Benign skin tumors
I. Nevus cell nevus
Mole cell nevus, also known as melanocytic nevus, is the most common benign tumor in humans, which can exist at birth, but often occurs after 2 years of age, progresses slowly and has no conscious symptoms. The life cycle of nevus cells usually goes through different stages such as development, maturation and aging, and gradually moves from the epidermis to the dermis with age. According to the different distribution locations of nevus cells in the skin, nevus cell nevus is usually divided into three types: junctional nevus, mixed nevus and intradermal nevus.
Clinical manifestations
According to the location of nevus cells in the skin, different clinical manifestations occur. Most flat damages suggest junctional nevi; most slightly elevated damages and some papilloma damages are mixed nevi; most papilloma damages and almost all hemispherical and tipped damages are dermal nevi.
1.Junctional nevus can be seen at birth, but it is common after 2 years of age. Clinically, it is a light brown to dark brown flat spot, ranging from several millimeters to several centimeters in diameter, showing smooth and hairless, and can occur in any part of the body; those occurring in the palmoplantar or scrotum are mostly junctional nevi. In adulthood, some junctional nevi become mixed nevi or intradermal nevi, but some still remain flat junctional nevi.
2.Compound nevi are mostly seen in older children or adults. Most of the lesions are slightly higher than the skin surface, some are papilloma-like, yellowish brown to brown in color, and may or may not have hair on the surface.
Intradermal nevus is the most common pigmented nevus in adults with hemispheric elevation, tinged damage or papilloma-like. It is brown or black in color, and there are also cases without pigment. There may be hair on the surface of the lesion. In older patients, intradermal nevus may gradually flatten and fade.
Treatment
Generally, treatment is not necessary. Congenital nevus cell nevus has a 10% chance of melanoma, so it is generally better to remove it. In acquired nevus, unless there are signs of malignancy (sudden increase in size, darkening, surface desquamation, erosion, exudation, crusting, bleeding, ulceration, inflammatory swelling, self-induced pain or itching, satellite lesions, etc.), it should be removed immediately. Crossborder nevi and mixed nevi occurring in the palmoplantar, waistline, axilla, groin and other easy-to-injure areas can also be considered for excision. Some acquired plagiocytosis occurs on the face, which is an obstacle to beauty, and if the patient requests treatment, the nevus can also be cut to make it flush with the skin surface, and then coated with hemostatic agent ferrous sulfate solution or 30% aluminum chloride to stop bleeding. In addition, a penetrating suture can be performed. Cryotherapy or laser treatment.
Sebaceous nevus
Sebaceous nevus is a kind of misshapen tumor composed of sebaceous glands, also known as organoid nevus. Sebaceous nevus is more common and usually develops at birth or shortly after birth, and is usually found on the head and neck, especially on the scalp. There are also three periods of age-related changes. In infancy or childhood, in addition to mild hyperplasia, small incompletely differentiated hair follicle structures are visible, while sebaceous glands are poorly developed. In adolescence, the epidermis shows warty or papilloma-like hyperplasia, and a large number of mature or nearly mature sebaceous glands are seen in the dermis.
Clinical manifestations
Sebaceous nevus is more common and develops at birth or shortly after birth, and is usually found on the head and neck, especially on the scalp. Most of them are solitary, but a few are multiple. The rash is a well-defined, raised, round nodule, yellowish to grayish brown, with a wax-like appearance. There is no hair growth on the surface of the scalp. In adolescence, the lesions thicken and enlarge, with a papilloma-like surface and a distinct yellow color. In adults, sebaceous nevi become verrucous and firm in texture. In a few patients, adnexal tumors, such as sweat gland tumors, may develop on top of this disease, and even metastasis may occur.
Diagnosis
The diagnosis is not difficult according to the age of onset, the location of the rash and the manifestation. Sometimes it needs to be distinguished from juvenile yellow granuloma, verrucous nevus, papillary sweat duct cystadenoma, when pathological examination is required.
Treatment
1.Non-surgical treatment: freezing, electrocautery, electrodesiccation, CO2 laser.
2.Surgical treatment: surgical excision should be deep enough to reach the sweat gland area, and the effect is reliable. It can also be treated by scraping.
