Approach to skin and soft tissue lesions: Clinical sciences

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A 45-year-old man presents to his primary care physician's office for evaluation of a new skin lesion on the abdomen. The patient noticed the lesion while showering 3 weeks ago. He has no significant past medical history. Physical exam shows a 3 mm dome-shaped, red lesion on the abdomen that does not blanch with pressure as seen in the image below. Which of the following additional findings would be most consistent with the likely diagnosis?
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Skin and soft tissue lesions are dermatological abnormalities that look different from the surrounding skin in terms of color, size, or texture.

Most skin and soft tissue lesions are benign. However, some can be malignant or premalignant, so it's important to have a high clinical suspicion for any patient presenting with a new lesion.

Alright, your first step in evaluating a patient who presents with a skin or soft tissue lesion is to obtain a focused history and physical exam to help differentiate between a benign or a malignant lesion. If, on history, the patient reports a slow growing asymptomatic lesion with minimal changes over time that doesn’t bleed easily, and a physical exam reveals that it’s symmetrical in color, shape, and structure, consider benign lesions.

Now, let's dive into our first diagnosis, a benign vascular lesion. Patients often report a mass or a lump that had an early onset in the first few months of life. They might have associated congenital syndromes like Sturge-Weber Syndrome.

On examination, you might find a salmon-colored patch, port-wine stain, strawberry or bright cherry red dome-shaped papules or macules that are blanchable when you press on them. These lesions are usually located on the trunk, face, or upper extremities.

If these are your findings, you are dealing with a benign vascular lesion. Examples of benign vascular lesions include hemangioma, arteriovenous malformations, or pyogenic granuloma.

Most vascular lesions tend to decrease in size as the patient gets older, so they usually don’t need any treatment. If there are aesthetic concerns, you can offer topical agents like timolol, silver nitrate, or in some cases laser ablation or surgical excision.

Alright, let's talk about another group of benign lesions: cysts and lipomas. History will reveal solitary, or multiple, slow growing lesions. Moving on to the physical exam.

Skin cysts are divided into two types: epidermoid or dermoid. Epidermoid cysts are sebaceous cysts that originate from hair follicles. They’re usually filled with keratin, so they look like firm, whitish nodules with a central punctum.

On the other hand, dermoid cysts form from entrapped ectodermal embryonic tissue, and may contain elements like hair follicles, sweat glands, and even teeth. These are often congenital and present early in life. On exam, they tend to be slightly larger in size and deeper in the skin than epidermal cysts, and do not have a punctum.

Sources

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  4. "WHO Classification of Soft Tissue Tumors. In Imaging of Soft Tissue Tumors (pp. 187-196). " Universitat de Girona. (2017)
  5. "Skin and Soft Tissue Lesions in a District Hospital in Central Nigeria: A Histopathological Study." Dermatol Res Pract. (2019;2019:8143680. Published 2019 Dec 26)
  6. "Dermatology of the head and neck: skin cancer and benign skin lesions. " Dent Clin North Am. (2012;56(4):771-790. )
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  8. " Cutaneous Squamous Cell Carcinoma. " Hematol Oncol Clin North Am. (2019;33(1):1-12.)