Good morning. How's everyone doing today? Bright and early. Okay, great. So my name is Jeremy and I'm here to talk a little bit about benign skin lesions and I'll just integrate up these kind of components to each slide so really to start we have to just discuss a little bit the terminology because I'll be using these words and Anything that you can't feel less than a centimeter is called a macule if it's bigger than a centimeter. We call it a patch If you can feel it and it's less than a centimeter. It's a papule if it's larger It's a plaque and that's just the common language. I would use to describe lesions and that can really help you with diagnosis and Then finally if it's got some fluid in it and it's small. It's a vesicle and if it's larger we call it bulla Rather than you know papula squamous macula papular. So these are just the kind of the important words So anyone want to venture a guess how you describe this red lesion? using those terms Papule that's right. So this is just a common angioma Red papule more common after age of 30 really you see them a lot on the trunk, but they can be on the arms Treatment for this would just be electro desiccation or just reassurance But for the patient that does want it removed you could just use a hypher cater at a low Low energy and is obliterates it sometimes with a little bit of local lidocaine Warts we see them everywhere. I think a distinguishing feature of this you'll see the purple dots on it Excuse me thrombus capillaries Treatment can be cryotherapy immunotherapy with candida injections Lasers, but I don't recommend just because of the plume it can be transferred to the your own larynx and Someone like this you think about HIV infection with really extensive warts like this What you see here is Kind of a fairy ring wart. So the middle has been treated with cryotherapy and then the wart just spreads around it So that's a side effect of treatment and that's what's going on This is molluscum another virus More common in kids and what you see these are papules and you'll see the central umbilication. So these are Something you may see on you know certifying exams. It's just pattern recognition some of these described Just by seeing them and then some it's a little bit more information, but molluscum What you see for herpes is kind of this grouped herpetiform and this would be earlier on you know later on The vesicles can coalesce into Ebola and eventually these will rupture and you'll just have an erosion or an ulcer With some erythema. So you want to think about this on the hands? Fingers it may not present like this But as an erosion that recurs and just think about herpes and send it off for culture or direct fluorescent antibody So what you see here is Just think about herpes and send it off for culture or direct fluorescent antibody Very common anyone been asked about these before by patients or family members so seborrheic keratosis It's a benign growth typically described as stuck on papule or plaque These are very superficial and you can just curet them off and with high patient satisfaction Again a little bit of local lidocaine and just use a curette disposable curette and it'll come right off without any scarring They can grow back These are commonly referred to us for concern of melanoma. So this is another good thing to think about for boards What makes it different than a melanoma sometimes very hard to distinguish but typically raised It's a little bit more keratotic and rough than a melanoma But something like this can be confusing when compared to squamous cell carcinoma So you really want to look at the patient's history. Is it a 80 year old farmer or a 20 year old? Dermatofibroma just a benign scar like lesion More common on the legs, but we do see them on the upper extremity in the arms If you push from both sides, you'll see it dimples down and that's kind of a little sign to look for Benign reassurance nothing's really needed to be done. But some patients do prefer to have them excised It's a condition granuloma annulari, this is commonly misdiagnosed as recalcitrant tinea and so you can see an annular plaque here and the difference between this and tinea is it's a dermal process So it's a little bit deeper down and you don't see scaling And so if you try to do a potassium hydroxide or koh exam, there would be no scale to examine it So remember GA we call it as a something that's commonly happens on the hands and elbows this is a different form papular GA and Diagnosis would be with a biopsy or just clinically and treatment would be a topical steroid These lesions on the hands that you can use interlesional steroids Just a benign solar lentigo, so this would be a brown macule in an older person Nice treatment is just some light cryotherapy If you have a liquid nitrogen in your office, you can use a q-tip and apply it for maybe 10 seconds And get these to fade away Otherwise, if you have an NDA laser q-switched you can really clean up hands and that's a nice aesthetic result you can get I Think infection will be discussed a little bit later, but the chronic plaque that's not healing really it's in the history Someone is cleaning the fish tank is kind of the classic boards approach But patients really will spill this history of you know Cleaning their boat at the lake or something like that and it's just a chronic infection You look for sporotrichoids spread and any evidence of adenopathy Management would be biopsy for H&E staining as well as special culture And those results can take up to a month to come back So you want to make sure you're let the lab know you're looking for mycobacterium So then there's just the foreign body again, it's in history this might be diagnosed as lichen simplex chronicus, which is chronic scratching But this person could say, you know splinter I've had patients who worked in labs and had glass go into their finger literally 20 years and then You know small punch biopsy you take out the shard of glass and it's curative. So again, it's really in the history something like this You guys are very familiar with this probably just a myxoid cysts either white or a bluish color Hands up has anyone treated one of these before Great So nevi there's blue nevi which are a little bit deeper down So you get the blue bluish color the Tyndall effect the way the light scatters versus a more superficial nevi Which all of you have seen the concern for these in a referral is using melanoma and so Biopsy is sufficient. These are pretty common on top of the hand. Usually reassurance is fine unless it's been changing Has anyone seen one of these before been referred for management Okay, so pretty simple. You can just shave them off there. You would consider summa numeri