Diagnosis
The most characteristic lesion is a pink, pearly, translucent papule or nodule with telangiectasias, rolled borders, and central depression with ulceration. Superficial BCCs are well demarcated, irregularly bordered, red patches; they tend to enlarge radi- ally rather than invading into deeper structures. Patients may have a history of radiation therapy, immunosuppression, arsenic exposure, or (most commonly) excessive sun exposure. Choose biopsy for clinically suspicious lesions.
Actinic Keratoses: Multiple white, scaly patches measuring 1 to 3 mm on the
hands, characteristic of actinic keratoses.
Cutaneous Squamous Cell Carcinoma: Typically presents as a slowly evolving,
isolated, keratotic, or eroded macule, papule, or nodule that commonly appears on the scalp, neck, pinna, or lip.
Dermatology
Therapy
Most BCCs are treated with simple excision. Ill-defined lesions, high-risk histologic types, and tumors on the face and hands are often best treated with Mohs micrographic surgery, which is a staged tumor excision with mapping of specimens and preparation and interpretation of the frozen sections.
Dysplastic Nevi
Diagnosis
Dysplastic nevi are markers for melanoma diathesis. A low percentage transform into melanoma. Dysplastic nevi have some features of melanoma, including:
• diameter ≥5 mm
• asymmetric shape with indistinct borders
• a “fried egg” appearance with a darker, elevated, central portion and tan, flat
shoulders blending into surrounding skin
• pigmentation ranging from light tan to dark brown and occasionally black
Autosomal-dominant familial melanoma/dysplastic nevus syndrome is defined by the presence of melanoma in at least two relatives and dysplastic nevi in other family members.
Therapy
Dysplastic nevi that develop increased characteristics associated with melanoma (fuzzy or ill-defined borders, multiple colors, diameter ≥5 mm), have otherwise changed, or stand out from other nevi must be removed and sent for pathology.
Melanoma
Prevention
Select sun avoidance and sun-protective clothing as first-line prevention. Use of sun screening agents is adjunctive therapy.
Diagnosis
StUDY tABLe: “ABCDE” Rule to Diagnose Melanoma
Characteristic Description
Asymmetry Not regularly round or oval
Border irregularity Notching, scalloping, or poorly defined margins
Color variegation Shades of brown, tan, red, white, blue-black, or combinations
Diameter Size >6 mm (early melanomas may be diagnosed at a smaller size)
Evolution Lateral expansion or vertical growth
Basal Cell Carcinoma: This pink, pearly, translu-
cent, dome-shaped papule with telangiectasias is characteristic of BCC.
Dysplastic Nevi: Dysplastic nevi share similar char-
acteristics with melanoma including asymmetry, indistinct and irregular borders, and variation in pigmentation.
Dermatology
There are several subtypes of melanoma.
• Lentigo maligna begins as a uniformly pigmented, light brown patch on the face or upper trunk that is confined to the
epidermis and resembles a solar lentigo. Over time, the lesion expands and becomes more variegated in color.
• Superficial spreading melanoma presents as a well-defined asymmetric patch or plaque with an irregular border, variation
in color, and an expanding diameter. This type tends to occur on the back in men and the legs in women (areas that receive intermittent sun and are prone to sunburn).
• Nodular melanomas are the most aggressive form (invading deeper structures); they are responsible for the majority of
deaths from melanoma.
• Acral lentiginous melanomas are the most common type of melanoma seen in patients with dark skin and usually occur
on the hands and feet.
Lentigo Maligna: This carcinoma in situ appears as a brown patch on sun-
exposed skin. Melanoma: This asymmetric pigmented skin lesion has irregular, scalloped, notched, and indistinct borders with variegated coloration.
Therapy
Complete excision is the preferred biopsy technique for most varieties of melanoma, and sentinel lymph node biopsy is indi- cated for melanomas >1 mm thick. The extent of the surgical excision depends on the thickness of the primary melanoma. Melanomas >4 mm thick or with lymph node involvement are associated with an increased risk of dying. In these patients adjuvant immunotherapy with interferon alfa improves relapse-free survival, but its impact on overall survival is not clear.
Surgical resection for metastatic disease limited to one or a few sites can result in prolonged survival. In these patients, immu- notherapy (interleukin-2 and ipilimumab) or targeted therapy is preferred over chemotherapy.
For patients with the V600E BRAF mutation, targeted therapy with vemurafenib is recommended over immunotherapy for patients with poor performance status and/or more advanced disease.
Follow-up routine blood tests are not recommended, and the value of screening test radiography, CT scanning, or PET/CT
scanning is questionable. Acral Melanoma: Acral melanoma on the toe.
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Dermatology
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◆Don’t Be trickeD
• Lentigo maligna melanoma is treated with a broad, shallow shave biopsy, not excision as other melanomas are treated.
Urticaria
Diagnosis
The hallmark of urticaria (hives) is the wheal, a superficial itchy swelling of the skin. Wheals involving the skin around the mouth are considered an emergency, requiring careful observation and investigation for airway obstruction.
Individual lesions of acute urticaria last only a few hours but may recur. β-Lactams, sulfonamides, NSAIDs, opioids, insect stings, contrast dyes, latex (including condoms), nuts, fish, and eggs are common causes. Urticaria can also be initiated by pres- sure, cold, heat, vibration, water, or sunlight.
Lesions persisting >24 hours with purpura/ecchymoses upon resolution are likely due to urticarial vasculitis. In this situation, definitive diagnosis is made by skin biopsy.
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◆Don’t Be trickeD
• Do not select ANA testing for acute or chronic urticaria.
StUDY tABLe: Differential Diagnosis of Urticaria
If you see this… Select this…
↑ESR, ↑CRP, lesions persisting >24 hours Vasculitic urticaria; perform skin biopsy and obtain serum complement levels, hepatitis B and C serology, cryoglobulins, and SPEP
Fever, adenopathy, arthralgia, and antigen or drug exposure Serum sickness; measure IgE level (elevated)
Features of anaphylaxis, obvious allergen exposure Immediate hypersensitivity reaction; treat emergently with epinephrine Marked eosinophilia Parasitic infection, possibly strongyloidiasis, filariasis, or trichinosis
(especially with periorbital edema)
Therapy
Avoid aspirin and other NSAIDs. Select nonsedating antihista- mines as first-line therapy. If no response is seen, add an H2-
blocker (cimetidine, ranitidine), although evidence for effective- ness is mixed. Doxepin blocks H1, H2, and serotonin receptors,
and is often effective. Short-term oral glucocorticoids are indi- cated in very symptomatic patients with acute urticaria.
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◆Don’t Be trickeD
• Systemic and topical glucocorticoids are not beneficial for patients with chronic urticaria.
• Measurement of C1 inhibitor levels is not indicated in patients with urticaria, because deficiency of C1 inhibitor is associated with angioedema, not with hives.
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❖test Yourself
A 31-year-old man has a 2-week history of hives. Individual lesions persist for less than 24 hours and are not worsened by cold, sunlight, or pressure. He has been taking diphenhydramine without relief.
ANSWER: The diagnosis is acute urticaria. Additional diagnostic studies are not indicated. Add an H2-blocker.
Urticaria: Urticaria is characterized by small white, pink, or flesh-colored pruritic
papules.
Dermatology