3.Hemangioma
Hemangioma is a congenital benign tumor or vascular malformation, mostly seen at birth or shortly after birth, which originates from residual embryonic angiogenic cells, and the hemangiomas occurring in the oral and maxillofacial area account for 60% of the hemangiomas in the whole body, most of which occur in the facial skin, subcutaneous tissues and oral mucosa, such as tongue, lips and floor of mouth, and a few occur in the jaw bone or deep tissue.
Clinical manifestations
(A) Capillary hemangioma consists of abnormal development of dilated capillaries.
1.Mostly occur in the face and oral mucosa.
2. If it is not higher than the skin, it is bright red or purplish red with clear boundary and irregular shape, like wine spot; if it is higher than the skin, the surface is uneven, like prune.
3.When the tumor is compressed, the surface color recedes because of the blood flowing out of the tumor. After the pressure is lifted, the blood immediately fills the tumor and restores the original size and color.
(B) Cavernous hemangioma consists of numerous blood sinuses with abnormal development.
1. Blue-purple, soft mass. It is compressible. Sometimes venous stones can be found in the soft tumor.
2. Positive postural metastasis test, i.e., when the tumor is lower than the heart level, the blood flow is obstructed and the tumor increases, while when the tumor is higher than the heart level, the blood flow is smooth and the tumor shrinks.
(3) Coagulable whole blood is drawn by puncture.
(3) Trapezoid hemangioma is formed by direct anastomosis between artery and vein with significantly dilated vessel wall.
1.The tumor rises high in the shape of beads, and the surface temperature is high.
2.There is pulsating sensation on palpation and wind-like murmur on auscultation.
3.The pulsation and murmur will disappear if the blood supply artery is pressed.
Diagnosis
1.The appearance of the tumor is characteristic (wine-spotted or prune-shaped, etc.).
2.Discoloration or shrinkage by pressure
3.Positive posture test, venous stone on palpation, coagulated whole blood on puncture (sponge type), pulsation on palpation, wind-like murmur on auscultation, disappearance of murmur if blood supply artery is pressed and closed (trapezoid type)
4.Angiography shows the concentration of contrast agent in the tumor area or vascular malformation
5.Pathological histological examination to confirm the diagnosis
Treatment
(A) Treatment principles
1.Surgical treatment, all of them can be removed if they are limited, and some of them can be removed if they are extensive.
2.Microwave heat treatment, mainly used for spongy type.
3.Radiation therapy is used for infant capillary hemangioma and superficial cavernous hemangioma.
4.Sclerotherapy, used for cavernous hemangioma.
5. Cryotherapy, used for poplar and cavernous hemangioma 6. Hormone therapy, used for infantile hemangioma 7. Endovascular embolization, used for trabecular and giant cavernous hemangioma
(II) Principles of medication
Sulfonamides (such as cotrimoxazole) or drugs that mainly act on Gram-positive bacteria (such as red enzyme, cyanase, etc.) are used for prophylactic anti-infection of general surgery. The combination of drugs is often used for those who are in poor health or have complications, and is more commonly used as: drugs that act on Gram-positive bacteria (such as cyanasein) + drugs that act on Gram-positive bacteria (such as gentamicin) + drugs that act on anaerobic bacteria (such as methotrexate). Those with severe infection or complications before and after surgery can choose effective antibiotics based on clinical and drug sensitivity tests.
IV. Sweat duct tumor
Syringoma, also known as Syringocystoma or sweat duct cyst adenoma, is an adenoma of the small sweat ducts within the epidermis. Sweat duct tumors are benign tumors that do not affect human health, and no cases of transformation to malignant tumors (cancer) have been found. The majority of patients with sweat duct tumors are women (and some men), and the rash often increases in women during pregnancy, premenstruation, or when using female hormones. Some patients have a family history of the disease, which is inherited in an autosomal dominant manner.
Etiology]
Sweat duct tumor is a nevus-like tumor of small sweat ducts in human epidermis caused by fat metabolism disorder, which is related to endocrine, pregnancy, menstruation and family genetic factors. The ducts are lined with two layers of epithelial cells and the lumen contains amorphous fragments, and some of the ducts are comma-like or tadpole-like in appearance with small cords of epithelial cells.
