Skin lesions of Surgical importance

Terms (of surgical importance) used to describe skin pathology
Macule Localized change in color of the skin

Not elevated (or palpable) or freckled

Papule Small solid elevation

Flat toped, conical, rounded, polyhedral, follicular (hairs), smooth or scaly

Vesicle Small collection of fluid

Between the dermis and epidermis (a blister)

Bulla Collection of fluid larger than a vesicle

Under epidermis

Wheal Transient elevation of the skin caused by edema
Cyst Tumor that contains fluid
Naevus Lesion present from birth

Composed of mature structures normally found in the skin but present in excess or an abnormal disposition

Also used to describe lesions composed of naevus cells as melanocytic or pigmented naevi

Papilloma Benign overgrowth of epithelial tissue
Tumor Literally, a swelling

Commonly but inaccurately used to mean an malignant swelling

Hamartoma Overgrowth of one or more cell types that are normal constituents of the organ in which they arise

The commonest examples

Haemangiomata

Lymphngiomata

Neurofibromata

Ulcer Area of solution of an epithelial surface

Causes of ulceration of the skin of the lower limb
Venous
60% (half varicose and half post-thrombotic)
Ischemia 20% (one-quarter have associated venous cause)
Collagen disease 5% (rheumatic and SLE)
Neuropathic 2%
Traumatic 1%
Neoplastic 1%
Many rare causes 5%
Unknown 10%
Common causes of drug eruption
  • Antibiotics
  • Barbiturates
  • Non-steroidal anti-inflammatory drugs
  • Diuretics
  • Chlorpromazine
The causes of chronic abscess or persistent sinus
  • Inadequate drainage
  • Specific chronic infection (e.g. TB)
  • Foreign body (e.g. stitch)
  • Epithelialization of the cavity
  • Malignant change in the wall of the cavity

Differences between lipoma and sebaceous cyst

Lipoma

Sebaceous cyst

History

as any swelling 

Site
  • Subcutaneous
  • Subfascial
  • Intermuscular
  • Submucous
  • Parosteal
  • Extradural
  • Intra-articular
  • Scalp
  • Face
  • Neck
  • Scrotum
  • Any where except palm and sole of the foot which are devoid of sebaceous gland
Onset
Course Very slow Slowly growing
Duration
Relation to other symptom
Possible Cause Benign tumor
  • Retention cyst
  • Caused by blockage of a sebaceous gland duct
Constitutional symptoms

Examination

as any swelling

Inspection
Number
  • Solitary
  • Multiple lipomatosis
  • Diffuse lipomatous deposits
Solitary or multiple
Site
Shape
Size
  • Small
  • Sometimes large
Surface Lobulated
Skin and color A punctum may be seen
Special signs
Palpation
  • Relations to the surroundings
  • Mobility
Relation to skin Not attached to skin Attached to skin at one point which is the site of the duct
Relation to other deep structures Mobile
Other swellings
Temperature
Tenderness No
Edge Well defined slippery Well defined
Reducibility
Solid, fluid or gas

Consistence

Fluctuation

  • Soft
  • Pseudofluctuation
  • Due to mobility of the tumor in its bed
cystic

 

Differences between basal cell carcinoma and squamous cell carcinoma (Common skin malignant ulcers)

History (As any Ulcer)

Basal cell carcinoma

Squamous cell carcinoma

Site
  • Face
  • Above a line from the lobule of the ear to the angle of the mouth
  • Upper part of the face
  • Lower lip
  • Dorsum of the hand
  • Muco-cutaneous junction
Onset
Course Rate of growth is very slow Grows rapidly
Duration
Relation to other symptoms
Possible Cause
  • Prolonged exposure to UV rays of the sun
    • Farmers
    • Sailors
    • Country-men living in sunny areas
  • Albinism
  • Xerodermia pigmentosa
  • Ionizing radiation
  • Immunosuppression
  • Prolonged exposure to UV rays of the sun
  • Previous irradiation
  • Albinism
  • Xerodermia pigmentosa
  • Long standing irritation
    • Chronic granuloma
    • Chronic ulcers
    • Osteomyelitis
    • Sinuses
    • Old burn scar “Marjolin’s ulcer”
  • Prolonged exposure to carcinogenic agents
    • Polycyclic hydrocarbons
    • Coal tar derivatives
    • Mineral oils
  • Immunosuppression
Constitutional symptoms
Examination (As any Ulcer)
Inspection Basal cell carcinoma Squamous cell carcinoma
Number
Site
  • Face
  • Above a line from the lobule of the ear to the angle of the mouth
  • Upper part of the face
  • Lower lip
  • Dorsum of the hand
  • Muco-cutaneous junction
Shape Beaded
Size and depth Small
Floor
  • Red
  • Granular
  • Covered with dry crust or scab
Malignant fungating tissue
Edge Rolled-in like the tyre of a car Raised and everted
Margin
Discharge
  • Serous
  • Blood
Surroundings
Arteries
Nerves
Bones and joints
Palpation
Lymph nodes
Base
Extent and motility Becomes rapidly fixed to underlying tissues (Rodent ulcer)
Induration Indurated
Tenderness

The diagnostic features of the four common surgical skin lesions

Duration of growth

Physical features

Squamous cell carcinoma Few months Occasional bleeding

Nodule or ulcer with everted edges

Basal cell carcinoma Many months or years Nodule or ulcer with rolled edges

Permanent scab

Keratoacanthoma Few weeks Nodule with central necrotic core

No bleeding

Spontaneous regression

Pyogenic granuloma Few days Soft red nodule

That becomes covered with epithelium

Bleeds easily

Differences between strawberry angioma and port wine stain “naevus flammeus”

History

Strawberry angioma

Port wine stain

Site

  • Face
  • Head
  • Sometimes it take the distribution of one of the branches of the trigeminal nerve
  • But does not cross the middle line

Onset

Few weeks after birth Since birth

Course

  • Increase in size over the next months until the age of one year
  • After age of one year the lesion starts to undergo involution
  • Complete involution at the age of 7 to 8 years
Not undergo involution

Duration

Other swellings

Relation to other symptoms like pain

Similar lesions in meninges “Sturge-Weber syndrome”

Possible Cause

Examination

Color

Red Dark purple

Surface

Slightly elevated Not raised above the surface

Effect of pressure

Pressure causes blanching but the color returns immediately after release of the pressure