inflammation induced dermal-epidermal separation
toxic epidermal necrolysis (TEN)
most severe of the exfoliative dermatoses
restore hemodynamics, pulmonary toilette/intubate
TF to burn center (equivalent of 2nd degree burn), burn protocol Rx for local
no systemic antibiotics, enteral feeding
erythema multiforme (EM)
most often associated with herpes simplex
Stevens-Johnson syndrome (SJS)
blistering, erosion multiple mucous membranes
widespread small blisters on purpuric macules
Pyogenic granuloma
capillary proliferation with or without trauma Hx
Infection
impetigo
superficial ulceration with overlying bulla
bullous: staph, non-bullous: staph or strep
erysipelas
rapid spread, warmth, erythema, pain, fever, WBC
superficial skin and lymphatics (not as deep as celulitis)
strep skin infection may lead to glomerulonephritis
Pyoderma gangrenosum
rapid, painful, blue, undermined ulcerations lower extremities and trunk
associated with inflammatory bowel disease
outside boundary of incision, remains elevated, continues to grow
mature keloid: excise plus lo dose adjuvant RT, silicone sheet, TAM (decreases collagen
Hypertrophic scar
Basal cell
30-50% of caucasians in lifetime, locally destructive 30% will develop a 2nd within a year excise with 4-7mm margin lymph node concern only for basosquamous and clinically palpable MOHs (successive margin frozen sections to clear) only for hi risk Squamous
2/3 from pre-existing mole, 1/3 de novo 5% of all skin cancers, increasing at 5%/y, 80% between 25-65, average 53yo spreads radially first, then deep risk: Celtic, white (20:1), M>F, 10% familial disposition, dysplastic nevus syndrome, xeroderma pigmentosa, non-melanotic skin cancer, higher socioeconomic class, urban characteristics (ABCDE) Asymmetry Borders:
lentigo: 10%, older women (70s), superficial, exposed skin
superficial spreading: 70%, preexisting nevus, radial growth
nodular: 20%, little radial growth phase, don’t follow ABCs, smooth border
acral lentiginous: 2%, fingers, palms, soles, toes, 50s, 50% in darker skinned, rare in caucasians
T1 < 1mm depth; T2 1-2mm; T3 2-4mm; T4 > 4
N1: 1 node positive, N2: 2-3 nodes, N3: 4 or >
c: other viscera (to bone, lung, liver, brain)
III: 49% 5y survival (= node involvement)
worse: male, trunk, hand, foot, LN invasion, higher number of lymph nodes, satellitosis,
ulceration, high mitotic index, nodular, acral lentiginous, ulcerated, male
better prognosis: female, extremities, presence of tumor-infiltrating lymphocytes
> 1mm: 2cm (all depths > 1mm) + SLN
face 1cm, MOHs surgery for clear margin, cosmetic concerns
depth > 1mm, Clark’s level IV or V, or ulcerated do sentinel lymph node (SLN)(gamma count
chance of LN met 5% if lesion is < 1mm
SLN should be done before wide excision for accuracy
(no more discussion of elective node dissection, before SLN were 80% negative)
node +: interferon increases disease-free interval and survival
search for primary: ocular, mucosal, anus, pelvis
anterior scalp, forehead and face can go to parotid as well as levels I, II and III
ocular melanoma has a propensity to go to liver
I & II, > 4mm, ulcerated, desmoplastic flat: 25% recurrence
excise (small margin) local or nodal, if no distant disease, 25% long term survival
isolation/perfusion: melphalan & TNF 80% response
recurrence too big to resect, distal extremity
Merkel cell carcinoma:
mechanoreceptor cells at base of epidermis
neuroendocrine, aggressive, 20% lymph node involvement (v 10% melanoma), 11%
satellitosis @ Dx, hi local recurrence, 55% 3y survival (v 80% 5y melanoma)
wide and deep (cells extend to subQ fat) excision, adjuvant XRT to tumor site and nodal
painless, solitary violaceous dermal nodule or plaque sun-exposed areas
50% head and neck, 40% extremities, 10% trunk
histo: cytokeratin IHC (CK20), conspicuous paranuclear dots
neuroendocrine markers: neuron specific enolase, chromogranin, synaptophysin
differentiate from small cell lung (CK7), melanoma, keratoacnthoma
70% recurrence after wide local excision
Other skin cancers