Benign skin lesions: Clinical sciences

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Introduction 0:00–0:57

Benign skin lesions are non-cancerous skin growths that are symmetrical in shape, color, and structure. They are typically stable with no change in appearance and no spontaneous bleeding.
Benign skin lesions are classified by their cellular origin and include melanocytic, subcutaneous, keratinocytic, vascular, and fibrous.
Here’s a clinical pearl! Benign skin lesions are often diagnosed clinically.
However, dermatologists may use other methods to help diagnose skin lesions. One tool is dermoscopy, which is a skin surface microscope that helps differentiate benign lesions from dysplastic and malignant lesions.
Another option is skin biopsy either with shave, scissor, curettage, punch, or scalpel excision. Now, if a patient presents with a chief concern suggesting a skin lesion, first obtain a focused history and physical examination.

H&P 0:57–2:01

Your patient will report a growth on their skin, with no change in size, shape, or color. Physical exam will reveal a dermatologic lesion, which is typically symmetric, with a well-defined border, consistent coloration, and a diameter less than 6 millimeters.
With these findings, diagnose a benign skin lesion. Here’s a high-yield fact!
When assessing a skin lesion, it's also important to know the features of a malignant skin lesion, like melanoma. Use the acronym ABCDE to help in your assessment.
This stands for asymmetry, irregular borders, varying colors, diameter usually greater than 6 millimeters, and evolving in size, shape, or color.
If any of these features are present, suspect a malignant skin lesion! Your next step is to assess for a melanocytic lesion, most commonly a nevus!

Melanocytic Lesions - Nevus 2:01–2:53

Your patient will report a pink, tan, or brown mole that hasn’t changed in size, shape, or color. There will also be no report of bleeding.
Physical exam will reveal a flesh-colored, pink, tan, or brown papule that’s dome-shaped or pedunculated with a stem. It is typically soft or rubbery in texture.
With these findings, diagnose nevus! Management of a nevus consists of monitoring for the development of malignant characteristics.
If your patient prefers lesion removal for aesthetic reasons, this includes treatment like cryotherapy, shave excision, microdissection, or laser therapy.
Okay, next let’s evaluate for a subcutaneous lesion such as a lipoma! Your patient will report a mass under the skin in fatty areas of the body like the neck, trunk, and proximal extremities.

Subcutaneous Lesions - Lipoma 2:53–3:33

Physical exam will show a soft, mobile, subcutaneous density with a rubbery texture. You may elicit the slippage sign, where on palpation, the density will slip from under the fingers when pressure is applied at the edge.
With these findings, diagnose lipoma. No medical management is necessary, but again, if your patient prefers removal of the lesion, you might offer surgical excision.
Okay moving on, next assess for keratinocytic lesions which includes lentigo, seborrheic keratosis, sebaceous hyperplasia, actinic keratosis, and epidermoid cyst.

Keratinocytic Lesions 3:33–3:48

First up is lentigo! These patients will report a brown patch, and may have a history of fair skin, sun damage, phototherapy, or radiation therapy.

Lentigo 3:48–4:22

Physical exam will show a pigmented flat or slightly raised lesion with a clearly defined edge. With these findings, diagnose lentigo.
While there’s no specific medical management of lentigo, aesthetic treatment includes bleaching creams to lighten the discoloration or lesion removal with cryotherapy and laser therapy.
Next up is seborrheic keratosis! These patients report a brown, yellow, or gray growth that might be itchy or painful.

Seborrheic Keratosis 4:22–5:14

Physical exam reveals a lesion with a dull, waxy surface with a “stuck on” appearance. With these findings, diagnose seborrheic keratosis.
If the lesion causes your patient discomfort or if your patient prefers lesion removal, you can utilize cryotherapy, shave excision, electrocautery, or laser therapy.
Here's a high-yield fact! The abrupt onset of multiple seborrheic keratoses, known as the sign of Leser-Trelat, is a finding associated with the presence of an internal malignancy, such as gastrointestinal or pulmonary carcinomas!
Let’s move on to sebaceous hyperplasia! These patients report a growth on their face or upper trunk.

Sebaceous Hyperplasia 5:14–6:02

They are often undergoing hormonal changes, such as menopause, or have a history of immunosuppressive therapy or antiretroviral medication use.
Physical exam reveals a yellow or skin-colored dome-shaped papule with central umbilication. With these findings, diagnose sebaceous hyperplasia.
If the appearance is bothersome, offer topical trichloroacetic acid or oral isotretinoin which can help fade the lesion.
Alternatively, your patient may prefer to have the lesion removed with cryotherapy, surgical excision, electrocautery, or laser therapy.
Next up is actinic keratosis! These patients report a growth on a sun-exposed area of the body, often in the context of repeated sun exposure.

