Lesions and Rashes: When to consider doing a biopsy

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Lesions and Rashes When to consider doing a
biopsy

• Margaret Constante MSN, FNP-BC
• Donna Jarvis MSN, ANP-BC

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A Review of Terms
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Basic Morphologies

• Macule-circumscribed, flat discoloration can be
  brown, blue, red or hypopigmented
• (nevus depigmentosus)
• Papule-elevated solid lesion 0.5 cm diameter
  color varies may become confluent and form
  plaques
• (acneiform drug eruption)

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• Plaque-circumscribed, elevated, superficial,
  solid lesion 0.5 cm in diameter
• (psoriasis)
• Patch-circumscribed area of skin tissue that
  differs from the surrounding area in color,
  texture or both not elevated
• (pityriasis rosea)

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• Nodule-circumscribed, elevated, solid lesion
• 0.5 cm
• (lymphoma)
• Tumor-a very large nodule proliferation of
  cells can be benign or malignant
• (hemangioma)

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• Wheal-firm edematous plaque due to infiltration
  of the dermis with fluid transient and may last
  only a few hours
• (urticaria)
• Pustule-collection of leukocytes and free fluid
  that varies in size
• (inflammatory acne)

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• Vesicle-circumscribed collection of free fluid up
  0.5 cm in diameter
• (herpes zoster)
• Bullae-collection of free fluid 0.5 cm in
  diameter
• (bullous pemphigoid)

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Secondary Morphologies

• Cyst-closed sac lined with epithelium and
  containing fluid or semisolid material
• (epidermoid cyst)
• Scale-excess dead epidermal cells produced by
  abnormal keratinization and shedding
• (ichthyosis)

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• Crust-collection of dried serum and cellular
  debris
• (impetigo)
• Erosions-focal loss of epidermis dont penetrate
  below the dermo-epidermal junction heal without
  scarring
• (junctional epidermolysis bullosa)

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• Ulcer-focal loss of epidermis and dermis heal
  with scarring
• (venous stasis dermatitis with ulcer)
• Fissure-linear loss of epidermis and dermis with
  sharply defined vertical walls cracks
• (fissured tongue)

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• Atrophy-depression in the skin resulting from
  thinning of the epidermis or dermis
• (involuted hemangioma)
• Telangiectasia- dilated blood vessels

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• Blaschkos lines- invisible patterns built into
  human DNA define the growth between the original
  cells of embryonic development. Some diseases of
  the skin manifest themselves along these patterns
  creating the visual appearance of stripes or
  whirls.
• Lichenification- thickened leathery skin with
  exaggerated skin markings hyperpigmented from
  chronic rubbing and scratching

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Formulating a Diagnosis
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Thorough History

• History
• How long what did it look like changes
  exacerbating/ameliorating factors treatments
• Medications and allergies
• New and long term meds exposures to allergens
• General medical history
• Family history
• Social history
• Day care contacts with same
• Travel, occupation, hobbies
• Rare infestations working with chemicals, latex
  exposures
• Review of Systems

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Physical Findings

• General appearance and behaviors
• Physical findings
• Types of lesions rash distribution areas
  affected hair pull
• Any vitals, height, weight
• Get any laboratory data
• Scrapings, KOH, stains, cultures, blood work,
  biopsy, x-rays, ultrasound
• Other data
• Records/data from other providers pathology old
  biopsies

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• Differential diagnoses
• What is it most consistent with
• Diagnosing/diagnosing with a few potentials

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Follow up Its Not Improving!

• Review differential diagnoses
• Failure of treatment may steer you to another
  diagnoses
• Some similar looking disorders may have similar
  treatments and time may tell what the true
  diagnosis is later (eczema/psoriasis)
• Was the history incomplete more info provided on
  follow-up
• Were clinical findings misinterpreted? False
  positive or false negative? Lab error?
• Consider other studies or re-biopsy

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Should I Switch My Thinking?

• well, if you hadnt by now,
• its time for a biopsy

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Neoplasms of the Skin
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Non-melanoma Skin Cancer
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Non-melanoma Skin Cancers

• Most common malignancy in humans
• Most are related to UV light exposure
• Other factors include exposure to ionizing
  radiation, arsenic, HPV, immunosuppression, and
  genetic predisposition
• Prevention sun protection, avoidance of
  irritants
• Death is very rare can cause disfigurement

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Basal Cell Carcinoma

• Slow growing, locally invasive and destructive
• Virtually never metastasizes
• Sun exposure greatest risk
• Papular, nodular, or flattened plaque, can be
  shiny, rolled border, central ulcer or sunken in,
  telangiectasia, or crusted

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Squamous Cell Carcinoma

• Bowens disease- AKA SCC in situ.
• Erythematous, scaly or slightly elevated
• Sun exposed area
• Can arise as a new lesion or from a pre-existing
  precancerous lesion (AK)

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Squamous Cell Carcinoma

• Can also be invasive
• May give history of tenderness
• Not healing
• Rapidly or slowly enlarging
• Erythematous, keratotic papule or nodule
• Varying degrees of hyperkeratosis
• May ulcerate

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Actinic Keratosis

• Precancerous lesion
• Can turn into a SCC if left untreated
• Most frequently encountered lesion
• Erythematous papule or patch with white or yellow
  scale older lesions are thicker, more well
  defined
• May be tender
• On sun exposed areas

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Keratoacanthoma

• Indistinguishable from SCC clinically and
  histologically
• 4-6 wks of rapid growth spontaneous involution
• Firm nodule central crust or crater containing a
  keratin plug
• Originally viewed as a benign tumor, now
  considered to be a variant of SCClocal
  destruction and ability to metastasize

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Biopsy.

