Common Birthmarks, Dysplastic Nevi and Congenital Nevi

A birthmark is a colored mark on or under the skin that’s present at birth or develops shortly after birth.Some birthmarks fade with time; others become more pronounced. Birthmarks may be caused by extra pigment in the skin or by blood vessels that do not grow normally. Most birthmarks are painless and harmless. In rare cases, they can cause complications or are associated with other conditions. All birthmarks should be checked by a doctor.

See  the slideshow here:   http://www.medicinenet.com/birthmarks_pictures_slideshow/article.htm

Former Soviet President Mikhail Gorbachev has a port wine stain.

Salmon Patches

Salmon patches are nests of blood vessels that appear as small, pink, flat marks on the skin. They occur in 1/3 of newborn babies. Salmon patches can appear on the back of the neck (“stork bite”), between the eyes (“angel’s kiss”), or on the forehead, nose, upper lip, or eyelids. Some fade as baby grows, but patches on the back of the neck usually don’t go away. Salmon patches require no treatment.

Port Wine Stains

A port wine stain begins as a flat, pinkish-red mark at birth and gradually becomes darker and reddish-purple with age. Most will get bigger and thicker, too. Port wine stains are caused by dilated blood capillaries. Those on the eyelid may increase the risk of glaucoma. Port wine stains may be a sign of other disorders, but usually not. Treatment includes laser therapy, skin grafts, and masking makeup.

Mongolian Spots

Mongolian spots are flat, smooth marks that are present from birth. Frequently found on the buttocks or lower back, they’re typically blue, but can also be bluish gray, bluish black, or brown. They may resemble a bruise. Mongolian spots are most common on darker-skinned babies. They usually fade by school age, but may never disappear entirely. No treatment is required.

Cafe-Au-Lait Spots

Cafe-au-lait spots are smooth and oval and range in color from light to medium brown, which is how they got their name, “coffee with milk” in French. They’re typically found on the torso, buttocks, and legs. Cafe-au-lait spots may get bigger and darker with age, but are generally not considered a problem. However, having several spots larger than a quarter is linked with neurofibromatosis and the rare McCune-Albright syndrome. Consult a doctor if your child has several spots.

Strawberry Hemangiomas

Hemangiomas are a collection of small, closely packed blood vessels. Strawberry hemangiomas occur on the surface of the skin, usually on the face, scalp, back, or chest. They may be red or purple; they can be flat or slightly raised, with sharp borders. Strawberry hemangiomas usually develop a few weeks after birth. They grow rapidly through the first year before subsiding around age 9. Some slight discoloration or puckering of the skin may remain at the site. No treatment is required, but when desired, medicines and laser therapy are effective.

Cavernous Hemangiomas

Present at birth, deeper cavernous hemangiomas are just under the skin and appear as a bluish spongy mass of tissue filled with blood. If they’re deep enough, the overlying skin may look normal. Cavernous hemangiomas typically appear on the head or neck. Most disappear by puberty. A combination of cavernous and strawberry hemangioma can occur.

Venous Malformation

Venous malformations are caused by abnormally formed, dilated veins. Although present at birth, they may not become apparent until later in childhood or adulthood. Venous malformations appear in 1% to 4% of babies. They are often found on the jaw, cheek, tongue, and lips. They may also appear on the limbs, trunk and internal organs, including the brain. They will continue to grow slowly, and they don’t shrink with time. Treatment — often sclerotherapy or surgery — may be necessary for pain or impaired function.

Pigmented Nevi (Moles)

Moles occur when cells in the skin grow in a cluster instead of being spread throughout the skin. They can appear anywhere on the body, alone or in groups. Moles are usually flesh-colored, brown, or black. Moles may darken with sun exposure and during pregnancy. They tend to lose color during adulthood and may disappear in old age. Most moles are not cause for alarm. However, moles may have a slightly increased risk of becoming skin cancer. Moles should be checked by a doctor if:

* They change size or shape
* They look diffrent from other moles
* They appear after age 20

Actress Eva Mendes sports a “beauty mark” on her check.

Congenital Nevi

Congenital nevi are moles that appear at birth. The skin texture may range from normal to raised, or nodular to irregular. Congenital
nevi can grow anywhere on the body and vary in size –from a small 1-inch mark to a giant birthmark covering half of the body or more. Small congenital nevi occur in 1% of newborns. Most moles are not dangerous. But congenital nevi, especially large ones, should always be evaluated by a doctor since they may have an increased risk of becoming skin cancer.

