February 26 (Mon



February 26 (Mon.)

ICM – 8am

Dr. Rapini

Nicolau / Minns

I022608.doc

Scribe for hire: James Morgan

Dermal Tumors and Eczema

Note: Once again, Dr. Rapini stated that all material you need for his lectures ONLY will come from class material, not the book.

Remember, “-osis” = disorder, “-oma” = neoplasm; carcinoma = epithelial derived, sarcoma = stromal / mesenchymal derived

What is a dermal tumor? Glad you asked….

-Any tumor below the epidermis in the stroma = mesenchyme

-derived from: nerves, vessels, smooth muscle, collagen, elastic tissue

I. Benign Dermal Tumors

A. Neurofibroma (very common)

1. Who gets ‘em?

-anyone at any age

2. What do they look like?

a. Soft, skin colored nodule

-if > 6 nodules, 95% chance of Neurofibromatosis

b. may also have café-au-lait spots

-light brown macules – usually >1cm (coffee colored)

3. Nodules

a. mixture of collagen (fibroblasts) and nerve tissue (Schwann cells)

-soft b/c of mucin (GAG’s)

b. very large ones = plexiform neurofibroma (‘bag of worms’)

c. “button hole” sign = push nodules in/out like a button

4. von Recklinghausen’s Disease (congenital Neurofibromatosis)

a. autosomal dominant

b. Sx

-Freckles in armpit (pathognomic)

-neurofibromas everywhere (range from >6 to 100’s)

-can have extremely large plexiform neurofibroma

-café-au-lait spots (>6)

-pheochromocytoma

-scoliosis

-Lisch nodules (pigmented growth in iris, harmless)

5. rarely = ( malignant (neurofibrosarcoma)

B. Dermatofibroma (very common)

1. What does it look/feel like?

a. Indurated (( amnt of collagen forms a nodule)

b. Brown – from melanocytic stimulation (reason not known)

-not an ( in #melanocytes, just stimulated

-so looks like a mole but harder

c. when squeezed, it dimples in the center

2. on arms/legs

3. Cause

a. insect bites

b. trauma

c. folliculitis (inflamed hair follicles)

4. Micro = proliferation of fibroblasts, dense collagen, stimulated melanocytes

Keloid

1. More common in African-Americans

2. Begins as scar tissue but w/excessive growth (tumor-like)

a. burns, ear piercing, acne

3. firm

C. Acrochordon (skin tags)

1. Idiopathic

2. 1-3mm pedunculated papules

a. more common in large (overweight) people

b. armpits, groin, neck

3. Tx

a. really this is purely aesthetic

b. this will probably be the only lecture we will ever get (most med-schools don’t even get one!)

c. so to treat, you need a pair of scissors (and maybe a piece of ice to numb the area)

D. Hemangioma = blood vessel tumor

1. General Info

a. Color

-usually red

-can be blue/black if poorly O2’d (may resemble a melanoma)

b. Can be macular / plaque / nodular

c. many look just like birthmarks when born, but during puberty they grow

2. Cavernous Hemangioma (if deep in the tissue)

3. Cherry Hemangioma

a. pt are > 30 y/o

b. < 3mm red papules on trunk

c. these do not go away

d. no Tx

4. Strawberry Hemangioma

a. In children

b. Looks strawberry = red, exuberant/roughened surface

c. Severity depends on location:

1) can cause blindness (if in eye) or airway obstruction (if on trachea)

2) when they are deep, may be related to certain syndromes

-effects soft tissue with bone and muscle abnormalities

d. Tx: usually goes away on its own, but will scar

5. Flat Hemangioma (Port Wine Stain = Nevus flammeus)

E. Spider Angioma (this is a small hemangioma – dermatologists just drop the “hem-“ when small)

1. Common in NL females (rarely males)

a. (’d incidence

1) pregnancy

2) Estrogen Tx (birth control pills & hormone replacement therapy)

3) Liver disease (usually HepC or Alcoholism)

-b/c ( level of estrogens

2. have central arteriole (spider head) with draining post-capillary venules (spider legs)

Pyogenic granuloma

1. what does it all mean?

a. pyo = pus

b. granuloma is really a granulation tissue (there are no macrophages to make it a granuloma)

2. Cause: trauma induced production of too much granulation tissue

3. what does it look like and what is in that thing?

a. red, weeping, fast growing, nodule w/pus

-lots of inflammatory cells with proliferation of blood vessels

-on a stalk

b. common in pregnancy

4. Clinically

a. patient comes in with “band-aid” sign

-have lots of band-aids all over it b/c it keeps bleeding

5. Tx = surgery

F. Lipoma

1. Sub-Q lump of fat (soft, freely movable)

2. cause = unknown

3. like skin tags, this is only an aesthetic problem

a. to remove, sometimes just cut a slit and it pops out

b. other times, it may be deep and surrounding important tissues (but causing no problems) and to cut it out would be very complicated.