Clinical manifestations
1. Prevalent in females, with onset in adolescence. Multiple lesions are seen on the face, especially on the eyelids, neck and forehead. In addition to the face, the chest, abdomen and extremities may have extensive symmetrical rashes. It is usually symmetrically distributed, and a few patients have a family history.
2. Flat papules with a diameter of 1-5 mm and raised above the skin, similar to corn grains, with a color similar to normal skin tone and a slight waxy sheen, which may change from yellowish to dark brown.
3, papules are mostly single scattered distribution, a few to dozens of numbers vary, sometimes can be dense into a patch, some are single occurrence. However, the two adjacent bumps do not fuse, and the bumps are slightly hard and solid to the touch, with a few having a soft texture.
4. There are no uncomfortable symptoms such as itching, pain, redness and swelling, and there are usually no conscious symptoms, but some patients have itching or burning sensation in summer due to sweating difficulties.
5.It is a chronic disease, most of which lasts for decades and rarely subsides on its own.
6. It has no effect on human health, but partly affects beauty and can cause long-term mental and emotional depression.
7. Sweat duct tumors can be divided into three types.
a. Eyelid type: The most common type, mostly occurring in women, appearing during or after development, by mostly in the lower eyelid.
b. Rash type: It is common in male adolescents and occurs in batches on the front of the trunk and the flexor side of the upper arm.
c. Restricted type: located in the vulva, called genital sweat duct tumor, and in the extensor surface of the fingers, called extremity sweat duct tumor.
Diagnosis
The diagnosis is usually made by the doctor based on the external features of the disease and the patient’s oral symptoms. In a few cases, if the diagnosis cannot be made by the external features, skin section surgery can be performed to confirm the diagnosis.
Treatment
Most medical books describe sweat duct tumors as benign skin tumors that have no effect on health and do not require treatment. For cosmetic purposes, electrolysis, superficial electrocoagulation and carbon dioxide laser treatment can be applied, and spot removal solution or 20% urea cream can be used externally to make the epidermis peel off and reduce symptoms. Chinese medicine acupuncture and other therapies can also be used.
V. Dermatofibroma
Dermatofibroma is a benign tumor in the dermis caused by focal proliferation of fibroblasts or histiocytes. It is also known as histiocytoma, nodular subepidermal fibrosis or sclerosing hemangioma. The disease can occur at any age, but is more common in young and middle-aged people. It is more common in women than in men. It can occur naturally or after trauma. A yellowish-brown or reddish intradermal papule or nodule is the clinical characteristic of the disease. The lesions grow slowly, persist for a long time, and rarely fade on their own.
Etiology and pathogenesis
The etiology of focal proliferation of fibroblasts or histiocytes is unknown. Some cases may be associated with minor local injuries, such as insect bites or blunt force trauma. It is also thought that there is a relationship with viral infection.
There are 2 types of lesions according to the proportion of cellular components to collagen fibers.
1, fiber type accounts for the majority of the disease is almost entirely composed of fibroblasts and collagen fibers fibroblast nuclei are long rhombus-shaped, with little cytoplasm. Collagen fibers are mostly naive, light blue, sparsely distributed and not in dense bundles, irregularly woven or swirled arrangement.
2. Cellular cell type (histiocytoma), the main component is histiocytes (phagocytes). Collagen fibers are few and naive. Histiocytes have round or oval nuclei, abundant cytoplasm, and irregularly arranged.
Clinical manifestations
1, the prevalent sites are mostly found in the extensor side of the limbs are more likely to occur in the lower limbs, above the elbow or both sides of the trunk and the back of the shoulder, other parts can also occur.
2, clinical symptoms.
(1) lesions: clinically valuable for diagnosis, intradermal papules or nodules, elevated and hard, the base can be pushed, but connected to the epidermis. The skin on the surface is smooth or rough, with varying shades of color can be normal skin color, but also yellowish brown, dark brown or light red. It is usually seen in middle-aged adults and rarely in children. They are usually round or ovoid papules or nodules, about 25px in diameter and usually no larger than 50px, occasionally 50px or larger. The lesions are often persistent and may fade on their own after several years.
(2) They are usually asymptomatic and may occasionally be mildly painful. Some patients may develop multiple dermatofibromas, the latter in association with lupus erythematosus and H IV infection treated with prednisone or immunosuppressive drugs.
