was originally used to describe a congenital lesion or birthmark (mother's mark). In modern usage, the term describes cutaneous hamartoma, or benign…

Cutaneous Signs of Nutritional Disturbances

Key Points: 1. Pellagra is due to deficiency of niacin and/or nicotinic acid (vitamin B 3 ) and presents with the classic tetrad “the 4 D’s”: diarrhea, dermatitis, dementia, and death. 2. Patients with scurvy (vitamin C deficiency) exhibit follicular hyperkeratosis, gingival bleeding, and the development of corkscrew hairs with perifollicular hemorrhage. 3. Two important findings in vitamin A deficiency are phrynoderma (“toad skin”) and Bitot's…

Cutaneous Manifestations of Aids

1 How significant is the occurrence of skin disease in the setting of HIV infection? Dermatologic diseases are frequently encountered in HIV-infected patients. In one study of 100 serial outpatients, a 92% prevalence of skin disease was noted. Skin disease may also be the first manifestation of HIV disease and may suggest HIV infection because of increased severity of presentation, atypical clinical appearance, or increased resistance…

Cutaneous Manifestations of Renal Disease

1 What skin changes are associated with renal disease? Renal disease can manifest in the skin in three ways: Skin changes that associated with renal failure Systemic diseases with renal and cutaneous manifestations (e.g., Henoch-Schönlein purpura) Diseases affecting the kidney where skin biopsy may be helpful in making the diagnosis, even if cutaneous findings are not prominent (e.g., primary systemic amyloidosis). Gagnon AL, Desai T. Dermatological…

Skin Signs of Gastrointestinal Disease

1 List some of the hallmark skin signs seen with diseases of the digestive tract Cirrhosis: Jaundice, ascites, purpura, spider angiomas Peutz-Jeghers syndrome (PJS): Lip lentigines Inflammatory bowel disease: Pyoderma gangrenosum (PG) Gardner syndrome: Osteomas, epidermoid cysts Many diseases of the skin also involve the oral and anal mucosa. Embryologically, the foregut (forming the oral epithelium) and the hindgut (creating the anal mucosa) share a common…

Cutaneous Manifestations of Endocrinologic Disease

1 How does endocrinologic disease cause skin disorders? Endocrinologic disease can produce cutaneous changes in several different ways: Hormones interact with cell surface receptors to regulate cellular function, and many cell types in skin have such hormone receptors. This means that hormone levels can directly alter skin metabolism. For example, both skin and skin appendages express thyroid hormone receptors, and thyroid hormones can alter expression of…

Cutaneous Manifestations of Internal Malignancy

1 List the five criteria that establish an association between a skin disease and internal malignancy. Helen Curth, while evaluating acanthosis nigricans, established the five criteria known as Curth's postulates: 1. Concurrent onset of the cutaneous disease and internal malignancy. 2. Parallel course of the skin disease and internal malignancy. 3. A specific type or site of malignancy associated with the skin disease. 4. Sound statistical…

Arthropod Bites and Stings

1 What are arthropods? Arthropods compose the largest number and most diverse group of animals on earth. They are invertebrates that arise from eggs and share these three anatomic features: segmented bodies, hard exoskeleton, and symmetrically paired and jointed appendages. 2 Are most arthropods harmful to humans? Less than 0.5% of the 1 million named species are injurious to humans. Most are harmless, while others are…