but, if in doubt, the lesion should be examined histologically.

Seborrheic KeratosesIt is a rare elderly patient who does not have any seborrheic keratoses. These are the unattractive “moles” or “warts”P.269

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that perturb the elderly patient, occasionally become irritated, but are benign (Fig . 26-1 ).

TABLE 26-3 ▪ Classification of Tumors Based on Location

Location Possible Tumor Type

Scalp Seborrheic keratosis

Epidermal cyst (pilar cyst)

Nevus

Actinic keratosis (bald males)

Wart

Trichilemmal cyst

Basal cell carcinoma

Squamous cell carcinoma

Nevus sebaceous

Proliferating trichilemmal tumor

Cylindroma

Syringocystadenoma papilliferum

Seborrheic keratosis

Ear Actinic keratoses

Basal cell carcinoma

Nevus

Squamous cell carcinoma

Keloid

Epidermal cyst

Chondrodermatitis nodularis helicis

Venous lakes (varix)

Gouty tophus

Face Seborrheic keratosis

Sebaceous gland hyperplasia

Actinic keratosis

Lentigo

Milium

Nevi

Basal cell carcinoma

Squamous cell carcinoma

Lentigo maligna melanoma

Flat wart

Trichoepithelioma

Dermatosis papulosa nigra (African American women)

Fibrous papule of the nose

Colloid milium

Dilated pore of Winer

Keratoacanthoma

Pyogenic granuloma

Spitz nevus

Ephelides

Hemangioma

Adenoma sebaceum

Apocrine hydrocystoma

Eccrine hydrocystoma

Trichilemmoma

Trichofolliculoma

Merkel cell carcinoma

Angiosarcoma (elderly men)

Nevus of Ota

  Warty dyskeratoma

Atypical fibroxanthoma

Angiolymphoid hyperplasia with eosinophilia

Blue nevus

Pedunculated fibroma

Eyelids Seborrheic keratosisMilium

Syringomas

Basal cell carcinoma

Xanthoma

Pedunculated fibroma

Neck Seborrheic keratosisEpidermal cyst

Keloid

Fordyce’s disease

Lip and mouth LentigoVenous lake (varix)

Mucous retention cyst

Leukoplakia

Pyogenic granuloma

Squamous cell carcinoma

Granular cell tumor (tongue)

Giant cell epulis (gingivae)

Verrucous carcinoma

White sponge nevus

Acral lentiginous melanoma

Pedunculated fibroma

Axilla Epidermal cystMolluscum contagiosum

Lentigo (multiple lentigo in axillae neurofibromatosis called Crowe’s sign)

Seborrheic keratosis

Chest and back AngiomaNevi

Ephelides

Actinic keratosis

Lipoma

Basal cell carcinoma

Epidermal cyst

Keloid

Lentigo

Café-au-lait spot

Squamous cell carcinoma

Melanoma

Hemangioma

Histiocytoma

Steatocystoma multiplex

Eruptive vellus hair cyst

Blue nevus

Nevus of Ito

Becker’s nevus

Pedunculated fibroma

Groin and Seborrheic keratosisMolluscum contagiosum

crural areas Wart

Bowen’s disease

Extramammary Paget disease

Wart

Molluscum contagiosum

Genitalia Squamous intraepithelial lesions

Epidermal cyst

Angiokeratoma (scrotum)

Pearly penile papules (around edge of glans)

Squamous cell carcinoma

Seborrheic keratosis

Erythroplasia of Queyrat

Bowen’s disease

Median raphe cyst of penis

Verrucous carcinoma

Hidradenoma papilliferum (labia majora)

Wart

Hands Seborrheic keratosisActinic keratosis

Lentigo

Myxoid cyst (proximal nail fold)

Squamous cell carcinoma

Glomus tumor (nail bed)

Ganglion

Common blue nevus

Acral lentigines melanoma

Giant cell tumor of tendon sheath

Pyogenic granuloma

Acquired digital fibrokeratoma

Recurrent infantile digital fibroma

Traumatic fibroma

Xanthoma

Dupuytren contracture

Wart

Feet NeviBlue nevus

Acral lentigines melanoma

Seborrheic keratosis

Verrucous carcinoma

Eccrine poroma

Seborrheic keratosis

Lentigo

Arms and legs Wart

Histiocytoma

Actinic keratosis

Squamous cell carcinoma

Melanoma

Lipoma

Xanthoma

Clear cell acanthoma

(legs)

Kaposi’s sarcoma (legs, classic type)

Dermatosis papulosa nigra is a form of seborrheic keratosis of African Americans that occur on the face, mainly in women. These small, black, multiple tumors can be removed, but there is the possibility of causing keloids or hypopigmentation. Stucco keratoses are numerous white 1- to 3-mm seborrheic keratoses mainly over feet, ankles, and lower legs. A very large seborrheic keratosis is sometimes referred to as a melanoacanthoma.

Presentation and CharacteristicsDescriptionThe size of seborrheic keratoses varies up to 3 cm for the largest, but the average diameter is 1 cm. The color may be flesh-colored, tan, brown, or coal black. They are usually oval in shape, elevated, and have a greasy, warty sensation to touch. White, brown, or black pinhead-sized keratotic areas called pseudohorned cysts are commonly seen within this tumor. There is an appearance of being superficial and “stuck on” the skin. Pruritus is common and sudden appearance may occur. Numerous lesions coming on rapidly can be a marker of underlying cancer (sign of Leser-Trélat).DistributionThe lesions appear on the face, neck, scalp, back, and upper chest, and less frequently on arms, legs, and the lower part of the trunk.CourseLesions become darker and enlarge slowly. However, sometimes they can enlarge rapidly and this can be accompanied by bleeding and inflammation, which is very frightening to the patient. Trauma from clothing occasionally results inP.271

infection and bleeding, and this prompts the patient to seek medical care. Any inflammatory dermatitis around these lesions causes them to enlarge temporarily and become more evident, so much so that many patients suddenly note them for the first time. Malignant degeneration of seborrheic keratoses is doubted.