• If you dont know
• If you are uncertain of the diagnosis
• If you suspect cancer
• To identify a lesion before sending for complete
  removal
• Sometimes it is hard to differentiate between AK,
  BCC, SCC, warts, SK, benign lichenoid lesions or
  even plaque psoriasis and nummular eczema

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Sowhat do we have here?
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And here?
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Benign Epidermal Tumors and Proliferations
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Seborrheic Keratosis

• Benign persistent epidermal lesion
• Genetic tendency
• Unusual before age 30
• Solitary or multiple, tan to black, macular,
  papular or verrucous lesions
• Not on palms or soles
• Can be confused with melanocytic neoplasms

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SK variations

• Dermatosis papulosa nigra (DPN)- common in AA
  symmetric can appear during adolescence and
  increase in size with age
• Stucco keratosis- whitish stuck-on papules or
  small plaques lower extremities of older adults

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• Epidermal nevus (EN)-within the 1st year of life
  usually linear hyperpigmented papillomatous
  papules and plaques along Blaschkos lines
• Inflammatory linear verrucous epidermal nevus
  (ILVEN)- like a linear EN (above), but
  erythematous and pruritic

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Cutaneous Horn

• Firm, white to yellow, conical, keratotic papule
• Millimeters to centimeters in size
• Abnormal accumulation of keratin arranged in an
  elongated vertical column
• 20 arise over AKs or SCCs can arise from
  verrucae or SKs

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Benign Melanocytic Neoplasms
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Café-au-lait Macules

• Homogenous color coffee with milk
• Light to dark brown oval macule with regular or
  coastal shaped borders
• 2 mm to gt20 cm grows proportionately with body
• No tendency toward malignancy
• Isolated or multiple multiple lesions can be
  associated with disease

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Beckers Nevus

• Unilateral, hyperpigmented, hypertrichotic patch
  or slightly elevated plaque
• Usually on the shoulder of male patients
• Onset during adolescence
• More noticeable after sun exposure
• Block like or linear shaped
• Irregular borders
• Hairs become coarser over time
• No reported malignancies

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Nevus of Ota

• Facial more common in Asians and African
  Americans
• Onset ½ at birth to 1 year the rest at puberty
• Confluent macules few mm in size
• Overall, appearances irregularly demarcated and
  often mottled patch
• Mostly unilateral can be bilateral
• Shades of tan and brown to gray, blue, black and
  purple
• Malignancies are rare, however, biopsy suspicious
  lesions or new subcutaneous nodules

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Nevus Spilus

• Tan macule with superimposed darker macules or
  papules
• Macule persists and number of speckles increases
  over time
• Reports of melanoma arising from nevus spilus and
  dysplasia
• Monitor the lesion and biopsy if overall changes,
  unusual looking speckles or changes in speckles

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Blue Nevi

• Onset most commonly in childhood or adolescence
• Some are congenital
• Well-circumscribed, dome-shaped papules, blue,
  bluegray or blueblack in color
• 0.5-1 cm in diameter rarely larger
• Malignant blue nevi are rare
• de novo lesions, multinodular or plaque-like
  lesions, or changing lesions should be removed

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Nevi of Acral Skin

• Uniform brown or dark brown in color but with
  striations due to the parallel ridges and furrows
  of the acral skin
• Lattice-like pattern can be seen
• Sometimes white dots at the eccrine pores

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Congenital Melanocytic Nevi

• Present at birth or shortly after
• May be slightly raised, hypertrichosis,
  perifollicular hypo/hyperpigmentation
• May become more elevated and darker with age
  surface may be verrucous or pebbly
• Can become lighter with age become halo nevi or
  regress
• Biopsy if asymmetry, variation in color,
  development of papules or nodules or any other
  change over time

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Spitz Nevus

• 2 mm-2 cm usually 8 mm well circumscribed,
  dome-shaped pink to dark brown smooth or
  verrucous surface
• Arise within months history of recent rapid
  growth
• Pathology is misleading sometimes atypical
  histologically similar to melanoma and hard to
  differentiate
• Complete excision recommended

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Atypical Melanocytic Nevi

• Acquired, de novo or as part of a compound nevus
• Can be larger or varigated in color, asymmetric,
  irregular borders
• Can occur sporadically or familial
• potential precursors to melanoma
• Lifetime risks for MM
• General pop 1.2
• Familial AMN synd w/ 2 blood relatives with MM
  100
• All other patients with AMN 18
• 1 AMN doubles risk for melanoma
• 10 AMN risk increases 12 fold

