A brief guide to benign and malignant skin and soft tissue lesions

Actinic keratosis

Otherwise known as solar keratosis, actinic keratosis (AK) is a roughening of the skin in response to sun damage. The lesion appears pink-red. In rare cases an AK can progress in to an SCC. Treatment is usually non-surgical (Effudix cream, cryotherapy) but surgical excision is sometimes offered, especially where it is difficult to distinguish the lesion from a superficial BCC.

Basal cell Carcinoma

Basal cell carcinoma (BCC) is the commonest form of skin cancer that develops as a result of sun exposure. In the vast majority of patients, it is a localised lesion that can be simply excised to achieve a cure. It does not tend to spread around the body, so after complete excision no further follow-up is usually required.

BCC can present in a number of different forms ranging from discrete nodular lesions to diffuse flat lesions, most commonly on the face or elsewhere on the head and neck.

Basal Cell Carcinoma Skin Cancer left cheek - Cosmetic Surgeon Christopher Stone

BCCs can also ulcerate, which gives them their name ‘rodent ulcers’. Apart from surgery, including ‘Mohs’ surgery, there is a range of non-surgical treatments that can be useful for some types of BCCs. These include the use of topical creams such as Effudix, curettage and cautery, cryotherapy and photodynamic therapy (PDT).

Mr Stone can advise you on all these treatments, the advantages and disadvantages of each and his recommendation for the treatment of your particular lesion.

Bowen’s disease

Bowen’s disease typically presents as a red plaque on the lower legs of elderly patients. It is best considered as a premalignant condition with a high risk of transformation in to an SCC, although this may take some years. Surgical excision is curative, but some patients may benefit from non-surgical treatments such as cryotherapy if the surgical wound after excision is likely to struggle to heal.

Chondrodermatitis nodularis helicis chronica (CDNHC)

CDNHC presents typically as a painful nodule on the external ear, which is almost always the preferred ear to sleep on at night. It is a benign lesion that can be successfully managed by pressure avoidance measures. Where these fail, CDNHC van be surgically excised although recurrence is not uncommon.

Cryotherapy

The lesion is frozen with liquid nitrogen to cause the destruction of the abnormal cells. A blister may form at the treatment site, although this would be expected to resolve over several days.

Dermoscopy

Dermoscopy is a useful tool for the diagnosis of skin lesions. It combines surface microscopy with an intense light to enable the assessment of both benign and malignant skin lesions. Dermoscopy is especially useful for the assessment of pigmented lesions to distinguish benign from malignant moles, but can also assist in the diagnosis of benign vascular lesions, BCCs and seborrhoeic keratoses.

Dermatofibroma

A dermatofibroma is a common pink-brown nodular benign skin lesion that presents typically on the lower legs, and more often in women. Dermatofibromas can arise as an exaggerated inflammatory response to a simple skin injury, such as an insect bite. No specific treatment is necessary. Dermatofibromas flatten over time, but some patients may prefer surgical excision for cosmetic reasons.

Fibroepithelial polyps

Otherwise known as skin tags, these may occur as single lesions or in clusters, on the neck, in the axillae or groins. Skin tags can be easily excised under local anaesthetic, although new lesions may form as time goes on.

Intradermal naevus

This is the commonest form of benign mole. It is usually less than 1cm in diameter, symmetrical, slightly raised, uniformly pink-brown in colour and may contain hairs.

Keratoacanthoma

This is a rapidly enlarging skin lesion that appears alarming and similar to an SCC. However, a keratoacanthoma (KA) would usually begin to regress at around six weeks. If there is a clinical suspicion of an SCC, the safest option may be to fully excise the lesion rather than to await involution.

Keratoacanthoma - Cosmetic Surgeon Christopher Stone

Lipoma

A lipoma is a benign tumour of fat tissue. They are felt underneath the skin; lipomas are usually soft, mobile and non-tender. Lipomas are extremely common and can usually be simply excised under local anaesthetic. Occasionally an ultrasound scan is required to confirm the diagnosis. When a patient presents with a lump that it bigger than 4-5cm, is rapidly enlarging or painful, or where the lump is deeply located, it is important that it is properly checked to exclude a sarcoma.

