Recognizing Neoplastic Skin Lesions: A Photo Guide



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Am Fam Physician. 1998 Sep 15;58(4):873-884.

  Patient information: See related handout on skin cancer, written by the author of this article.

Malignant lesions of the skin are common. Patients who develop squamous cell carcinoma and malignant melanoma often have recognizable precursor conditions. A few skin lesions resemble malignancies. Lesions that are growing, spreading or pigmented, or those that occur on exposed areas of skin are of particular concern. Knowing the similarities and differences between these lesions allows the primary physician to make a diagnosis in most cases by simple inspection and palpation. When in doubt, it is appropriate to perform an excisional biopsy of small lesions or punch biopsy of larger lesions. Removal of premalignant lesions will reduce the occurrence of malignant disease. Almost all skin cancers can be cured by early excision or destruction. For these reasons, physicians should be aware of the risk factors for skin cancer, educate patients about risk reduction and include skin inspection for premalignant and malignant lesions as a part of routine health maintenance examinations.

Primary neoplastic disease of the skin is common. Early recognition of such lesions is important because complete excision will cure almost all cases of skin cancer if performed in the early stages. A presumptive diagnosis can often be made by considering the patient's risk factors, the history of the lesion and its location, appearance and texture. The definitive diagnosis is made by histologic examination of biopsy specimens.

Factors that Contribute to Skin Cancer

Most primary skin neoplasms occur in skin that is exposed to adverse conditions. Ultraviolet light from sunlight is most often a contributing factor. Desert sunlight is particularly dangerous, but water and snow both reflect a high proportion of the ultraviolet light from the sky, increasing the risk for sailors, beach lovers and winter-sports enthusiasts. In farmers and ranchers, the skin of the face, neck and arms is also at high risk.

Exposure to immunosuppressive drugs or ionizing radiation is a less common cause.1 Use of organic arsenics and tars predisposes to skin cancer. A history of malignant melanoma in a first-degree relative or the presence of numerous melanotic nevi, which may be familial or sporadic, greatly increases the risk of developing malignant melanoma.24 Persons with fair or freckled skin that does not tan are at increased risk. Dark hair and skin provide some protection from skin cancer. Family physicians should educate their patients about these risks and encourage them to protect their skin.

Skin lesions come to the attention of the physician in three ways: (1) the patient may be aware of the lesion and consult the physician about it; (2) the physician may notice the lesion when examining the patient for some other reason; or (3) the physician inspects the entire skin surface for lesions as part of a pre-employment or health maintenance examination. A complete skin examination is important particularly in high-risk patients because, at the stage when they are curable, skin cancers are painless and often inconspicuous. The top of the head, the face, the neck, the shoulders and the extensor surfaces of the arms are particularly important, but the areola, the vulva and the foreskin are also areas of high risk. In black patients, the palms of the hands, soles of the feet and periungual areas are particularly vulnerable. A detailed description and measurement of all suspicious skin lesions should be documented in the patient's medical record.

Basal Cell Carcinoma

Comprising 60 percent of primary skin cancers, the basal cell carcinoma is a slow-growing lesion that invades tissue but rarely metastasizes. Most metastatic basal cell carcinomas arise from large tumors.5 Basal cell carcinomas that have recurred after excision may be at greater risk of metastasis.6 Basal cell carcinoma is common on the face and on other exposed skin surfaces but may occur anywhere (Figure 1). The common form first appears as a small round or oval area of skin thickening. Usually there is no itching, pain or change in skin color. The area very slowly extends circumferentially, creating a slightly raised edge, which may have a shiny, pearly or slightly translucent appearance (Figure 2).

FIGURE 1.

Small basal cell carcinoma.

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FIGURE 1.

Small basal cell carcinoma.


FIGURE 1.

Small basal cell carcinoma.

FIGURE 2.

Basal cell carcinoma with the characteristic shiny appearance.

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FIGURE 2.

Basal cell carcinoma with the characteristic shiny appearance.


FIGURE 2.

Basal cell carcinoma with the characteristic shiny appearance.

As the lesion continues to grow, the central area becomes atrophic, leaving a hollow that is covered by thin skin, often with visible vessels, which eventually ulcerates (Figure 3). The growing edges become more irregular, and the shape becomes uneven. The base is also invasive and gradually erodes the underlying tissue, making it difficult to excise the lesion completely.

