FINAL YEAR MEDICAL STUDENTS

Skin Tumours

Dr Tan Suat Hoon ( Sr Consultant )

Dr Joyce Lee ( Consultant )

Approach to Skin Tumours

• Skin tumours can broadly be divided under the following categories:

- Benign
- Malignant
- Premalignant

• Histological classification
- tissue/cell of origin
- tumour differentiation

• Tumours in the skin can arise from practically every cell constituent in the skin.

• Tumours can be further categorised under tumours arising from :

- Epidermis
- Adnexal structures eg. hair follicles, sweat ducts
- Blood vessels
- Lymphatic vessels
- Nerves
- Melanocytes

A. BENIGN SKIN TUMOURS

Epithelial Tumours :

Seborrhoeic Keratosis
Occurs in the elderly - on the face, upper trunk.
Looks like a greasy warty plaque “stuck” on the epidermis. May be pedunculated.
Dark brown to black in colour with keratin plugs in the follicles - 1 mm to several cms.

Complications
Irritation or infection. May have bleeding, oozing and crusting.

Treatment
1. Curettage
2. Liquid nitrogen (smaller lesions)

Dermatosis papulosa nigra

Common in Negroes.
Variant of seborrhoeic keratosis.
Resemble skin tags.
Multiple black or dark brown papules. Usually on the malar region, forehead, chest, back and
neck.
Treatment
1. Cautery

Skin Tags
Occurs in the middle-aged and elderly.
Usually multiple, pedunculated (approximately 2mm diameter), soft, often pigmented but may
be skin-coloured. Occurs on the side of the neck, face, chest, back, axillae and groins.

Treatment

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1. Snip excision
2. Cautery
3. Liquid nitrogen
Keratoacanthoma
Common tumour occuring in middle-aged.
Rapid growth within a few weeks.
Starts as a firm, flesh-coloured or erythematous papule, grows into a nodule with a keratin-filled
central crater covered with a crust.
Spontaneous resolution occurs usually within 3 months, leaving a scar.
Occurs on the central part of the face - nose, cheeks, eyelids and lips, also on the dorsum of
the hands, wrist and forearms.
Resembles squamous cell carcinoma histologically.

Treatment
1. Excision + Histology
2. Radiotherapy

Hair Follicle Tumours :

Trichoepithelioma
Often familial.
Appear at puberty, often multiple.
Small, round, translucent papules.
Occurs on cheeks, eyelids and nasolabial folds.

Different diagnoses
1. Milia
2. Syringoma

Treatment
1. Excision if large

Cysts Of The Skin :

Epidermal Cyst
Keratin-containing cyst.
Occurs in young and middle-aged adults.
Yellowish, white or skin-coloured.
Firm, elastic dome-shaped mobile protuberance.
May be multiple.
Slowly growing, may get inflamed and suppurate and sometimes may calcify.
Treatment
1. Excision

Pilar Cyst
1. Keratin-containing cyst.
2. Usually on the scalp.
3. May be multiple and may be familial.
4. Smooth, mobile, firm, rounded nodule.
5. Large lesions may be lobular.
6. May get inflamed and suppurate.

Treatment
1. Excision

Milia
Small keratin cyst.
Occurs in all ages.
May be eruptive.
May follow trauma such as blistering, dermabrasion, steroid atrophy, radiotherapy.

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White or yellowish firm papule.

Treatment
1. Incision and squeezing out cyst contents.

Steatocystoma Multiplex
Occurs in adolescence or early adult life.
Autosomal dominant inheritance.
Multiple, smooth elastic nodules within the dermis, reaching a limiting size of few mm to 20 mm.
May look yellowish.
Oily fluid expressed if pricked.
Commonly on presternal area of the trunk and the forearms.

Treatment
1. Leave alone.

Sweat Duct Tumours :

Syringoma
In adults. Females more than males.
Small, skin-coloured, translucent papules.
Bilateral symmetrical distribution - upper and lower eyelids.
Reaching a limiting size.
May be eruptive.

Treatment
1. Cautery for small lesions
2. Excision (esp. if occuring on lower eyelids)
3. Laser

Lentigines :

Solar Lentigo
(Syn. Old Age Spot, Senile Lentigo, Liver Spot)
A benign pigmented macule that develops only on skin that has been damaged by years of
exposure to sunlight. Most commonly situated on the face, backs of hands and wrists, “V” of
the chest and the extensor surfaces of the forearms.

Clinically appear as yellow, tan or brown macules from a few millimetre to more than a
centimetre in diameter. Round or oval and may be sharply demarcated.

