Dermatology Block 1, Week 1

A ______ is a circumscribed change of skin color without elevation and is up to 1cm in diameter

macule

A _______ is a large macule (greater than 1 cm diameter)

patch

A ______ is a raised, solid lesion that is LESS than 1 cm in diameter

papule

A ________ is a large papule that is greater than or equal to 1 cm in diameter

plaque

A ______ is a solid, palpable lesion originating in the dermis or subdermis that may or may not be elevated above the level of the surrounding skin and is up to 1 cm in diameter

nodule

A _______ is a large nodule that is greater than or equal to 1cm in diameter

tumor

A ______ is a circumscribed, elevated lesion containing fluid, less than 1 cm in diameter

vesicle

A _______ is a large vesicle that is greater than or equal to 1cm in diameter

bulla

A _______ is a circumscribed lesion containing pus ("pus-filled")

pustule

A _______ is a non-blanching, violaceous discoloration of the skin and it can be palpable or non-palpable

purpura

_________ refers to a purpura that is less than 1 cm in diameter

petechiae

_______ refers to a purpura that is greater or equal to 1 cm in diameter

ecchymosis

_____ refers to an evanescent, edematous (swollen), erythematous papule or plaque that is usually pruritic ("Hive")

wheal

_________ refers to small superficial blood vessels, dilated capillaries, blanchable

telangiectasia

An _______ refers to a superficial denudation of the skin, mainly the epidermis (loss of the epidermis)

erosion

An _____ refers to a denudation of the skin involving the dermis

ulcer

A ______ is an excess accumulation of "dead skin"

scale

A _________ is a linear crack in the epidermis

fissure

_______ can range from pink to deep red hue in the skin due to vasodilation and it indicates vascular inflammation or dilation

erythema

_____ refers to depression of the skin due to thinning of the epidermis, dermis or subcutaneous fat

atrophy

______ are permanent fibrotic changes that occur on the skin following damage to the dermis

scars

What are the functions of the skin?

-barrier

-immunologic

-temperature regulation

-protection from radiation

-nerve sensation

-injury repair

-appearance/quality of life

The _________ is the topmost layer of skin and consists of primarily _________

epidermis, keratinocytes

The ______ lies below the epidermis and consists primarily of fibroblasts, collagen and elastic fibers

dermis

What are the layers of the epidermis from inner to outer?

stratum basale,

stratum spinosum,

stratum granulosum,

stratum corenum

What are the key functions of the stratum basal epidermal layer?

-cell division

-source of epidermal stem cells

-keratinocytes start in this layer and move upwards

What are the key functions of the stratum spinosum epidermal layer?

has "spiny" appearance due to desmosomal junctions holding keratinocytes together

What are the key functions of the stratum granulosum epidermal layer?

lipids in this layer form a water barrier that keeps water in the skin

What are the key functions of the stratum corneum epidermal layer?

provides barrier against trauma and infection

Bullous Pamphigoid

Clinical Presentation:

tense bullae on an erythematous base on the skin

Bullous Pamphigoid

Risk Factors:

Age (typically affects elderyly)

Bullous Pamphigoid

Cause:

Loss of Adhesion; autoantibodies form to antigens beneath the basal layer of the epidermis so epidermis forms roof of blister and dermis forms base of the blister

IgG autoantibodies bind to antigens that comprise the hemidesmosome adhesion complex in the basement membrane of the skin

Bullous Pamphigoid is an __________ blistering disease

autoimmune

Pemphigus Vulgaris

Clinical Presentation:

erosions or flaccid bullae

Pemphigus Vulgaris

Risk Factors:

young to middle aged adults

Pemphigus Vulgaris

Cause:

Loss of adhesion: autoantibodies form to desmosomes that attach keritonocytes to one another.

