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Skin Lesions CASE STUDIES

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Skin Lesions

The skin is the largest organ in the body and helps protect our bodies from the external environment. Skin growths, called lesions, will occur throughout your life and may require medical attention. When caught early, these lesions are rarely life-altering. However, these skin lesions can become tender and interfere with daily routine activity. When these lesions enlarge in size, they can become tender when they press on sensory nerves. Skin lesions that cause pain or discomfort are called symptomatic lesions. Two frequent symptomatic lesions that grow directly under the skin and can become symptomatic include:

Cyst:

A skin cyst, also known as an epidermal cyst, is a non-cancerous closed pocket of skin tissue that can get involuted underneath the skin; this involuted skin tissue can form a sac that can become filled with fluid, pus, or other material. A skin cyst which forms a sac will typically possess a pore to the outside air but it can occasionally become clogged. Once it gets clogged, it will typically grow in size and can eventually become infected. Sebaceous cysts are the most common form of epidermal cysts and are filled with sebum, the material sound in acne lesions. These cysts are usually painless and slow-growing but will require medical attention if they become enlarged, create irregularities of the skin, or become infected.

Lipoma:

A lipoma is a soft lump felt under the skin that can be felt or become visible when it is enlarged. What you feel as a lipoma is actually a single fat cell that begins to grow without inhibition. This is in contrast to your other fat cells which are kept in check unless you undergo weight gain. Interestingly, patients will often notice lipomas when they lose weight since their normal fat cells will shrink but the lipoma fat cells will not! Skin lipomas are typically soft to the touch and create a bulge of the skin; the lipoma lumps will be mobile if they are located superficial or be fixed in position if they are located deeper in the muscle.  Since lipomas can grow out of control they are classified as a tumor, but most of them are typically harmless and not malignant. They are commonly found in the arms or upper chest, abdomen, and back and are typically smaller than a couple of inches wide.

Other skin lesions can grow and look abnormal, i.e. atypical or premalignant lesions, and if left unintended can eventually become malignant. These premalignant skin lesions are called suspicious lesions and require a biopsy to confirm their identity and rule out malignancy. If a mole is biopsied and found to be abnormal on its pathology, it is called an atypical nevus and will require a formal excision. Atypical nevi typically do not look like normal moles with abnormal features that include: enlarged diameter, darker color, raised, irregular border, and growing in size faster than normal. What makes atypical nevi concerning is that they possess the potential to become malignant. The risk of transforming into a malignant melanoma increases significantly when a person has several rather than an isolated atypical nevus. Another common suspicious lesion includes an actinic keratosis which can transform into a squamous cell carcinoma. Actinic keratosis lesions can usually be kept in control with cryotherapy that is applied topically without the need for excision. In summary, premalignant lesions must be either monitored or treated vigilantly in order to avoid transformation into malignant skin lesions. Malignant lesions are dangerous because they can metastasize, i.e. spread, to distant regions. Metastasis of malignant cells to the lungs or brain is the leading cause of death from malignant cells. Malignant skin lesions include

  1. Basal cell carcinoma
  2. Squamous cell carcinoma
  3. Malignant melanoma.

Basal Cell Carcinoma

Basal Cell Carcinomas (BCC) is a type of cancer that develops from basal skin cells, cells in the deepest layer of the epidermis. These are the cells that produce new skin as older skin cells die and shed away. These carcinomas often appear as a slight bump on the skin and may contain dark spots. Typically, Basal cell carcinoma lesions develop on the sun-exposed parts of the body, most commonly over the nose, ears, face, and neck. Basal cell carcinoma lesions almost never metastasize (spread) from the site of origin and are thus rarely life-threatening if not treated promptly. Of all cancers, BCCs are the most frequently occurring but fortunately the least lethal.