Treatment

1. Liquid nitrogen
2. Pigment laser

Tumours of Blood Vessels :

Pyogenic Granuloma
Occurs at any age, after minor injury, usually penetrating.
Vascular nodule - bright red to brownish red to blue-black colour.
Pedunculated base with a collar of epidermis.
Older lesions usually eroded, crusted.
Bleed easily.
Commonly occur on the fingers, lips, feet, head, upper trunk, mucosal surfaces of the mouth
and perianal area.
Grows to a limited size of 5 - 10 mm.

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Treatment
1. Curettage and cautery

Strawberry Naevus or Haemangioma

Appear during first few weeks of life
Superficial angiomatous naevus.
Sharply circumscribed oval or round, soft domed swelling of intense red colour.
Surface smooth or lobulated.
Most common on the head and neck.
Also occurs on the trunk, perianal area and vulva.
Usually single but may be multiple.
Reach ultimate size by 3 to 6 months.
Complete spontaneous resolution is common, occurring in 75% by age 7.
Angiomas may be superficial or subcutaneous.
Subcutaneous angiomatous naevi feel like a “bag of worms”.

Complications
1. Bleeding and ulceration.
2. High output cardiac failure due to shunting of large volumes of blood.
3. The haemangioma-haemorrhage syndrome (Kasabach-Merritt Syndrome) - due to
platelet sequestration and consumption of clotting factors.

Treatment
1. Systemic corticosteroids - 2 - 4 mg/kg/day of Prednisolone
2. Surgical treatment - may result in severe bleeding.
3. Radiotherapy - occasionally effective but slow onset of action.
4. Platelet and plasma transfusions
5. Laser

Kaposi’s Sarcoma
- now regarded as non-neoplastic reactive vascular proliferation probably viral in etiology
(Human Herpes Virus-8)

Classical Kaposi’s Sarcoma

Occurs in Central and Eastern European Jews and in Africa.
Tumour composed of proliferating capillaries and perivascular connective tissue cells.
May be multifocal.
Dark blue or purplish nodules or macules.
Adjacent areas may fuse to form a plaque or tumour.
May become eroded, ulcerated or fungating.
Occurs on the feet, hands, ears or nose.

Treatment
1. Excision
2. Cryotherapy
3. Radiotherapy
4. Cytotoxic drugs for extensive lesions.

Kaposi’s Sarcoma and AIDS

Occurs in homosexuals with AIDS.
Lesions may be very subtle or very extensive.

Vascular Malformation :
(Not a tumour)

Port-Wine Stain :

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The Sturge-Weber Syndrome
Unilateral facial port-wine stain involving the areas served by the ophthalmic and maxillary
divisions of the trigeminal nerve.
Tends to be extensive.
Involves much of one side of the face, scalp, neck and sometimes other parts of the body. Oral
and nasal mucosae and lips may be greatly swollen.
May be bilateral.
Associated with homolateral leptomeningeal angiomatosis.
Epilepsy occurs in 80 - 90% of cases - grand mal type.
Starts during infancy usually.
50% of cases have eye involvement - most commonly chroidal angioma or congential
glaucoma.

Tumours of Lymphatic Vessels :

Lymphangioma Circumscriptum
The commonest type of lymphangioma.
Usually at birth or during childhood.
Commonest sites - axillary folds, shoulders, neck, proximal parts of limbs, perineum, tongue
and buccal mucous membrane.
May be extensive.

Treatment
1. Surgery - excision
2. Laser
Tumours of Nerve :

Neurofibroma
May be solitary or multiple (von Recklinghousen’s disease).
Skin-coloured soft nodules occuring on the face, scalp, body and limbs.
May undergo malignant change.

Tumours of Melanocytes :

Benign Melanocytic Nevi

1. Junctional Nevus
Benign proliferation of epidermal melanocytes that are organised into nests at the
dermoepidermal junction.
Sharply demarcated hyperpigmented macules or slightly elevated papules that occur
anywhere on the skin.
Develop during childhood.
May evolve into compound or intradermal nevi.

2. Compound Nevi
Benign proliferation of melanocytes that are organised into nests at the
dermoepidermal junction and within the dermis.
Sharply circumscribed, round or oval pigmented papules. May have coarse hair.
Tan to dark brown in colour.
Slightly elevated to dome-shaped or sessile.
Occurs in all ages.

3. Intradermal Nevus
Benign proliferation of melanocytes, derived from epidermal melanocytes, that are
orgnised into nests within the dermis.
Usually in adults.
The most common type of melanocytic nevus.
Smooth, dome shaped papules.
May be papillomatous or polypoid
Flesh coloured or slightly pigmented.

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 May have coarse hairs.