Dysplastic Nevi (Atypical Moles)

Atypical moles are generally larger (one-quarter inch across or more) than ordinary moles and have irregular and indistinct borders. They may resemble cancerous moles. They may have a mix of colors including pink, red, tan and brown.These moles tend to be hereditary. Atypical moles have an increased chance of developing into melanoma skin cancer. Have a doctor evaluate all moles that look unusual, grow larger, or change in any way.

Common Bacterial Infections of the Skin

Our skin is host to a number of bacteria, most of which are beneficial. Including the friendly flora in our gut, more than 200 species of bacteria reside within the tissues exposed to the external environment. Skin infections result from these bacteria when the integrity of the skin breaks down or when the immune defense system is weak.

Skin infections can occur on the skin surface or deeper within the skin tissue. The most common bacteria that infect the skin are Staphylococcus aureus and Streptococcus pyogenes. Read more about bacterial infections on www.skincareguide.ca/conditions/bacterial_infections

TYPES OF BACTERIAL INFECTIONS:

Impetigo and Ecthyma

Impetigo begins with a redness of the skin and progresses to blisters that fill with fluid and itch, and then produce honey-colored crusts. Lesions usually form around the nose and face. Ecthyma is a deeper version of impetigo that usually forms on the legs. It causes large boils, crusts, and deep sores that leave scars.

Folliculitis

Folliculitis is an infection of the hair follicles. It produces pimplelike skin bumps and small blisters with pus. Folliculitis occurs on the face, upper trunk, arms, and buttocks. When the infection goes deeper, feels tender, and produces more pus, it is furunculosis. Carbuncles are furuncles that have fused.

Abscess

An abscess is a deep infection that appears like a closed blister or an open hole with pus. It is usually tender and becomes sore and painful as the infection progresses.

Erysipelas and Cellulitis

Erysipelas is a superficial infection that tends to occur in young children and the elderly. It is also seen in those who have chronic swelling of the limbs, are addicted to alcohol, have diabetes mellitus, or have experienced trauma. Erysipelas mostly occurs on the face or legs. A fever occurs abruptly, the cheeks become red, and the skin feels hot, tense, and swollen. Cellulitis is a deeper form of this infection.

TREATMENTS:

Bacterial skin infections are treated according to their severity. Your physician may incise and drain deeper infections and abscesses, and recommend that you apply warm compresses. Creams such as Fucidin® or Bactroban® are prescribed for mild stages of:

* impetigo
* ecthyma
* folliculitis
* abscess

If the infection is more extensive, oral antibiotics such as Cloxacillin or Cephalexin are used as well as those in the erythromycin family. Penicillin is often used to treat for strep.

Antibiotic resistance is an increasing problem so it is best to have early adequate proper treatment to minimize risk of exposure to antibiotics and lower the risk of transmission to others.

During treatment, remember to wash your hands daily with an antibacterial solution such as Trisan®, Tersaseptic® or Hibitane®, or use a product like Safe4Hours® (www.invisicare.com) which kills bacteria for four hours. Hand washing is the most important thing you can do to minimize the spread of infection.

If you suspect a bacterial skin infection, see your doctor before it becomes severe. Due to the increase of bacterial resistance to drugs in general, it is important to take the full course of your prescribed medicines.

Skin Biopsies and Skin Lesions

Skin biopsy is a biopsy technique in which a skin lesion is removed and sent to the pathologist to render a microscopic diagnosis. It is usually done under local anesthetic in a physician’s office, and results are often available in 4 to 10 days. It is commonly performed by dermatologists.

Skin biopsies are also done by family physicians, internists, surgeons, and other specialties. However, performed incorrectly, and without appropriate clinical information, a pathologist’s interpretation of a skin biopsy can be severely limited. There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy. The choice of the different skin biopsies is dependent on the suspected diagnosis of the skin lesion.

Like most biopsies, patient consent and anesthesia (usually lidocaine injected into the skin) are prerequisites.

Different types of skin biopsies

Shave biopsy

This is done with either a small scalpel blade, a curved razor blade, or a broken piece of “safety” razor. The technique is very much user skill dependent, as some surgeons can remove a small fragment of skin with minimal blemish using any one of the above tools, while others have great difficulty securing the devices. Ideally, the razor will shave only a small fragment of protruding tumor and leaving the skin relatively flat after the procedure. Hemostasis is obtained using light electrocautery, Monsel solution, or aluminum chloride. This is the ideal method of diagnosis for basal cell
cancer.