(3) They are usually solitary, or two to five, or occasionally multiple. The surface of the nodules is smooth or rough and warty, often single or even multiple.
3, clinical signs: the nature of solid, hard to touch, the upper and epidermal adhesions, and deep tissue non-adhesive, the lower can move freely. Fitzpatri proposed the name “dimple sign” to indicate its characteristic features. The “dimple” sign is positive (pinch the tumor from both sides with the thumb and index finger and see the skin above it sink slightly.
Diagnosis
The diagnosis can be made based on clinical manifestations and histopathology, immunohistochemical examination.
1. Medical history Local history of minor trauma or viral infection.
2, clinical characteristics of intradermal papules or nodules yellow-brown or light red, and deep tissue non-adhesive “dimple” sign positive.
3.Histopathological examination is consistent with the pathological changes of dermatofibroma
4. Clinically, it should be differentiated from granulosa cell tumor, disseminated bean-like dermal fibrosis, clear cell echinocytoma and melanoma. It should also be distinguished from malignant nodular yellow tumor and keloid tumor.
Treatment
1, generally do not need treatment, the damage can fade within a few years. If a single damage with pain caused by the patient pain feasible surgery to remove, can also try cryotherapy.
2, Chinese medicine external treatment methods such as quinoa cream external application, has the effect of reducing the scope, transferring poison from deep to shallow; or use ammonia mercury chloride (white mercury) to make a paste with rice external application; external paste Wan Ying cream, 2-3 days to change the medicine once, so that the tumor necrosis off, and then use the muscle to make local healing.
3, corticosteroid intradermal injection for multiple skin lesions can be tried containing trimethoprim (Coninectone A) 1ml (containing 40mg of de-inflammatory pine) injected into the skin lesions, 2-3 weeks injection. If there is difficulty in injecting more corticosteroids, the lesions can be treated with liquid nitrogen freezing before injection to make them edematous and soft before hormone injection.
Pre-cancerous skin disease and skin cancer
Clinical manifestations
Early skin cancer mostly appears as erythematous or papular lesions slightly above the skin surface, often accompanied by scaly flaking or scab formation on the surface, and the symptoms are similar to benign skin diseases such as psoriasis, eczema and inflammation. Further development of the lesion results in the appearance of certain characteristic signs, such as a shiny, translucent papule-like nodule with oozing blood and dilated capillaries. Or a scar-like fibrous plaque with a smooth surface and no visible capillary dilation, ulceration, or elevation. Or there are black, fused dots within the lesion.
The above features of skin cancer are very similar to the symptoms of some pre-cancerous lesions such as solar keratosis and keratoacanthoma, which are difficult to distinguish. Sun keratosis has rough erythematous spots above the skin surface, covered with scales, and after removing the scales, the erythematous spots often have no obvious elevation. This is very similar to in situ squamous cell carcinoma, which has a well-defined, slightly raised erythematous papule, except that in the latter, the scales and scabs are more pronounced and the lesion is more substantial. Keratoacanthoma often occurs in sun-exposed areas and rapidly appears as a smooth red nodule with a central keratinous plug and dilated capillaries at the edge of the nodule within 2 to 3 weeks without any aura. The nodules of squamous cell carcinoma, which are distinguished from it, are not smooth and have translucent nodule edges.
Differential diagnosis]
Because it is extremely difficult to distinguish pre-cancerous lesions from skin cancer, when you suspect a disease is skin cancer, it is better to have a pathological biopsy to confirm your judgment.
Basal cell carcinoma and squamous cell carcinoma in skin cancer should be distinguished from each other, and also from seborrheic keratosis, carcinoma in situ of skin, discoid lupus erythematosus, etc.
1.Metastatic skin cancer: metastasis from primary cancer of other organs to skin, usually multiple, with symptoms and signs of primary cancer of other organs at the same time.
2, seborrheic keratosis: also known as senile warts, most often in men over 50 years old, mostly in the face, neck, chest, back and back of the hand, the damage is slightly higher than the skin of round or oval flat warts-like rash, rotten yellow, yellow-brown to coal-black, clear borders, soft texture, slightly rough surface, covered with greasy scales crust. The number of rashes is variable and often numerous. Seborrheic keratosis can exist permanently without malignant transformation, and individual damage of very few patients can develop into basal cell carcinoma, which can be diagnosed by histopathological examination.