TABLE 26-4 ▪ Classification of Skin Tumors Based on Clinical

Appearance

Appearance Possible Tumor Type

Flat, skin-colored tumors

1. Flat warts (viral)2. Histiocytomas3. Leukoplakia

Flat, pigmented tumors

1. Nevi, usually junctional type2. Lentigo3. Café-au-lait spot4. Histiocytomas5. Mongolian spot6. Melanoma (superficial spreading

type)

Raised, skin-colored tumors

1. Warts (viral)2. Pedunculated fibromas (skin tags)3. Nevi, usually intradermal type4. Cysts5. Lipomas6. Keloids7. Basal cell carcinomas8. Squamous cell carcinoma9. Molluscum contagiosum (viral)10. Xanthogranuloma (yellowish, usually

children)

Raised, brownish tumors

1. Warts (viral)2. Nevi, usually compound type3. Actinic keratoses4. Seborrheic keratoses5. Pedunculated fibromas (skin tags)6. Basal cell epitheliomas7. Squamous cell carcinoma8. Malignant melanoma9. Granuloma pyogenicum10. Keratoacanthomas

Raised, reddish tumors

1. Hemangiomas2. Actinic keratoses3. Granuloma pyogenicum

4. Glomus tumors5. Senile or cherry angiomas

Raised, blackish tumors

1. Seborrheic keratoses2. Nevi3. Granuloma pyogenicum4. Malignant melanomas5. Blue nevi6. Thrombosed angiomas or

hemangiomas

CauseHeredity is the biggest factor, along with old age.

Differential Diagnosis● Actinic keratoses: See Table 26-5 ● Pigmented nevi: Longer duration, smoother surface, softer to

touch; may not be able to differentiate clinically (see later in this chapter)

● Flat warts: In younger patients; acute onset, with rapid development of new lesions, colorless and flat topped without pseudohorned cysts; tiny black thrombosed capillaries may be seen usually smaller; may Koebnerize (see Chap . 23 )

● Malignant melanoma: Less common, usually with rapid growth, indurated; examination histologically with biopsy may be necessary (see later)

TreatmentCase ExampleA 58-year-old woman requests the removal of a warty, tannish, slightly elevated 2- × 2-cm lesion of the right side of her forehead.

1. The lesion should be examined carefully. The diagnosis usually can be made clinically, but if there is any question, a scissors biopsy (see Chap . 2 ) can be performed. It would be ideal if all of these seborrheic keratoses could be examined histologically, but this is not economically feasible or necessary.

2. An adequate form of therapy is curettement, with or without local anesthesia, followed by a light application

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of trichloroacetic acid. The resulting fine atrophic scar will hardly be noticeable in several months.

FIGURE 26-1 ▪ (A) Actinic keratoses in an oil refinery worker. (B) Hyperkeratotic actinic keratoses. (C) Seborrheic keratoses

on back. (D) Pedunculated seborrheic keratosis of eyelid. (Courtesy of Stiefel Laboratories, Inc.)

3. Electrosurgery can be used, but this usually requires anesthesia.

4. Liquid nitrogen freezing therapy works well, if available. It is the therapy of choice of most dermatologists. Do not freeze excessively.

5. Laser therapy has been used recently by some authors.6. Surgical excision is an unnecessary and more expensive form of

removal.SAUER’S NOTES

1. For many benign lesions, it often is best cosmetically to err on the side of surgical undertreatment rather than overtreatment. You can always remove any remaining growth later, but you cannot put back what you took off.

2. Scarring should be kept to a minimum.3. After any surgical procedure, I hand out a “Surgical Notes”

sheet that indicates postoperative care. Skin surgery sites usually heal without any complication. However, there are always questions and concerns from the patient about aftercare.

SURGICAL NOTES FOR THE PATIENT

Minor surgery has been performed for the removal or biopsy of a skin lesion.If liquid nitrogen was used to remove the growth, a blister or peeling at the growth site will develop in 24 hours; if electrosurgery, laser, or burning was used, a crust and scab will form; if a biopsy was made, there will be a crust or suture(s).The sites treated heal better if they are covered with a dressing with Polysporin ointment underneath during the day for 5 to 7 days and left uncovered at night and while bathing. Do not pick at the spot and try to avoid accidentally hitting the area.You can wash over the area lightly.A certain amount of redness and swelling around the surgery site is to be expected. Also you might have a small amount of drainage and crusting. A mild amount of redness and infection can be treated with Polysporin ointment locally three times a day.If more drainage or infection develops, apply a wet dressing with sheeting, or soak the area. Oral antibiotics can be given. Use a solution made with 1 teaspoon of salt to 1 pint of cool water or

Domeboro compresses and apply for 20 minutes three times a day. Make a fresh solution every day.If the infection becomes excessive, call the office or go to a hospital emergency department.If the scab is knocked off prematurely, bleeding may occur. This can be stopped by applying firm pressure with gauze or cotton for 10 minutes by the clock, and then releasing pressure gradually.Depending on the size of the surgery site, healing takes from 1 to 8 weeks. Some scarring or loss of pigment at the surgery site is possible. A few individuals have a tendency to form thick or keloidal scars, which is not predictable.If a biopsy was done, you may receive a separate bill for the pathology study from the laboratory. Call the office in 7 days for this report.Return to the office for further care or follow-up as directed.

Sauer’s Manual of Skin Diseases9th Edition

© 2006 Lippincott Williams & Wilkins