FIGURE 3.

Ulcerating basal cell carcinoma.

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FIGURE 3.

Ulcerating basal cell carcinoma.


FIGURE 3.

Ulcerating basal cell carcinoma.

Less common forms include a superficial basal cell carcinoma that resembles a patch of dermatitis, a pigmented basal cell carcinoma that resembles a nodular malignant melanoma and an aggressive-growth basal cell carcinoma. Aggressive-growth basal cell carcinoma is an infiltrating sclerosing lesion that may appear similar to a scar with a firm or hard base. In patients younger than 35 years, basal cell carcinoma tends to adopt the more aggressive forms.7

No premalignant conditions precede basal cell carcinoma. Basal cell carcinoma and lesions of similar appearance are compared in Table 1.

TABLE 1

Features of Basal Cell Carcinoma and Lesions of Similar Appearance

Lesion Location Surface Color Outline Other features

Basal cell carcinoma

Most common on face, but can occur anywhere

Raised, pearly, firm

Normal skin color

Round at first, irregular later

May ulcerate

Superficial basal cell carcinoma

Any location

Roughened

Skin-colored or pink

Round or irregular

Resembles dermatitis

Pigmented basal cell carcinoma

Most commonly occurs on the face

Nodule

Growing area is dark brown or black

Becomes irregular as growth progresses

Looks like a nodular malignant melanoma

Infiltrating basal cell carcinoma

Any location

Smooth

Skin-colored

Various

Looks like a firm scar that grows aggressively

Tricoepithelioma

Any location

Raised, pearly

Normal skin color

Round

Does not become malignant

Keloid after

Site of previous injury

Raised, rounded, smooth

Usually pink, may be skin-colored

Varies, often linear

Often large, but no growth one year

Molluscum contagiosum

Face and hands of children, areas of sexual contact

Raised, rounded central hollow

Skin-colored

Round

Usually multiple, in clusters or scattered; contagious

Soft, fleshy

Dermatofibroma

Often occurs on limbs, rarely on face

Flat or slightly raised, edge not thickened or pearly

Skin-colored, firm under the surface but not on the surface

Usually round or oval

Usually >5 mm diameter when first noticed

TABLE 1   Features of Basal Cell Carcinoma and Lesions of Similar Appearance

View Table

TABLE 1

Features of Basal Cell Carcinoma and Lesions of Similar Appearance

Lesion Location Surface Color Outline Other features

Basal cell carcinoma

Most common on face, but can occur anywhere

Raised, pearly, firm

Normal skin color

Round at first, irregular later

May ulcerate

Superficial basal cell carcinoma

Any location

Roughened

Skin-colored or pink

Round or irregular

Resembles dermatitis

Pigmented basal cell carcinoma

Most commonly occurs on the face

Nodule

Growing area is dark brown or black

Becomes irregular as growth progresses

Looks like a nodular malignant melanoma

Infiltrating basal cell carcinoma

Any location

Smooth

Skin-colored

Various

Looks like a firm scar that grows aggressively

Tricoepithelioma

Any location

Raised, pearly

Normal skin color

Round

Does not become malignant

Keloid after

Site of previous injury

Raised, rounded, smooth

Usually pink, may be skin-colored

Varies, often linear

Often large, but no growth one year

Molluscum contagiosum

Face and hands of children, areas of sexual contact

Raised, rounded central hollow

Skin-colored

Round

Usually multiple, in clusters or scattered; contagious

Soft, fleshy

Dermatofibroma

Often occurs on limbs, rarely on face

Flat or slightly raised, edge not thickened or pearly

Skin-colored, firm under the surface but not on the surface

Usually round or oval

Usually >5 mm diameter when first noticed

Squamous Cell Carcinoma

Squamous cell carcinoma comprises 20 percent of all cases of skin cancer. It typically occurs on areas of the skin that have been exposed to sunlight for many years. It may also appear in areas that have been subjected to ionizing irradiation or in other locations in patients who have undergone treatment with immunosuppressive drugs1 or have been exposed to organic trivalent arsenic compounds or tars. Squamous cell carcinoma of the lip may be related to pipe smoking, as well as to sunlight exposure.