Squamous Cell Carcinoma

Squamous Cell Carcinoma (SCC) lesions develop from the squamous cells of the skin, the outermost cells in the skin’s layer. These carcinomas appear as red patches, as open sores, or as warts that are elevated. Early in their development, they will frequently appear as red patches, called actinic keratosis lesions, which are premalignant lesions. These lesions may often crust or bleed and feel unpleasant to the touch. Long-term exposure to ultraviolet (UV) radiation from the sun over one’s lifetime is the leading cause of most SCCs. They can also develop over chronic sores or wounds that do not heal over several years. Squamous cell carcinoma lesions can occur anywhere on the body but are most often observed in areas of high sun exposure. What makes squamous cell carcinomas more concerning is the fact that they have the potential for metastasis especially when they grow greater than 2cm in diameter.

Malignant Melanoma

The most dangerous form of skin cancers, malignant melanoma lesions are caused by excessive ultraviolet (UV) radiation exposure of skin cells. These cancers originate in the pigment-producing melanocytes in the basal layer of the epidermis and usually resemble moles. These lesions are usually black and brown, but may infrequently be lighter in color. Treatment of melanomas must be early and aggressive in order to avoid metastasis or spread to other parts of the body which may be fatal. Surgical treatment of malignant melanoma lesions is extremely regimented and based on the depth of lesion penetration. The excision of melanoma lesions requires generous margins of excision as well as a sampling of lymph nodes for more aggressive lesions.

In summary, skin cancer lesion treatments are dictated by the likelihood of metastasis. Basal cell carcinoma lesions will grow locally and damage adjacent skin tissues. As such, Basal cell carcinoma lesions may be treated conservatively such as with topical cryotherapy prior to excision. Squamous cell carcinoma lesions are more aggressive in their growth cycle and have a low risk for metastasis if they become large in size (typically greater than 2cm in diameter). As such, they are routinely treated with local excision. Malignant melanoma lesions are the most detrimental with a high propensity of at least 10% for metastasis. As such, these lesions are treated with wider excisions.

Frequent monitoring of your skin with monthly self-examinations and annual medical examinations is critical to keeping your skin healthy. At Cosmetic Plastic Surgery Institute, we offer comprehensive skin care monitoring and treatments with over 5000 skin clients to date.

Frequently Asked Questions:

I would like to have a small lipoma removed that's above my left eyebrow, will there be significant scarring?

Removal of lipoma from over the eyebrow is routine but requires a plastic surgeon in order to avoid injury to underlying nerves and vessels. The incision can be hidden right over the eyebrow hairs making it less noticeable.

What is the best mole removal procedure for a mole on the face?

The only definitive technique to remove a mole is to excise it; this means cutting it out completely so that you don't have to worry about it comming back or leaving cells that can become abnormal in the future

Why mole is coming back? What can I do about the pain in, and around it?

Recurrent nevi are dangerous and need to be re-excised with proper margins. Please make an appointment this removed as soon as possible.

I am looking to have a mole removed that's in the corner of my right eye. Would this be possible without scarring?

Anytime you have a mole or any other lesion removed you will be replacing a lesion with an incision. So you have to make sure your surgeon can leave you with a surgical incision that is more aesthetically pleasing than your lesion.

Patient-Specific Questions:

Lipoma large red and Infected - green discharge on scalp. What should I do?

Likely you have an infected scalp cyst; we treat these routinely and it does require I and D then excision of the cyst shell 5 days later; insurance does cover this procedure and yes it can be done in the office.

How do I address this basal cell right below my eye I have?

BCC on your eyelid is common and requires MOHS or Frozen section surgery to be removed. It doesn't matter how deep it is as it will be removed entirely with above modalities and cleared from your eyelid. Eyelids can be repaired regardless of how deep the lesion extends.

Could you tell me if a heating pad would relieve the scarred incision following Mohs surgery after 4 months?

A heating pad to an incision line really won't do much for the outcome of your scar. Massaging is one of the best ways to manage your incision. If internal sutures were used the absorption of some of them can take up to 3 to 4 months for them to dissolve.

Can a mole regrow back after cryotherapy after just hours of the mole falling off?

Can a mole regrow back after cryotherapy after just hours of the mole falling off?

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