Dermal & subcutaneous lesions

Learning objectives
Vascular tumours
Neural tumours
Fibrous tumours
Metastatic tumours
Miscellaneous tumours
Activity

Learning objectives

• Describe clinical features and management of dermal and subcutaneous tumours of vascular, neural, fibrous, metastatic or other origin.

Vascular tumours

Angiokeratoma

Angiokeratoma is a scaly vascular papule due to epidermal proliferation encircling dilated vessels. Angiokeratoma may be solitary or diffuse. Diffuse lesions may be genital (Fordyce), acral (Mibelli) or rarely, generalised (Fabry's disease: deficiency of ceramide trihexosidase resulting in deposition of glycosphingolipids).

Angiokeratoma

Solitary angiokeratoma

Scrotal angiokeratoma Fordyce

Vulval angiokeratoma

Diffuse angiokeratoma Mibelli ©R Suhonen

Pyogenic granuloma

Pyogenic granulomas are formed of granulation tissue (vascular proliferation with inflammatory infiltrate). There is a characteristic collarette of skin around a juicy or friable red nodule that bleeds easily. Pyogenic granulomas may be due to minor trauma plus Staphylococcal infection. They are particularly common on lips and fingers, and during pregnancy and childhood.

Pyogenic granuloma

©R Suhonen

Cherry angioma

Cherry angiomas are extremely common benign red, blue, purple or almost black lesions occurring in middle age on the trunk. They can readily be distinguished from melanocytic lesions by dermoscopy, which shows red, blue or purple lacunes. Occasionally they become thrombosed and may fall off or persist as a firm bluish papule.

Cherry angiomas: clinical and dermoscopic images

Thrombosed cherry angiomas: clinical and dermoscopic images

Glomus tumour
Glomus tumor presents most often as a painful subungual papule.

Glomus tumour ©R Suhonen

Malignant vascular lesions

Angiosarcoma usually arises on the head and neck, or arise in areas of chronic lymphoedema. It presents as an advancing area of purpura and ecchymosis, usually in an elderly person. Prognosis is poor as the tumour is often multifocal so difficult to excise, and only partially sensitive to radiation.

Kaposi sarcoma (KS) is a low grade vascular malignancy related to human herpesvirus 8. There are four types.

• Classic KS
• African endemic KS
• KS in iatrogenically immunocompromised patients
• AIDS-related KS

Angiosarcoma

Angiosarcoma

Kaposi s sarcoma

Acquired telangiectasia

Acquired telangiectasia is common and affects vessels of various size. Some examples are illustrated.

Spider naevus	Rosacea	Acquired telangiectatic naevus	Systemic sclerosis (CRST syndrome)
Hereditary telangiectasia (Osler-Rendu-Weber) ©R Suhonen	Hereditary telangiectasia	Benign hereditary telangiectasia	Telangiectasia eruptiva macularis perstans (mastocytosis)
Oestrogen-induced telangiectasia (pregnancy)	Essential telangiectasia	Telangiectasia due to potent topical steroids	Thread veins / venulectasia (venous disease)
Photodamage	Basal cell carcinoma	Venous lake	Telangiectasia of unknown origin

Acquired lymphangiectasia

Acquired lymphangiectasia usually follows lymph node dissection, or traumatic injury interrupting lymphatic drainage, usually in the axilla or genital area. Frogspawn-like clear or haemorrhagic papules develop some time later and tend to cause distressing ooze.

Acquired lymphangiectasia following lymph node clearance for cancer

Neural tumours

Neurofibroma

Neurofibromas are spindle cell tumours and present as soft to firm, single or multiple dermal nodules that may be pedunculated. Sometimes it is possible to invaginate the lesions because there is a defect in the dermis. There are diffuse, pigmented and plexiform variants. Plexiform neurofibroma is pathognomonic of NF1 neurofibromatosis; these may rarely undergo malignant transformation. Neurofibromatosis may also present with café au lait macules (>6), which are present at birth; axillary freckling; and other types of cutaneous neurofibroma, which arise later in childhood and adult life.

Neurofibromatosis

Other neural tumours include neurilemmoma, neuroma, granular cell tumour and neurofibrosarcoma (malignant schwannoma).

Merkel cell carcinoma

Merkel cell carcinoma (primary neuroendocrine carcinoma of the skin) is rare. It presents as a rapidly growing violaceous nodule that can ulcerate. It frequently recurs after excision; distant metastases develop in about 40% and 30% die of their disease within 5 years.

Merkel cell carcinoma

Fibrous tumours

Dermatofibroma

Dermatofibromas (histiocytomas) are common firm dermal papules caused by a proliferation of fibroblasts. They often follow insect bites, so most frequently arise on lower legs. They dimple on lateral compression.

Dermatofibroma

Scar

Keloids are scars with excessive bands of collagen.

Keloids

Traumatic keloid

Keloid due to burns

Surgical keloid

Angiofibroma

A solitary angiofibroma may also be called fibrous papule or perifollicular fibroma. These are very common the nose and look like intradermal naevi. They can be removed by shave excision or electrodessication. Multiple angiofibromas around the nose and cheeks are associated with tuberous sclerosis, which appear during childhood and become increasingly prominent. These patients may also have periungual fibromas.

Angiofibromas

Fibrous papule of nose

Early lesions tuberous sclerosis

Pronounced lesions tuberous sclerosis

Periungual fibromas

Acrochordon

Skin tags are pedunculated papillomas filled with loose collagen.

Skin tags

Other fibrous lesions include:

• Acquired digital fibrokeratoma
• Infantile digital fibromatosis
• Giant cell tumour
• Dermatofibrosarcoma protuberans
• Malignant fibrous histocytoma
• Atypical fibroxanthoma
• Fibrosarcoma
• Epithelioid sarcoma

Infantile digital fibromatosis

Metastatic tumours

Cutaneous lesions due to distant primaries are most often due to:

• Metastatic squamous cell carcinoma
• Metastatic adenocarcinoma
• Metastatic breast carcinoma
• Metastatic small cell (oat-cell) carcinoma of lung

Adenocarcinoma

Miscellaneous tumours

Lipoma

Lipomas are very common. They are due to a proliferation of adipose tissue and present as solitary or multiple asymptomatic soft subcutaneous nodules. Multiple lesions are seen in association with various syndromes and may be familial.

Lipomas

Leiomyoma

Leiomyoma includes multiple piloleiomyomas, genital leiomyoma and angioleiomyoma. They usually present in young adults and may be painful.

Piloleimyomas

Uncommon skin tumours include:

• Hibernoma
• Liposarcoma
• Leiomyosarcoma
• Osteoma cutis
• Cutaneous endometriosis
• Accessory tragus

Activity

Look for the skin lesions described in this section in the next twenty or so patients you see.

 

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