Human papillomavirus infection may be a precursor of keratoacanthoma and periungual, genital and other squamous cell carcinomas, especially in immunosuppressed patients.8 The affected area develops a slight redness, scaling, fissuring and an uneven surface. Superficial dilated vessels may be visible. The lesion often appears very dry and may bleed when stretched or abraded. It spreads laterally from the edges and may heap up irregularly. New lesions often appear near old ones. Clusters of lesions may occur as fleshy masses (Figure 4). The centers may become atrophic and develop raw patches or frank ulceration (Figure 5).

FIGURE 4.

Squamous cell carcinoma showing clusters of lesions.

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FIGURE 4.

Squamous cell carcinoma showing clusters of lesions.


FIGURE 4.

Squamous cell carcinoma showing clusters of lesions.

FIGURE 5.

Ulcerating squamous cell carcinoma of the lip.

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FIGURE 5.

Ulcerating squamous cell carcinoma of the lip.


FIGURE 5.

Ulcerating squamous cell carcinoma of the lip.

Two other skin lesions are considered part of the squamous cell carcinoma spectrum. The first type, keratoacanthoma, is closely related to squamous cell carcinoma. Like squamous cell carcinoma, it appears on skin damaged by sunlight or chemicals. It often occurs at the site of trauma, especially in immunosuppressed patients. It is sometimes associated with human papillomavirus infection. Keratoacanthoma appears as a skin-colored or pink smooth lesion, which becomes dome-shaped during a period of very rapid growth. When mature, it is volcano-shaped, with protruding masses of keratin resembling lava. Classic keratoacanthoma is not malignant and regresses spontaneously, but atypical lesions may actually be squamous cell carcinoma.7 Many dermatopathologists include keratoacanthoma in the spectrum of squamous cell carcinoma9 (Figure 6).

FIGURE 6.

Keratoacanthoma with typical volcano appearance.

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FIGURE 6.

Keratoacanthoma with typical volcano appearance.


FIGURE 6.

Keratoacanthoma with typical volcano appearance.

The second type is verrucous carcinoma, a variant of squamous cell carcinoma that features an irregular warty surface (Figure 7).

FIGURE 7.

Irregular warty surface of verrucous carcinoma.

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FIGURE 7.

Irregular warty surface of verrucous carcinoma.


FIGURE 7.

Irregular warty surface of verrucous carcinoma.

While metastasis of common sunlight-induced squamous cell carcinoma is unusual, lesions more likely to metastasize are lesions of the lip or ear, lesions that recur after previous therapy, lesions at the site of a burn and those that are more deeply invasive. Squamous cell carcinoma of the skin may be metastatic from other locations (Figure 8).

A variety of skin lesions are considered precursors of squamous cell carcinoma. Actinic keratosis appears very similar to the less severe lesions of squamous cell carcinoma. It is always found on skin that has received heavy exposure to sunlight.9,10 Actinic keratosis should be sought during routine inspection of the skin, especially in fair-skinned patients who have been exposed to sunlight frequently. Regular reexamination of affected skin and treatment of any areas showing growth or change can prevent neoplastic transformation or provide early treatment of malignancy11 (Figure 9).

FIGURE 8.

Metastatic squamous cell carcinoma.

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FIGURE 8.

Metastatic squamous cell carcinoma.


FIGURE 8.

Metastatic squamous cell carcinoma.

FIGURE 9.

Actinic keratosis.

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FIGURE 9.

Actinic keratosis.


FIGURE 9.

Actinic keratosis.

Epidermodysplasia verruciformis is an uncommon autosomal recessive disorder that predisposes patients to the development of squamous cell carcinoma (Figure 10). Actinic cheilitis is a condition that is similar to actinic keratitis but occurs on the vermilion of the lips.

FIGURE 10.

Epidermodysplasia verruciformis of the hand.

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FIGURE 10.

Epidermodysplasia verruciformis of the hand.


FIGURE 10.

Epidermodysplasia verruciformis of the hand.

Bowen's disease is squamous cell carcinoma in situ that resembles a plaque of psoriasis. When Bowen's disease occurs on the penis, it is called erythroplasia of Queyrat (Figure 11). Leukoplakia of the mouth or genital area may be premalignant (Figure 12).