digit but usually these are associated with trauma and just a shave biopsy with some Cautery will take care of it and it'll scar down and send it to pathology So I'm not going to talk too much about a lot of the common rashes But this might be treated as a chronic eczema and what it is is it's tiny incognito, so it's been treated with steroids in Fungus goes down the hair follicles and then you can get a granuloma dis process that will not respond to topical Antifungal so they need oral treatment So my okey's granuloma. It's actually just tinea This walks into your clinic on Friday at 5 o'clock Call the dermatologist so Really the nice part of this so is the morphology, right? That's kind of what we do what we love. So what you see are tense bulla Okay, and you've heard this is bolus pemphigoid Versus pemphigus vulgaris and typically what you'll see with that are popped blisters or bulla And the reason being in bolus pemphigoid the autoantibody is deeper down in the in the epidermis And so these stay intact whereas in pemphigus it's higher up and they just shear off Other things to look at is the drug list You could have a bolus drug reaction. If you see one of these it could be just a bolus arthropod bite. So bug bite Another drug reaction and is anyone heard about a fixed drug reaction so a fixed drug reaction is basically every time the person gets the Problematic medicine they'll get the same lesion in the same spot So it's an isolated area of t-cells that are sensitized to this and so 50% of these occur in the genitals on trimethoprim sulfa Or any of the NSAIDs, but they do happen on the upper extremity. So history is really important They'll say oh, yeah, every time I take Tylenol for my headache I get this red spot right here and it could be really intense edema that leads to this color red a scale on top but fixed drug eruption Pyogenic granuloma Just a vascular tumor that grows you see a choleret here as well And the thing you don't want to miss with this is a melanotic melanoma So it's easy to see these and say that's probably a PG Let's shave it off but just always send it for PATH because one or two cases a year we get a Merkel cell carcinoma or a Melanotic melanoma which gives us pause so just always send it for PATH But main treatment is shave and a little bit of cautery or you can use You know aluminum chloride if it's much smaller Has anyone seen knuckle pads before Okay, so just benign fibromas Reassurance you can try injections with steroids This is mostly up here just so everyone has seen it if a case it comes up or a patient walks in to your office Psoriasis real common so The big big important thing is in dermatology someone will want to show you a bump whether it's at a party or the patient and Really you want to look elsewhere and that can really help you with the diagnosis, especially in psoriasis and another condition I'll show you so they made to show you your elbow and then you say well let me see your hands write your hand surgeons and then they'll have pitting and oil spots and That can really help with diagnosis If you ever see a limited lesion asked to look elsewhere if you're interested and that can really help you with the diagnosis This is another condition where it's important to look elsewhere and lichen planus You can see it on the hands. You see a tridium of the fingernails. You can look in the patient's mouth for a rosive lichen planus Treatment it can be light therapy when it's extensive like this retinoids otherwise topical steroids Angiocarotoma probably it's like an angioma maybe associated with trauma But you want to also think about melanoma Pigmented basal cell carcinoma and so really it's a good idea to biopsy something like this and just remove it Epidermal nevus you saw in the previous talk you can try a blade of laser Excision, but otherwise they will just remain and reassurance is probably the best course KP or keratosis pilaris most commonly on the back of the arms Commonly asked about you can also see it on the front of the thighs You can use an emollient like ammonium lactate to soften the skin, but it won't cure it So no real cure. You can also use topical retinoids But just reassurance that it's nothing bad and it won't go away And it won't go away Cyst real common you probably get referred these for removal on the hands what you see here is the punctum here That's connected down to the cyst. This is a true cyst with the lining versus the myxoid cyst So you want to remove that sack in order to prevent recurrence? Rather than you know in the ER typically they're just I indeed, but that leaves a sack and they'll recur Lypomas Soft squishy nodules small incision and just pressure after you open up the capsule and they're released Neurofibromas and other squishy papule you know sometimes these are mistaken for nevi just a shave biopsy will be diagnostic and Finally the dreaded skin tag and this is my last slide so any questions you guys might have but Couple ways you can treat them cryotherapy to snip it or you can have the patient's applied dental floss to them Just tie a double knot around it and they'll auto necrosis after about a week So if someone comes in, you know obese patient with 150 of these you can tell them to treat it at home So you don't take up your whole afternoon taking these off Okay, so some of the treatment methods we discussed today and Any questions you guys might have? Thank you So I'm gonna ask you a question The recalcitrant wart I think pops up in our practices quite often. Yeah advice treatment You can just send them to you dub dermatology. No so the really the nicest thing about warts is if they're Immuno compromised it's just going to be tough But what I usually recommend is 40% salicylic acid. Okay, and that's over the over-the-counter And tell them they've got to do it at least for three months Apply it nightly because people can do it while they're sleeping. They're not going to do treatments during the day After that, then you want to think about injections even things like bleomycin And that's really it I Don't use that xylocaine, I mean that we've heard right duct tape garlic Yelling at it. I think really what you're doing is the virus is hidden within the cell And so anything you do to create trauma is going to stimulate the immune system And then it'll come and take care of the wart, but there's so many HPV types You know one and two the mermer seal wart they can get another one But if it's HIV, they're immunocompromised that immune system just isn't working So you can do xylocaine you could just stick it with a needle probably and that would work in a few patients Great thanks Jeremy

benign skin lesions

treatment options

dermatofibroma

cryotherapy

wart treatment