What causes Psoriasis?

over-proliferation of keratinocytes causing plaques

What are the four main types of cells that make up the epidermis?

kertainocytes

melanocytes

langerhans cells

merkel cells

________ are the main structural cell of the epidermis. They are held together by adhesion proteins called desmosomes.

Keratinocytes

_______ are pigment-producing cells that transfer a pigment called melanin to the keratinocytes in the basal cell layer

Melanocytes

__________ are dendritic cells found in the lower to mid-epidermis

Langerhans

_______ form a complex with afferent sensory nerve endings associated with touch, and are found more densely in touch-sensitive area of the skin

Merkel cells

What are the structural components of the dermis?

collagen type I (strength)

elastic fibers (elasticity)

extrafibrillar maxtrix

What are the cells of the dermis?

fibroblasts

macrophages

mast cells

Ehlers-Danlos Syndrome

Clinical Presentation:

hyper-extensible joints, skin or vascular aneurysms

Solar Elastosis

Clinical Presentation:

degradation of collagen and elastic fibers

Solar Elastosis

Cause:

chronic UV exposure

________ is a disorder of keratin retention in the infundibulum of the hair follicle

keratosis pilaris

What are the types of skin cancers?

1) Basal Cell Carcinoma

2) Squamous Cell Carcinoma

3) Malignant Melanoma

What is the most common skin cancer?

Basal Cell Carcinoma

Basal Cell Carcinoma

______ (Most/Least) common skin cancer and rarely ________

Arises from the _____ layer of the epidermis

Basal Cell Carcinoma

Most common skin cancer and rarely metastasizes

Arises from the basal layer of the epidermis

Basal Cell Carcinoma

Cause:

UV radiation causing DNA damage

Basal Cell Carcinoma

Treatment Options:

Surgical:

Non-surgical:

Surgical:

Mohs Surgery: done mainly on facial lesions or cosmetically sensitive areas and on recurrent BCC; allows for maximal conservation of tissue

Cryosurgery

Curette and desiccation (scraping and burning affected area)

Excision with standard 3-4 mm margins

Non-surgical:

topical Imiquimod cream

topical 5-fluoruracil cream

Describe the clinical representation of Nodular Basal Cell Carcinoma

pearly,

white,

translucent papule or plaque

central ulceration

rolled borders

haphazardly organized telangiectasias (dilated capillaries)

Describe the clinical representation of Superficial Basal Cell Carcinoma:

appears as a well-circumscribed, erythematous macule/patch or slightly raised, flat papule/plaque, mainly consists of a thinly-rolled border and a scant scale and haphazard telangiectasis

Describe the clinical representation of Morpheaform or Sclerosing Basal Cell Carcinoma

white, waxy, scar-like papule or plaque with indistinct borders, usually appears on the face

Describe the clinical representation of Pigmented Basal Cell Carcinoma

variable amounts of melanin within the lesion, globules of pigment

Basosquamous carcinoma is a mixed ________ cell and _______ cell carcinoma. These have an infiltrative growth pattern and can be more aggressive in their behavior

basal

squamous

When should you refer a patient that has Basal Cell Carcinoma to a dermatologist?

suspicion of BCC on the face or a cosmetically sensitive area

biopsy proven BCC

recurrent BCC, metastatic BCC

Basosquamous carcinoma

No or little experience in treating BCC

What causes actinic keratosis?

sun exposure

What can actinic keratosis develop into?

squamous cell carcinoma

Actinic Keratosis

Cell of Origin:

keratinocytes; typically premalignant SCC

Actinic Keratosis

Cause:

sun exposure

Actinic Keratosis

Clinical Presentation:

Clinical Presentation:

hyperkeratotic (thick, rough skin),

feels like "sandpaper,"

skin-colored to tan/brown colored,

irregularly shaped and ill-defined papules and plaques

Actinic Keratosis

Treatment Options:

Treatment Options:

cryotherapy, topical medications (5-FU, Imiquimod, Diclofenac, Tiranibulin), ED&C, Photodynamic therapy (PDT), chemical peels, laser surgery

Actinic Keratosis

Risk Factors:

fair skin (Fitzpatrick Type I-III), elderly, history of prolonged sun exposure, immunocompromised

Squamous Cell Carcinoma

Clinical Presentation:

Clinical Presentation:

-erythematous, scaly, indurated papules and plaques, +/- ulceration, +/- pain, tenderness

Squamous Cell Carcinoma

Cause:

Cause:

-sun exposure

-mutations in keratinocyte DNA, usually caused by UVB

-Tobacco use

-Subtypes of HPV

Squamous Cell Carcinoma

Risk Factors:

Risk Factors:

-Age/Sex (common in elderly males)