Basal cell carcinoma and squamous cell carcinoma: Basal cell carcinoma mainly occurs on the face, especially on the nose, forehead, eyes, cheekbones and upper lip, with slow development of damage, localized non-congestion, surface crusting without keratinization, rolled up edges, waxy translucency, no or mild inflammatory reaction, and rare metastasis. Squamous cell carcinoma can occur anywhere, especially in the skin mucous membrane junction and extremities, lower lip, nose, ear, back of hand and pubic area, often occurring at chronic skin lesions, with faster development of damage, obvious local congestion, or dilated capillaries around and on the surface, obvious keratinization, high hard edges, significant inflammatory reaction, and prone to lymph node metastasis.
4. Discoid lupus erythematosus: Mostly seen in middle-aged men and women, the damage is initially small papules, gradually expanding into plaques, dry in nature, with keratinous proliferation on the surface, dilated hair follicle opening, containing keratinous embolism spines, with atrophic spots, without forming ulcers, and congested edges. Those occurring on the face have a butterfly-shaped distribution. Blood sedimentation, rheumatoid factor, antinuclear antibody and histopathology can help to identify.
5.Carcinoma in situ of skin: The damage is usually found on the trunk and buttocks, and can be single or multiple, typically in the form of well-defined scaly papules, which can gradually expand or fuse with each other. Sometimes the central part of the lesion may partially fade or have scar formation, while new lesions appear nearby. They do not usually become ulcers. Histopathological examination helps in the diagnosis.
6. Paget’s disease: often invades the unilateral nipple and areola in women over 40 years of age. The early stage is only small scaly erythematous patches on the nipple, with clear boundaries, gradually spreading to the adjacent skin, the surface is easy to erode, and scratching shows eczema-like changes. The damage is slow to develop and has no tendency to heal on its own. Occasionally, it is seen in areas other than the breast where sweat glands are located, such as the axillae, external genitalia, perianal area, lips, nose, etc. Histopathological examination shows scattered or clustered Paget cells in the epidermis, and the diagnosis can be confirmed by seeing these cells.
7, keratoacanthoma: middle-aged men are more common, mostly on the face, especially the cheeks and nose, while the extremities and trunk are extremely rare. The damage is a solid hemispherical tumor towering over the skin, resembling a pale red acne or a nodule of similar color to the skin, with elevated edges and a crater-shaped central depression, containing a keratinous scab. This disease develops rapidly, but it will not continue to develop after its diameter reaches about 2 cm, and it can shrink by itself within 2-6 months and heal naturally, leaving an atrophic scar.
Malignant skin tumor
Malignant skin tumor is a kind of low-grade malignant tumor that originates from epidermal basal fine malignant cells or hair follicle outer root sheath. The onset of malignant skin tumor may be related to excessive sun exposure, so it is mostly seen on the face of men over 50 years old, especially around the nose, eyes and cheeks, starting as a smooth nodule of green bean size, gradually developing and expanding into a ring, often ulcerating in the center and destroying deep bone or cartilage, causing disfigurement of the nose or eyelids, so it is also called an erosive ulcer.
The common malignant tumors on the skin mainly include basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Early diagnosis and early treatment of skin malignant tumors is the key.
Disease Classification
I. Carcinoma in situ
It was first reported by Bowen’s in 1912, so it is also called Bowen’s disease. It is a kind of intradermal squamous cell carcinoma, which is a precancerous lesion of dyskeratosis.
1.Clinical manifestation: The lesions are light brown patches at first, then gradually grow up and fuse with each other to form plaques, often with grayish yellow or dark brown thick crust, or superficial erosion to form ulcers. Most often seen in patients over 40 years old. The disease can occur all over the body.
2. Histopathology: epidermal keratin thickening and incomplete keratinization, spiny cell hyperplasia, heterogeneous cells of different sizes and shapes, with large nuclei and uneven staining, called Bowen’s vesicles.