Actinic Keratosis 6:02–7:10

The lesion might be itchy or painful. Physical exam shows erythematous macules, papules, or plaques with a rough, scaly texture.
With these findings, diagnose actinic keratosis. Medical management is with topical agents like 5-fluorouracil, imiquimod, or diclofenac; or removal of the lesions with cryotherapy, laser therapy, or surgical excision.
Here's a clinical pearl! While actinic keratoses are benign skin lesions, they have the potential to progress to squamous cell carcinoma, a malignant skin lesion!
Chronic sun exposure is the most important risk factor for the development of actinic keratoses. At-risk individuals should have regular comprehensive skin exams and education on preventative strategies such as sunscreen use and covering up with wide brimmed hats, pants, and long sleeves.
Last up for keratinocytic lesions is epidermoid cyst, better known as a sebaceous cyst! These patients report a lump under their skin which might have thick, foul smelling, cheese-like drainage.

Epidermoid Cyst 7:10–7:58

Physical exam will reveal a non-fluctuant, raised, flesh-colored lesion that might have a central dark opening and surrounding inflammation.
With these findings, diagnose epidermoid cyst. Medical treatment with topical steroids is only indicated if there is surrounding inflammation.
If lesion removal is desired, your patient can undergo surgical excision. Okay, now let’s move on to vascular lesions, which includes cherry angioma and pyogenic granuloma.
First up is cherry angioma! Your patient will report a cherry-red spot on their skin.

Cherry Angioma 7:58–8:24

Physical exam will reveal a small, well-demarcated, dome-shaped, bright red papule that blanches with pressure. With these findings, diagnose cherry angioma.
If the patient desires removal for aesthetic purposes, perform shave excision, cryotherapy, or laser therapy. Next up is pyogenic granuloma!
Your patient will report a red growth on the skin surface or in the mouth oftentimes with recurrent bleeding. There might be a history of pregnancy or treatment with retinoids, chemotherapy, antiretrovirals, or immunosuppressive medication.

Pyogenic Granuloma 8:24–9:07

Physical exam reveals a red, pedunculated, friable papule. With these findings, diagnose pyogenic granuloma.
Medical management includes discontinuation of any offending medications. If your patient desires removal for aesthetic purposes, perform surgical excision, cryotherapy, laser therapy, or electrocautery.
Okay, and finally let’s assess for fibrous lesions. These include keloid, acrochordon, and dermatofibroma!

Fibrous Lesions 9:07–9:17

First up is keloid! Your patient will most likely have darker skin pigmentation, and report an area of excessive scarring with associated pain, burning or itching.

Keloid 9:17–10:08

There is often a history of skin trauma or inflammation that preceded the onset of scarring. Physical exam will reveal rubbery, erythematous, flesh-colored or hyperpigmented nodules extending beyond the area of trauma or injury.
With these findings, diagnose a keloid! If discomfort is present, treat with intralesional steroid injections.
Or if removal is desired, removal consists of surgical excision, cryotherapy, laser therapy, or radiotherapy but keep in mind that since skin trauma often precedes the development of a keloid, recurrence after removal is very common!
Next up is acrochordon, better known as a skin tag! Your patient will report a soft, round growth and they might have a history of obesity, type 2 diabetes mellitus, or hormonal imbalances.

Acrochordon 10:08–10:47

Physical exam reveals a flesh-colored or hyperpigmented, pedunculated lesion with a bag-like appearance. They most commonly are found on areas of friction near the neck, axilla, or groin.
With these findings, diagnose acrochordon! No medical management is necessary, but if removal is desired, perform skin excision, cryosurgery, or electrocautery.
Let’s move on to dermatofibroma! Your patient will report a pink, tan, or brown growth typically on the extremities; along with a history of local skin trauma or inflammation.

Dermatofibroma 10:47–11:24

Physical exam reveals a firm, pink, tan or brown nodule with a smooth surface. You may also observe a dimple sign, which is a depression produced by lateral pressure on the skin.
With these findings, diagnose dermatofibroma. No medical management is necessary, but offer surgical excision if complete lesion removal is preferred.
Alright, as a quick recap…Benign skin lesions are non-cancerous skin growths that are typically stable in size, shape, and color.

Review 11:24–12:21

Melanocytic lesions include nevi while subcutaneous lesions include lipomas. On the other hand, keratinocytic lesions include lentigo, seborrheic keratosis, sebaceous hyperplasia, actinic keratosis, and epidermoid cyst.
Vascular lesions include cherry angioma and pyogenic granuloma; while fibrous lesions include keloid, acrochordon, and dermatofibroma.
Treatment options for benign lesions largely include topical or oral medications to help fade the lesion. If lesion removal is preferred for aesthetic reasons, options include shave excision, cryosurgery, laser therapy,
Benign skin lesions: Video, Anatomy, and Function | Osmosis