FIGURE 11.

Erythroplasia of Queyrat (Bowen's disease of the penis).

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FIGURE 11.

Erythroplasia of Queyrat (Bowen's disease of the penis).


FIGURE 11.

Erythroplasia of Queyrat (Bowen's disease of the penis).

FIGURE 12.

Leukoplakia of the genital area.

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FIGURE 12.

Leukoplakia of the genital area.


FIGURE 12.

Leukoplakia of the genital area.

Human papillomavirus includes several strains that are associated with squamous cell carcinoma, especially in the genital areas.12  The virus may not be a precursor of squamous cell carcinoma but does increase the patient's risk for developing squamous cell carcinoma. In Table 2, squamous cell carcinoma and its variants are compared with other lesions of similar appearance (Figures 13 through 16).

TABLE 2

Features of Squamous Cell Carcinoma and Lesions of Similar Appearance

Lesion Location Surface Color Outline Other features

Squamous cell carcinoma

Areas exposed to sunlight, radiation or arsenicals

Rough, irregular, sometimes scaly, sometimes has visible vessels, sometimes warty or with fleshy masses

Skin-colored at first, sometimes reddened later

Vague

New lesions may appear near old ones

Does not clear with corticosteroid therapy

Keratoacanthoma (a variant of squamous cell carcinoma)

Exposed areas, especially face and hands

Smooth dome, becoming volcano-shaped

Skin-colored or slightly reddened

Well-defined

Goes through aperiod of very rapid growth, often regresses

Eczema and atopic dermatitis (Figure 13)

Atopic dermatitis behind ears, on flexure areas

Reddened, slightly scaly, sometimes with vesicles

Dry at first, fissured, may weep

Indefinite

Common in atopic persons and those exposed to irritants

Contact dermatitis (Figure 14)

Wherever skin comes in contact with an irritant

Reddened, slightly scaly, sometimes with vesicles

Dry at first, fissured, may weep

Circumscribed

Dermatitis clears with corticosteroid therapy

Psoriasis (Figure 15)

Elbows, knees, scalp, sacral cleft, nails

Scaly with underlying reddened base

White dry scales, smooth pink or red wherescales are removed; may bleed

Well-demarcated; round, irregular or confluent

Often widespread, sometimes itchy; varies with season

Seborrheic dermatitis (Figure 16)

Scalp, forehead, nasolabial fold, midline trunk

Raised, with scales

Yellow or brown

Well-demarcated

Some lesions can be easily removed

TABLE 2   Features of Squamous Cell Carcinoma and Lesions of Similar Appearance

View Table

TABLE 2

Features of Squamous Cell Carcinoma and Lesions of Similar Appearance

Lesion Location Surface Color Outline Other features

Squamous cell carcinoma

Areas exposed to sunlight, radiation or arsenicals

Rough, irregular, sometimes scaly, sometimes has visible vessels, sometimes warty or with fleshy masses

Skin-colored at first, sometimes reddened later

Vague

New lesions may appear near old ones

Does not clear with corticosteroid therapy

Keratoacanthoma (a variant of squamous cell carcinoma)

Exposed areas, especially face and hands

Smooth dome, becoming volcano-shaped

Skin-colored or slightly reddened

Well-defined

Goes through aperiod of very rapid growth, often regresses

Eczema and atopic dermatitis (Figure 13)

Atopic dermatitis behind ears, on flexure areas

Reddened, slightly scaly, sometimes with vesicles

Dry at first, fissured, may weep

Indefinite

Common in atopic persons and those exposed to irritants

Contact dermatitis (Figure 14)

Wherever skin comes in contact with an irritant

Reddened, slightly scaly, sometimes with vesicles

Dry at first, fissured, may weep

Circumscribed

Dermatitis clears with corticosteroid therapy

Psoriasis (Figure 15)

Elbows, knees, scalp, sacral cleft, nails

Scaly with underlying reddened base

White dry scales, smooth pink or red wherescales are removed; may bleed

Well-demarcated; round, irregular or confluent

Often widespread, sometimes itchy; varies with season

Seborrheic dermatitis (Figure 16)

Scalp, forehead, nasolabial fold, midline trunk

Raised, with scales

Yellow or brown

Well-demarcated

Some lesions can be easily removed

FIGURE 13.