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More Atypical Nevi
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Which would I remove or biopsy?
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Recurrent Melanocytic Nevus

• Proliferation of residual melanocytes following
  removal or biopsy
• Irregular pigmentation within a scar
• No need to remove if benign may want to if
  pigment unusual looking
• Remove if it was atypical

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Junctional Nevus

• A type of acquired nevus
• Macular lesion, slight accentuation of skin
  markings visible with side-lighting
• Uniform medium to dark brown color
• Dermoscopy uniform network that thins out toward
  periphery

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Halo Nevus

• Most commonly those under 20
• Overall, these people will have an increased
  number of melanocytic nevi
• 20 will have vitiligo
• Less often associated with melanoma or atypia
• Ring of depigmentation occurs over weeks or
  months the central nevus can persist or usually
  involutes within months or years

early
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Malignant Melanoma
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Superficial Spreading Melanoma

• Most common (70-80)
• May arise from pre-existing nevi most are de
  novo
• Trunk and extremities, but can be anywhere
• Usually 3-6mm, flat, asymmetric with varied
  coloration, may have areas of regression
• Spreads laterally within the skin over a few
  years before nodules develop

Reddish-tan
Black/thick
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Nodular Melanoma

• 15-30 of melanomas
• Extremities, but can be found anywhere
• Sometimes quite large
• Rapid vertical growth
• Dark brown, dark blueberry-like or uniformly dark
  raised lesion
• Can also be black, blue, bluish red or amelanotic
• May have focal hemorrhage
• Can be fatal

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ABCDE Rule

• A Asymmetry in shape
• B Border is irregular
• C Color is not uniform
• D Diameter greater than 6 mm
• E Elevation present and irregular
• Enlargement in size

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Melanoma
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Malignant Melanoma (MM)

• Tumor of melanocytes found on exposed and
  nonexposed skin
• Evolving from preexisting (dysplastic or
  congenital nevus-30) or de novo (new
  lesions-70)
• Leading fatal illness arising in the skin
• Potentially curable with early detection and
  treatment
• Can metastasize to any organ

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MM Statistics

• 4 men 3 women
• Most common malignancy in women ages 23-29
• Accounts for 13 of all pediatric malignancies
  (0.3 - 0.4 of all cases of mm)
• Incidence rates are rising faster than that of
  other cancers

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Lifetime Risk in the US

• 19351 in 1500
• 19921 in 105
• 20021 in 75
• 2010estimated 1 in 50
• Wolf Johnson, 2005

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2 Similar Looking Lesions

• 2 very different prognoses

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Other Proliferations and Tumors
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Vascular

• Pyogenic granuloma- benign externally
  proliferating lobe of small capillaries bleeds
  easily site of trauma persist if untreated
• Cherry Angioma- benign bright red, dome shaped
  papules consisting of dilated papules appear in
  adult life common on trunk

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Neural

• Neurofibroma-
• Solitary- benign skin colored to tan-violet
  fibrous or mucinous nodules or tumors
  pedunculated or button-hole proliferation of
  neuromesenchymal tissue and residual nerve fibers
• Plexiform- large sometimes pigmented bag-like
  masses similar constituents as the solitary
  lesions favor the trunk and extremities

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Fibrous

• Skin tag- benign most common fibrous lesion
  skin colored or hyperpigmented range from 1 mm
  to 1 or 2 cm in size thin or wide stock usually
  asymptomatic
• Dermatofibroma- second most common fibrous
  lesion usually in adults on the lower
  extremities minimally elevated to dome shaped
  papules 1 mm-1 cm usually hyperpigmented firm
  on palpation dimple sign

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• Fibrous papule- benign, solitary, shiny,
  dome-shaped papule on the face of adults
  commonly removed to exclude basal cell

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Cystic lesions

• Epidermoid Cyst- lined with stratified squamous
  epithelium
• Most common cutaneous cyst
• Well demarcated dermal nodule keratin filled
• Originate from follicular infundibulum visible
  punctum
• Becomes inflamed, painful, red when ruptured

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Cystic Lesions

• Hidrocystoma- lined with non-stratified squamous
  epithelium
• Translucent, skin-colored to bluish commonly on
  face
• If located on lash line, refer to ophthamology
  for removal
• Digital mucous cyst- no epithelial lining
• dorsal surface of the distal phalanx of the
  finger
• Characteristic depressed nail deformity distal to
  cyst
• Clear gelatinous material when punctured

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Dermatoscope
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Dermoscopy

• A hand held magnifier with a light and a liquid
  medium between the instrument and the skin used
  to illuminate the lesion. This process
  eliminates surface reflection rendering the skin
  surface translucent so structures within the
  epidermis, dermal-epidermal junction and
  superficial dermis can be better visualized.

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So when are you going to biopsy????

• When you are suspicious
• When you dont know what it is
• When youre unsure what it is, but your
  differentials are treated differently
• When treatments arent working
• To confirm a diagnosis
• Because the patient is frustrated and just wants
  to know what they have