Basal cell carcinoma
Basal cell carcinoma, also known as basal cell epithelioma, is caused by malignant proliferation of basal cells, which may be related to sunlight and ion radiation damage, and is the most common malignant tumor of skin.
1.Clinical manifestation: Initially, it is a hard nodule of bean or lentil size, with dark gray or yellowish brown crust on the surface and cancerous tissue lurking under it. The skin lesion continues to develop to form an ulcer, which is characterized by a slightly depressed center and a slightly elevated periphery in the shape of a dike. It is the size of a finger cap to a coin. It is mostly seen in the elderly, and is more common on the face, around the nose, and around the eyes. The course of the disease is slow and usually no metastasis occurs.
2.Histopathology: The tumor comes from basal cells arranged in a fenestrated pattern, and there is a gap between the tumor and the stroma.
3.Treatment: Stage I surgical resection is the most important method to treat basal cell carcinoma. For primary basal cell carcinoma of the face, the extended resection range is 4mm, for well-defined lesions, the extended resection range is 3-5mm, and for erosion type, the extended resection range is 7mm.
Squamous cell carcinoma
Squamous cell carcinoma is also called spiny cell carcinoma or epidermoid carcinoma. It is the second most common skin cancer after basal cell carcinoma, and is usually found in exposed areas. It often occurs on the basis of skin damage such as radiation therapy, syphilis, chronic ulcers, burn scars, solar keratosis, skin horns and granulomas.
1, clinical manifestations: initially bean grain large hard nodules, mostly red, rough surface, typically rotten cauliflower-shaped, ulcers formed after breaking, there is a bad smell. Most commonly seen in men over 50 years old. Preferably on the head, face and neck, easily metastasized.
2.Histopathology: cancerous tissues are in the shape of masses or cords, infiltrating the dermis or even subcutaneously. Lymph nodes must be examined, and if abnormal lymph nodes are found, positive lymph node biopsy of metastasis is required.
3.Treatment:
(1) Radiation therapy: Applicable to patients who are weak and not suitable for surgery, adjuvant treatment for large tumors with high stage
(2) Chemotherapy: commonly used in the adjuvant treatment of large tumor or recurrent tumor
(3)Surgical treatment:<50px, grade, low risk site, depth to dermis - enlarged by 4mm excision >50px, grade 2, 3, 4, high risk site, depth to subcutaneous fat – enlarged by 6mm excision. Lymph node dissection is required for palpable lymph nodes. Lymph node dissection should be performed for definite lymph node metastases.
4.Malignant melanoma
This disease is also called nevus cancer and melanoma. The incidence rate of melanoma is mostly in Caucasians in Europe and the United States, but in recent years, there are more and more of them in China. The common cancer-causing risk factors include: ultraviolet radiation, race, age, family history, nevus or pigmented mother spot on the body surface, which can be induced by long-term stimulation, incomplete treatment and biopsy, etc.
1. Clinical manifestations: The lesions are initially black flat or slightly elevated plaques, and then rapidly increase in size to papilloma-like black nodules or cauliflower-shaped, which can break down to form ulcers with black ooze. It is mostly seen in middle-aged and elderly patients, and it usually occurs on the foot, but it can also occur in other areas. It is an extremely malignant cancer. Histopathology: The morphology of cancer cells is similar to that of nevus cells, but with significant variation. There are melanin spindle-shaped cells, which form ribbon-like or nest-shaped cell clusters.
2.Treatment:
(1) Surgical resection: early and extensive resection of the tumor, depending on the stage to determine the extent of resection of abdominal pain, to avoid postoperative recurrence of recurrence, which affects the prognosis and survival time; tumor depth of more than 1mm, prophylactic regional lymph node dissection is advocated, which can prevent distant metastasis;
(2)Interferon treatment:For patients with regional lymph node metastasis or lymph node negative and primary malignant melanoma depth more than 4mm is beneficial, it is recommended to do immunotherapy, interferon alpha-2b 5 million units, 2-3 times/ intramuscular or subcutaneous injection.
(3)Chemotherapy:Dacarbazine, carmustine, cisplatin and tamoxifen can only help to relieve and reduce the tumor load.
(4)Radiation therapy:Not as the treatment of choice for malignant melanoma, only for unresectable localized areas to alleviate the symptoms of the disease.