Eczema dermatitis.

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FIGURE 13.

Eczema dermatitis.


FIGURE 13.

Eczema dermatitis.

FIGURE 14.

Contact dermatitis.

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FIGURE 14.

Contact dermatitis.


FIGURE 14.

Contact dermatitis.

FIGURE 15.

Psoriasis.

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FIGURE 15.

Psoriasis.


FIGURE 15.

Psoriasis.

FIGURE 16.

Seborrheic dermatitis.

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FIGURE 16.

Seborrheic dermatitis.


FIGURE 16.

Seborrheic dermatitis.

Malignant Melanoma

Although it comprises only 1 percent of skin cancers, malignant melanoma accounts for over 60 percent of skin cancer deaths.13 It metastasizes to remote sites early, and its metastases are characteristically unresponsive to treatment. Like the other skin cancers, malignant melanoma is more common on skin that has undergone excessive exposure to sunlight, but it can occur anywhere. Four types of malignant melanoma are identified.

The lesions of superficial spreading melanoma are dark brown or black. In the initial phase they have a slowly spreading irregular outline. Some areas may be a lighter shade. Vertical growth occurs later, penetrating into the dermis and causing some parts of the lesion to become raised. This is the most common kind of melanoma (Figure 17).

FIGURE 17.

Superficially spreading malignant melanoma.

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FIGURE 17.

Superficially spreading malignant melanoma.


FIGURE 17.

Superficially spreading malignant melanoma.

Nodular melanoma grows vertically from the start and is more likely to mestastasize early. It has little or no lateral extension, appearing as a shiny black dome.

Lentigo maligna melanoma occurs in a pre-existing lentigo maligna. The appearance of one or more nodules signals the change to an invasive lesion (Figure 18).

FIGURE 18.

Lentigo maligna. Note the multiple nodules signaling invasiveness of the lesion.

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FIGURE 18.

Lentigo maligna. Note the multiple nodules signaling invasiveness of the lesion.


FIGURE 18.

Lentigo maligna. Note the multiple nodules signaling invasiveness of the lesion.

Acral lentiginous melanoma occurs on the palms of the hands, the soles of the feet, under the nails and on mucosal surfaces. It is uncommon, comprising only 5 percent of melanomas in pale-skinned persons. Dark-skinned persons rarely get melanomas, but if they do, the lesions are likely to be acral melanomas (Figure 19).

FIGURE 19.

Acral lentiginous melanoma.

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FIGURE 19.

Acral lentiginous melanoma.


FIGURE 19.

Acral lentiginous melanoma.

Since not all malignant melanomas are visibly pigmented, physicians should be suspicious of any lesion that is growing or that bleeds on minor trauma. If the diagnosis is in doubt, it is better to take one or more adequate full skin thickness biopsies for histologic examination.

Certain skin lesions are considered precursors of malignant melanoma. Blue nevi occasionally become the site of melanocytic malignant change. Suspicious features, such as location on the scalp of men in their forties, growth, bleeding on minor trauma and the occurrence of dark satellite lesions around the nevus, may signal this change. All blue nevi should be carefully monitored or excised (Figure 20).

FIGURE 20.

Blue nevi.

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FIGURE 20.

Blue nevi.


FIGURE 20.

Blue nevi.

Lentigo maligna (melanotic freckle of Hutchison) occurs on the face or other sun-exposed skin of older, fair-skinned persons. It is a brown macule with some color variation, spreading slowly and unevenly at the edges. Dark invasive lesions with irregular borders may grow from it (Figure 18). Congenital nevomelanocytic nevi are brown patches of skin that are present at birth or develop in infancy. They usually have an irregular surface, and they may be slightly raised and exhibit coarse hair. Lesions that are more than 20 cm across are more likely to undergo neoplastic change into malignant melanoma, often when the child is between three and five years of age.

The presence of 10 or more dysplastic nevi confers a 12-fold risk of developing malignant melanoma.2 Dysplastic nevi may appear de novo or may develop from common melanocytic nevi.3 They occur in 5 percent of the general white population, but in 30 to 50 percent of those with sporadic (nonfamilial) primary melanoma and in almost all patients with familial cutaneous melanoma.4

In Table 3, the common varieties of malignant melanoma are compared with lesions of similar appearance (Figures 21 through 23).