-History of SCC or other skin cancers (BCC, MM)

-fair skin, blue eyes, blonde/red hair (FP I-III)

-h/o of smoking

-previous trauma to the area

-inherited syndroms (ex. albinism)

-exposures: ionizing radiation

Squamous Cell Carcinoma

Workup for suspected SCC:

Workup for suspected SCC:

-shave, punch or excisional biopsy (depending on site of lesion)

-CT/MRI for advanced stages of SCC

Squamous Cell Carcinoma

Treatment:

Treatment:

1) ED&C; low-risk, in-situ SCC of torso

2) Mohs surgery; for lesions of head/neck & for invasive SCC

3) Standard Excision; for low risk and primary SCC lesions in non-cosmetically sensitive areas

4) Radiation Therapy: used for patients who are poor surgical candidates

5) Chemotherapy/Immunotherapy; used for high risk /advanced cases of SCC

Can squamous cell carcinoma metastasize?

yes

When should you refer out a patient with SCC?

-biopsy proven SCC

-invasive SCC

-SCC of face/neck or cosmetically sensitive areas (refer for Mohs surgery)

-patients with h/o of skin cancer

-patients with history of excessive sun exposure and concomitant actinic damage

________ nevi consist of nests of nevus cells at the dermal-epidermal junction

Junctional

_______ nevi consist of nest of nevus cells within the dermis

Dermal

_______ nevi consists of nests of nevus cells both at the dermal-epidermal junction and within the dermis

Compound

A _________ nevus is a nevus with an appearance different from common nevi (atypical pigmentation, shape, behavior. This is also known as atypical nevus or nevus with architectural disorder and possibly with cytologic atypia

dysplastic

Dysplastic nevi are ________ (benign/malignant) lesions

benign (but they can indicate a greater risk for developing melanoma)

____________ is the predominant group of nevi in a person with multiple nevi

signature nevus

A ________ nevus has homogenous brown pigmentation

solid brown

A _______ nevus is present in fair-skinned individuals (Fitzpatrick I-II)

solid pink

A _______ nevus has a central area of dark pigmentation surrounded by rings of lighter and darker pigmentation

cockade

A ______ nevus is tan or pink in the central area with a surrounding ring of pigmentation

eclipse

A ______ nevus has a central raised papule with surrounding pigmentation. The central area may be lighter or darker than its surrounds.

fried egg

_____________ are hypopigmented areas surrounding hair follicles of a nevus

perifollicular

The "____________" refers to the one nevus among many that appears different from the others

ugly duckling

____________ __________ refers to a neoplasm of melanocytes (or of cells that have developed melanocytes)

malignant melanoma

Is malignant melanoma an aggressive form of cancer?

Yes, it can metastasize via direct extension, the lymphatic system or hematogenously

Describe the morphology of malignant melanoma:

irregularly shaped/pigmented macule, nodule, papule or plaque

Superficial Spreading Melanoma is the ________ (most/least) common form of melanoma and the lesion is confined to the _________

most

epidermis

Describe the morphology of Superficial Spreading Melanoma:

growth is primarily horizontal (radial)

In ___________ melanoma, growth is vertical and the lesion has started to grow downward, penetrating the basement membrane (vertical growth phase)

nodular

_______________ melanoma refers to a "changing freckle," in situ lesion. Growth is primarily horizontal and not vertical

Lentigo Maligna

__________ melanoma occurs on the acral surfaces (palms of hands, soles of feet, nail beds)

Acral Lentiginous

What is the most common type of melanoma in darker skin individuals?

Acral Lentiginous Melanoma

__________ melanoma is melanoma that does not produce pigment

Amelanotic

What mnemonic is commonly used clinically to identify melanoma and what does each letter represent?

ABCDEs

Asymmetry: lesion is asymmetric

Border: irregularly shaped or ill-defined borders

Color: variations of color within the lesion

Diameter: greater than 6mm

Evolution: lesion is changing in relation to any of the previous characteristics

*Note that not all lesions with these characteristics are melanoma nor will a melanoma exhibit all of these characteristics

_________ refers to lesion thickness of melanoma

Breslow Depth

_________ refers to involvement of skin compartment, I-V

Clark's level

The thicker the malignant melanoma, the ________ (worse/better) prognosis it is

worse