Malignant melanoma

Malignant melanoma is a type of skin cancer, arising from the pigment-containing melanocytes that reside in the basal layer of the epidermis. It is the 5th most common cancer overall in the UK, with around 13,000 new cases diagnosed each year. Malignant melanoma is linked to intense episodes of sun exposure in early life. Ultraviolet light, particularly UVA, is strongly associated with melanoma, which can arise either de novo in a new mole or in pre-existing moles.

Nodular malignant melanoma - Cosmetic Surgeon Christopher Stone

Mr Stone specialises in the management of malignant melanoma in his NHS practice. He is able to offer the full range of treatment for a patient with melanoma which includes: wide local excision of the melanoma; sentinel lymph node biopsy; full radiological disease staging; BRAF testing; lymph node removal where necessary from the head and neck, axillae, groins and pelvis; electrochemotherapy for inoperable skin metastases. Mr Stone will discuss all these treatments with you, and how they might apply to your own melanoma.

Mr Stone will also organise the appropriate follow-up for you, which commonly continues for up to five years. Some patients may benefit from new drugs that target the mutant BRAF or are designed to boost the immune response to melanoma. Mr Stone will organise an appointment for you with a melanoma oncologist where necessary.

Sebaceous cyst

A sebaceous, or epidermoid, cyst is a very common benign skin cyst containing keratin breakdown products with or without the oily sebum that is secreted on to hair follicles. They occasionally discharge a foul-smelling cheesy material, and can get infected. Excision under local anaesthetic with the cyst capsule intact is usually curative.

Seborrhoeic keratosis

A seborrhoeic keratosis (SK), otherwise known as a ‘senile wart’, is a common benign skin condition that mainly affects the face and trunk from the fifth decade onwards. An SK appears as a roughened, crusty or greasy plaque. Treatment for cosmetic reasons usually consists of curettage and cautery under local anaesthetic.

Skin flaps

Skin flaps can be used to reconstruct surgical defects all over the body. Skin flaps are moved from an area of skin close to the defect to leave a secondary defect, which closes directly. Skin flaps are advantaged by providing a good skin colour and textural match to the skin that has been removed and there is no requirement for the skin to ‘take’. Skin flaps usually heal in well although, as always, there is a small risk of flap failure.

Skin grafts

Skin grafts are useful to reconstruct surgical wounds that are unable to be closed directly. Depending upon the defect, a skin graft can either be ‘full thickness’ or ‘partial thickness’. Full thickness skin grafts are particularly useful for reconstructing defects on the face.

Full thickness graft inset - Cosmetic Surgeon Christopher Stone

Skin is borrowed from a suitable donor site, for example in front of the ear or from the neck, to leave a straight-line scar. Split skin grafts are useful for reconstructing defects on the scalp or lower limbs. A shaving of skin is taken from the thigh area, to leave a graze that heals with a dressing of the course of a couple of weeks.

Skin grafts must acquire a blood supply from the underlying wound bed – a process know as graft ‘take’. Occasionally this is unsuccessful, and a graft may fail.

Soft tissue sarcoma

Soft tissue sarcoma is a rare malignant tumour of mesenchymal tissue (such as fat, fibrous tissue, blood vessels, smooth and skeletal muscle), that accounts for less than 1% of all cancers.

In 2010, 3,300 people were diagnosed with a soft tissue sarcoma in the UK. Sarcoma occurs most commonly in the limbs and affects people over 65 years of age in 43% of cases. The incidence of soft tissue sarcoma has been increasing since the late 1990s in the UK.

Mr Stone specialises in the treatment of patients with soft tissue sarcoma in his NHS practice. He will discuss your diagnosis with you and will arrange the appropriate imaging investigations and a biopsy.

Mr Stone will also discuss what surgical treatment is required in your case and will provide this to you in an appropriate setting. Follow-up examination and imaging is usually required for five years following treatment. Some patients will require additional treatment such as radiotherapy.

Mr Stone will liaise on your behalf with his oncology colleagues in order to get you the treatment that you need.

Squamous cell carcinoma

Squamous cell carcinoma (SCC) is a type of skin cancer that arises in sun damaged skin typically in elderly patients. SCCs can range from slow growing tumours with a very low potential to spread, to more aggressive lesions. The treatment of SCCs is usually by surgical excision. Some patients require follow-up for a couple of years following treatment.

Hand Squamous Cell Carcinoma - Cosmetic Surgeon Christopher Stone

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