TABLE 3

Features of Four Forms of Malignant Melanoma and Lesions of Similar Appearance

Lesion Location Surface Color Outline Other features

Superficially spreading malignant melanoma

Most common on sun-exposed skin, but can occur anywhere

Smooth; vertical growth occurs later

Dark brown or black, may be variegated

Becomes more irregular as it grows

May have a pink or reddish halo

Nodular melanoma

Most common on sun-exposed skin, but can occur anywhere

Nodular form

Dark brown or black, may be variegated

May be regular or irregular

Grows aggressively, invades early

Lentigo maligna melanoma

In a pre-existing lentigo maligna, usually facial

Nodular against a smooth background

Dark or black on pale brown background

Irregular

Acral lentiginous melanoma

Nailbeds, palms of the hands, soles of the feet, mucosal areas

Smooth

Dark brown or black

Irregular

Occurs in both black and white persons

Common melanocytic nevi (Figure 21)

Widely scattered

Smooth, flat or uniformly elevated

Uniform light or dark brown

Regular, round or oval, rarely >10 mm diameter

Less common in black persons

Lentigo (freckles)

Mainly on sun-exposed surfaces

Smooth, flat brown or tan

Uniform light

Round, oval or polyhedric

Darken with sun exposure, lighten in winter

Blue nevi (Figure 20)

Most commonly occur on hands or feet; may occur anywhere

Papules or nodules

Blue, blue-gray, or blue-black

Round or oval, usually <10 mm diameter

Firm on palpation

Pigmented basal cell carcinoma (Figure 23)

Most common on the face

Nodule

Growing area is dark brown or black

Becomes irregular as growth progresses

TABLE 3   Features of Four Forms of Malignant Melanoma and Lesions of Similar Appearance

View Table

TABLE 3

Features of Four Forms of Malignant Melanoma and Lesions of Similar Appearance

Lesion Location Surface Color Outline Other features

Superficially spreading malignant melanoma

Most common on sun-exposed skin, but can occur anywhere

Smooth; vertical growth occurs later

Dark brown or black, may be variegated

Becomes more irregular as it grows

May have a pink or reddish halo

Nodular melanoma

Most common on sun-exposed skin, but can occur anywhere

Nodular form

Dark brown or black, may be variegated

May be regular or irregular

Grows aggressively, invades early

Lentigo maligna melanoma

In a pre-existing lentigo maligna, usually facial

Nodular against a smooth background

Dark or black on pale brown background

Irregular

Acral lentiginous melanoma

Nailbeds, palms of the hands, soles of the feet, mucosal areas

Smooth

Dark brown or black

Irregular

Occurs in both black and white persons

Common melanocytic nevi (Figure 21)

Widely scattered

Smooth, flat or uniformly elevated

Uniform light or dark brown

Regular, round or oval, rarely >10 mm diameter

Less common in black persons

Lentigo (freckles)

Mainly on sun-exposed surfaces

Smooth, flat brown or tan

Uniform light

Round, oval or polyhedric

Darken with sun exposure, lighten in winter

Blue nevi (Figure 20)

Most commonly occur on hands or feet; may occur anywhere

Papules or nodules

Blue, blue-gray, or blue-black

Round or oval, usually <10 mm diameter

Firm on palpation

Pigmented basal cell carcinoma (Figure 23)

Most common on the face

Nodule

Growing area is dark brown or black

Becomes irregular as growth progresses

FIGURE 21.

Common melanocytic nevi.

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FIGURE 21.

Common melanocytic nevi.


FIGURE 21.

Common melanocytic nevi.

FIGURE 22.

Malignant melanoma.

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FIGURE 22.

Malignant melanoma.


FIGURE 22.

Malignant melanoma.

FIGURE 23.

Pigmented basal cell carcinoma.

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FIGURE 23.

Pigmented basal cell carcinoma.


FIGURE 23.

Pigmented basal cell carcinoma.

Other Primary Malignancies of the Skin

Kaposi's sarcoma appears as intensely red, nonblanching, slightly raised or nodular lesions of the skin and mucous membranes. Usually there are many lesions of various sizes. It occurs more frequently in patients with acquired immunodeficiency syndrome (Figure 24).