I. Malignant Dermal Tumors

Kaposi’s Sarcoma

1. History:

a. Formerly

-mostly in the lower legs of Eastern European descendants

-slow growing (low grade)

b. Now: most common in AIDS

2. Appearance

a. start as red papules – look like nothing special

( then become red, brown, purple nodules

b. micro: see blood vessel proliferation (endothelial) w/RBC’s in “slits”

c. location = everywhere on AIDS pt (can be in mouth, lungs, etc. which leads to problems if they rupture and bleed)

3. Starting to think this is really not a true sarcoma b/c:

a. Virally induced (HSV-8) – may be a reaction to the virus

b. Resolves spontaneously

c. Multi-focal

-multiple lesions arise at the same time

-true cancer starts one place and then has METS

Eczema

Eczematous Diseases

General features

- Eczema = Greek for “boil over”

- Is epidermal inflammation (so eczema usually presents as scaly red skin)

- aka “dermatitis” (not really a good name b/c eczema assumes epidermal while you think dermal w/ “dermatitis”)

6 Pathogenesis/Pathology

-NL epidermis has blood supply from the dermal vessels

-layers go: stratum corneum (dead / horny layer w/flakes) ( epidermis ( dermis

1. Spongiosis = intercellular edema that accumulates b/c epidermal cells

a. if bad enough, will get vesicles b/t cells

b. epidermis is deranged then ( scaly

( Parakeratosis (retain nuclei in stratum corneum) leads to more scales

2. Exocytosis of lymphocytes from dermal vessels to epidermis

-accompanies spongiosis

3. This all becomes chronic and is itchy ( so we scratch it ( skin gets thicker

a. Acanthosis (thickened spinous layer)

b. Hyperkeratosis (thickened stratum corneum)

4. note: all the above bolded terms are used by pathologists (normal Dr.’s use the term lichenified, or lichen simplex chronicus, to describe this thickening)

I. Atopic Dermatitis/Eczema

- Atopic = “out of place” = rash is out of place when compared to where the allergen is

A. Epidemiology

1. generally people who hypersensitive (may have excessive asthma/hay fever)

a. allergens are inhaled or ingested

b. usually their skin is not sensitive to allergen (so different than contact dermatitis)

2. manifests in childhood (but 90% outgrow this)

3. familial

B. Clinically (given in order from top to bottom, specific to more general)

1. edema of eyelids w/ double folds under the lower ones (Dennie’s lines)

2. rhinitis (stuffy nose)

3. hyperlinearity of palms ((’d markings on palms)

4. eczema (erythematous scales)

-generally in antecubital fossa and popliteal fossa

a. infants = more on face

b. adults = more peripheral (places that are more dry)

5. pruritis

6. (’d IgE in blood

C. Pathology (gross)

-lesion = bright red and crusty (derm term for scab)

1. usually due to S. aureus infection (may need ABX then)

D. Tx

1. Corticosteroid cream (for almost all eczematous disease)

a. b/c most rashes are inflammatory

b. makes lymphocytes go away and allows pt to heal

II. Seborrheic Eczema (Seborrheic Dermatitis)

-another misnomer b/c doesn’t have anything to do w/sebaceous glands

A. Clinically (basically = dandruff)

1. erythematous/scaly skin, usually on the scalp

a. can go to forehead and then eyebrows

b. in infants = Cradlecap

c. on eyelids = blephoritis

d. if severe, then on chest, armpits

2. scale is greasy, but not b/c of sebaceous gland

3. can get infected (crusty) w/ S. aureus

4. can see ring pattern (NOT ringworm)

a. to differentiate, do scraping, do KOH prep and look under microscope

III. Stasis Dermatitis/Eczema

A. Pathogenesis

1. Failing valves in leg veins ( insufficient venous return ( blood pooling in legs

2. Pooled blood also causes:

a. (’d pressure in veins which leads to:

-proliferation of vessels

-dilate vessels ( varicosities

-edema (vessel walls are weakened and leak various stuff including RBCs)

b. poor oxygenation to skin

-RBCs breakdown & release hemosiderin ( brown skin

B. Clinically

1. pitting edema

2. brown skin

3. if bad enough, get stasis ulcer (from epidermis all the way to stroma)

a. (’d circulation ( skin breakdown

b. difficult to heal b/c of compromise in circulation

c. slide: surrounding skin is extremely discolored b/c it is dead

“By wisdom a house is built, and through understanding it is established; through knowledge its rooms are filled with rare and beautiful treasures.”

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