B. PREMALIGNANT EPITHELIAL TUMOURS

Solar Keratosis
Occurs after middle-age on sun-exposed fair skin.
Usually multiple.
Rough, dry adherent yellow or dirty brown scale - picked off with difficulty.
May become thick and horny with a sharp edge.
Occurs on the face, back of hands and forearms, vermillion of the lower lip.
Sign of malignant change is an indurated base.

Treatment
1. Liquid nitrogen
2. Cautery
3. 5-Fluorouracil ointment or lotion

C. MALIGNANT SKIN TUMOURS

Predisposing Factors to Skin Cancers (Malignant Epithelial Tumours)

• Environmental Factors
- UV radiation from sun exposure
- Arsenic exposure
- Viruses eg. human papilloma virus
• Host Factors
- Skin type; Caucasian skin more susceptible than
pigmented skin
- Genetic diseases eg. xeroderma pigmentosum
- Immunosuppression eg. transplant patients
- Chronic ulcers

Malignant Epithelial Tumours :

Basal Cell Carcinoma

Commonest malignant tumour of the skin.
Early tumours are small, translucent or pearly, raised and rounded areas covered by thin
epidermis through which a few dilated superficial vessels show.
Uneven pigment is seen.

Other presentation :
A small pearly erythematous lichenoid papule or plaque, or a keratotic or slightly indurated area
or a small superficial ulcer.
May spread deeply causing great destruction, especially around the eyes, nose or ears.
Bones of the face and skull may be invaded.
Occurs usually on the head and neck especially upper central part of the face.
Slow growing.
Rarely metastasizes.

Treatment
1. Excision with primary closure
2. Radiotherapy
3. Liquid nitrogen
4. Curettage
5. Cytotoxic agents eg. 5-Fluorouracil

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Squamous Cell Carcinoma
Occurs in later life.
Usually on sun-exposed skin - backs of hands and forearms, upper part of the face, ears and
lower lip.
May arise in chronic conditions such as scars and chronic ulcers.
May be plaque-like, verrucous, tumid or ulcerated.

Treatment
1. Surgery
2. Radiotherapy
Malignant Melanocytic Tumours :

Risk Factors for Melanoma

• congenital melanocytic naevus (giant)
• dysplastic melanocytic naevus
• 100 or more melanocytic naevi
• personal or family history of melanoma

Melanoma
Malignant neoplasm of melanocytes that begins with proliferation of melanocytes within the
epidermis and may eventuate in extension of atypical melanocytes into the dermis, and
sometimes, into the subcutaneous fat from which sites that may metastasize.
May arise de novo (75%) or in association with a pre-existing congenital melanocytic nevus.
Early lesions are small, lightly pigmented --- become asymmetrical, poorly circumscribed with
scalloped borders with variations in colour from tan to brown.
Become papular or nodular or ulcerated.
Zones of whiteness indicate partial regression.
Complete regression is a sign of poor prognosis.

Cutaneous Adnexal Carcinoma :

Paget’s Disease Of The Nipple

Progressive, marginated scaling or crusting of the nipple and areola due to invasion of the
epidermis by tumour cells (Paget’s cells). These cells originate in the intraductal carcinoma of
the breast which is present in this condition.
Uncommon tumour.
Occurs in women.
Early changes - small, crusted, intermittently moist area on the nipple.
Itching, pricking or burning sensation.
May have a serous or blood stained discharge from the nipple.
May have a lump in the breast.
Gradually produce an eczematous appearance.
Slow spreading.

Treatment
1. Mastectomy
2. Radiotherapy

Extramammary Paget’s Disease

A marginated plaque resembling Paget’s disease clinically and histologically.
Occurs in the anogenital area or the axillae.
Starts in the 5th decade or later.
25% have an underlying cutaneous apocrine carcinoma.
20% of cases have a primary carcinoma of other organs - rectum, urethra or cervix.
Sharp margin, erythematous, may be scaly, crusted or eroded.
Pruritic - may have excoriation or lichenification.
Commonest area : vulva, scrotum, penis and axillae.

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Itching and burning.
Eczematization may occur.
Relentless progression

Treatment
1. Surgical excision
2. Screen for primary site - anogenital tract, GIT

Malignant Vascular Tumour :

Angiosarcoma
Malignant tumour of blood vessel or lymphatic differentiation, with an aggressive behaviour.
Usually occurs in 6th or 7th decade, in the head and neck region.
Characteristic appearance : bruise-like dusky red macules or plaques, ill-defined edge. May
appear nodular.
May also occur against background of chronic lymphoedematous limbs eg. post-mastectomy
and post-irradiation.
Often delayed diagnosis because of insiduous onset and asymptomatic nature, which further
contributes to the dismal outcome.

Treatment
1. Surgical excision
2. Radiotherapy
3. Chemotherapy