FIGURE 24.

Kaposi's sarcoma.

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FIGURE 24.

Kaposi's sarcoma.


FIGURE 24.

Kaposi's sarcoma.

Sebaceous carcinoma has a nonspecific appearance similar to that of a squamous cell carcinoma of the skin, with nodularity, telangiectasias and hair loss (Figure 25).

FIGURE 25.

Sebaceous carcinoma at the outer angle of the left eye.

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FIGURE 25.

Sebaceous carcinoma at the outer angle of the left eye.


FIGURE 25.

Sebaceous carcinoma at the outer angle of the left eye.

Malignant eccrine spiradenoma is a slowly growing, deeply invasive sclerotic plaque that occurs on the face of older women. It is often painful (Figure 26).

FIGURE 26.

Malignant eccrine spiradenoma.

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FIGURE 26.

Malignant eccrine spiradenoma.


FIGURE 26.

Malignant eccrine spiradenoma.

Syringoid sweat duct carcinoma is a rare malignant condition that occurs on the face or scalp of elderly patients, causing local hair loss. The surface may be warty and secrete fluid (Figure 27).

FIGURE 27.

Syringoid sweat duct carcinoma. Note the characteristic warty appearance.

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FIGURE 27.

Syringoid sweat duct carcinoma. Note the characteristic warty appearance.


FIGURE 27.

Syringoid sweat duct carcinoma. Note the characteristic warty appearance.

Paget's disease of the nipple appears to be an unresponsive eczema of the areola but actually is a carcinoma in the ducts of the breast that grows outward to involve the skin.

Pigmented lesions that appear suspicious can be evaluated by using the “ABCD” rules: asymmetry, border irregularity, color variation and diameter 6 mm or greater.14,15 Two other suspicious signs are more rapid growth than other lesions and the presence of a narrow pink halo around the lesion.

Squamous cell carcinoma may be treated by excision, cryotherapy or topical chemotherapy; it should be diagnosed by full skin thickness punch biopsies. For basal cell carcinoma and other skin malignancies, it is better to remove the lesion completely whenever possible, with lateral and deep margins of several millimeters of healthy tissue. If any of the ABCD signs are found in a new pigmented lesion or in a melanocytic nevus that was previously uniformly colored, smooth, flat, round or oval (Figure 28), an excisional biopsy should be performed. All suspicious lesions should be excised down to a connective tissue base with a 2- to 3-mm lateral margin.15

FIGURE 28.

Dysplastic nevi cascade.

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FIGURE 28.

Dysplastic nevi cascade.


FIGURE 28.

Dysplastic nevi cascade.

If a cosmetically acceptable result would be difficult to obtain after excisional biopsy, full skin thickness punch biopsy of several areas may be performed, including the margins and any raised areas. If a biopsy shows dysplasia, the whole lesion should be removed with 5-mm margins using plastic surgical techniques, and the site should be monitored for recurrence. Malignant melanoma also requires excision with a margin of at least 5 mm, and many dermatologists recommend a 2-cm margin. All other pigmented lesions that occur in these patients should be observed for change at least annually. Serial photographs may be valuable.16

Final Comment

Physicians should assist patients in reducing factors that increase the risk for developing skin cancer. A complete skin examination for premalignant and malignant lesions should be performed during periodic health evaluations and when other opportunities occur. By doing so, the vigilant physician can intervene and reduce the morbidity and mortality of malignant skin disease. Excisional biopsy with an adequate margin is recommended whenever possible. For a large lesion, multiple punch biopsies of selected areas, including the growing edge, is an acceptable method for reaching a diagnosis. In these cases the definitive excision will require plastic surgical techniques. Mohs' micrographic surgery is a technique in which the histology of each layer of tissue is determined before removing the next layer. This technique permits complete excision without excessively large margins.17,18

The Author

LEWIS C. ROSE, M.B., B.S.(LOND), is an associate professor in the Department of Family Practice at the University of Texas Health Science Center at San Antonio. He received his medical training at University College Hospital Medical School, London, England. Dr. Rose is board certified in family practice in the United Kingdom, Canada and the United States.

Address correspondence to Lewis C. Rose, M.B., B.S.(Lond), Department of Family Practice, University of Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78284. Reprints are not available from the author.


Figures 1,3,5,7,8,1012,1522, and 2427 from the Division of Dermatology, Department of Medicine, University of Texas Health Science Center, San Antonio, Tex. Figures 2,4,6,9,13,14,23 and 28 from the American Academy of Family Physicians.

REFERENCES

1. Shamanin V, zur Hausen H, Lavergne D, Proby CM, Leigh IM, Neumann C, et al. Human papillomavirus infections in nonmelanoma skin cancers from renal transplant recipients and nonimmunosuppressed patients. J Natl Cancer Inst. 1996;88:802–11.

2. Tucker MA, Halpern A, Holly EA, Hartge P, Elder DE, Sagebiel RW, et al. Clinically recognized dysplastic nevi. A central risk factor for cutaneous melanoma. JAMA. 1997;227:1439–44.

3. Swerdlow AJ, English J, Mackie RM, O'Doherty CJ, Hunter JA, Clark J, et al. Benign melanocytic naevi as a risk factor for malignant melanoma. Br Med J. 1986;292:1555–9.

4. Elder DE, Goldman LI, Goldman SC, Greene MH, Clark WH Jr. Dysplastic nevus syndrome: a phenotypic association of sporadic cutaneoous melanoma. Cancer. 1980;46:1787–94.

5. Snow SN, Sahl W, Lo JS, Mohs FE, Warner T, Dekkinga JA, et al. Metastatic basal cell carcinoma. Report of five cases. Cancer. 1994;73:328–35.

6. Tavin E, Persky MS, Jacobs J. Metastatic basal cell carcinoma of the head and neck. Laryngoscope. 1995;105(8 Pt 1):814–7.

7. Netscher DT, Wigoda P, Green LK, Spira M. Keratoacanthoma: when to observe and when to operate and the importance of accurate diagnosis. South Med J. 1994;87:1272–6.

8. de Villiers EM, Lavergne D, McLaren K, Benton EC. Prevailing papillomavirus types in non-melanoma carcinomas of the skin in renal allograft recipients. Int J Cancer. 1997;73:356–61.

9. Krunic AL, Garrod DR, Smith NP, Orchard GS, Cvijetic OB. Differential expression of desmosomal glycoproteins in keratoacanthoma and squamous cell carcinoma of the skin: an immunohistochemical aid to diagnosis. Acta Derm Venereol. 1996;76:394–8.

10. Marks R. The role of treatment of actinic keratoses in the prevention of morbidity and mortality due to squamous cell carcinoma. Arch Dermatol. 1991;127:1031–3.

11. Dodson J, DeSpain J, Hewett JE, Clark DP. Malignant potential of actinic keratoses and controversy over treatment. Arch Dermatol. 1991;127:1029–31.

12. Leffell D, Headington JT, Wong DS, Swanson NA. Aggressive-growth basal cell carcinoma in young adults. Arch Dermatol. 1991;127:1663–7.

13. Sauer GC, Hall JC, eds. Skin tumors. In: A manual of skin diseases. 7th ed. Philadelphia: Lippincot-Raven, 1996:342.

14. Friedman RJ, Rigel DS, Kopf AW. Early detection of malignant melanoma: the role of the physician examination and self-examination of the skin. CA Cancer J Clin. 1985;35:130–51.

15. Roberson JK. A 28-year-old fair-skinned woman with multiple moles. JAMA. 1997;278:1693–9.

16. Shriner DL, Wagner RF Jr, Glowczwski JR. Photography for the early diagnosis of malignant melanoma in patients with atypical moles. Cutis. 1992;50:358–62.

17. Nelson BR, Railan D, Cohen S. Mohs' micrographic surgery for nonmelanoma skin cancers. Clin Plast Surg. 1997;24:705–18.

18. Zitelli JA, Brown CD, Hanusa BH. Surgical margins for excision of primary cutaneous melanoma. J Am Acad Dermatol. 1997;37(3 Pt 1):422–9.

Each year members of a different family practice department develop articles for “Problem-Oriented Diagnosis.” This series is coordinated by the Department of Family Practice at the University of Texas Health Science Center at San Antonio. Guest editors of the series are David A. Katerndahl, M.D., and Clinton Colmenares.



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