It can be used to diagnose squamous cell carcinoma and melanoma-in-situ, however, the doctor’s understanding of the growth of these last two cancers should be considered before one uses the shave method. The punch or incisional method is better for the latter two cancers as a false negative is less likely to occur (i.e. calling a squamous cell cancer an actinic keratosis or keratinous debris). Hemostasis for the shave technique can be difficult if one relied on electrocautery alone. A small “shave” biopsy often ends up being a large burn defect when the surgeon tries to control the bleeding with electrocautery alone. Pressure dressing or chemical astringent can help in hemostasis in patients taking anticoagulants.

Punch biopsy

This is done with a round shaped knife ranging in size from 1mm to 8 mm. Some punch biopsies are shaped like an ellipse, although one can accomplish the same desired shape with a standard scalpel. The 1 mm and 1.5 mm punch are ideal for locations where cosmetic appearance is difficult to accomplish with the shave method. Minimal bleeding is noted with the 1 mm punch, and often the wound is left to heal without stitching for the smaller punch biopsies. Disadvantage of the 1 mm punch is that the tissue obtained is almost impossible to see at times due to small size, and the 1.5 mm biopsy is preferred in most cases. The common punch size use to diagnose most inflammatory skin condition is the 3.5 or 4 mm punch. Ideally, the punch biopsy include the full thickness skin and subcutanous fat in the diagnosis of skin disease

Incisional biopsy

When a cut is made through the entire dermis down to the subcutanous fat. A punch biopsy is essentially an incisional biopsy, except it is round rather than elliptical as in most incisional biopsies done with a scalpel. Incisional biopsies can include the whole lesion (excisional), part of a lesion, or part of the affected skin plus part of the normal skin (to show the interface between normal and abnormal skin). Incisional biopsy often yield better diagnosis for deep pannicular skin diseases and more subcutanous tissue can be obtained than a punch biopsy. Long and thin deep incisional biopsy are excellent on the lower extremities as they allow a large amount of tissue to be harvested with minimal tension on the surgical wound. Advantage of the incisional biopsy over the punch method is that hemostasis can be done more easily due to better visualization. Dog ear defects are rarely seen in incisional biopsies with length at least twice as long as the width.

Excisional biopsy

This is essentially the same as incisional biopsy, except the entire lesion or tumor is included. This is the ideal method of diagnosis of small melanomas (when performed as an excision). Ideally, an entire melanoma should be submitted for diagnosis if it can be done safely and cosmetically. This “excisional” biopsy is often done with a narrow margin to make sure the deepest thickness of the melanoma is given before prognosis is decided. However, as many melanoma-in-situs are large and on the face, a physician will often chose to do multiple small punch biopsies before committing to a large excision for diagnostic purpose alone. Many prefer the small punch method for initial diagnostic value before resorting to the excisional biopsy. An initial small punch biopsy of a melanoma might say “severe cellular atypia, recommend wider excision”. At this point, the clinician can be confident that an excisional biopsy can be performed without risking committing a “false positive” clinical diagnosis.

Curettage biopsy

This can be done on the surface of tumors or on small epidermal lesions with minimal to no topical anesthetic using a round curette blade. Diagnosis of basal cell cancer can be made with some limitation, as morphology of the tumor is often disrupted. The pathologist must be informed about the type of anesthetic used, as topical anesthetic can cause artifact in the epidermal cells. Liquid nitrogen or cryotherapy can be used as a topical anesthetic, however, freezing artifact can severely hamper the dianosis of malignant skin cancers.

Fine needle aspirate

Needle aspiration biopsy[1] is done with the rapid stabbing motion of the hand guiding a needle tipped syringe and the rapid sucking motion applied to the syringe. It is a method used to diagnose tumor deep in the skin or lymphnodes under the skin. The cellular aspirate is mounted on a glass slide and immediate diagnosis can be made with proper staining or submitted to a laboratory for final diagnosis. A fine needle aspirate can be done with simply a small bore needle and a small syringe (1 cc) that can generate rapid changes in suction pressure. Fine needle aspirate can be used to distinguish a cystic lesion from a lipoma. Both the surgeon and the pathologist must be familiar with the method of procuring, fixing, and reading of the slide. Many center have dedicated team used in the harvest of fine needle aspirate.

Saucerization biopsy

Also known as “scoop”, “scallop”, or “shave” excisional biopsy[2], or “shave” excision. A trend has occurred in dermatology over the last 10 years with the advocacy of a deep shave excision of a pigmented lesion [3] [4] [5] An author published the result of this method and advocated it as better than standard excision and less time consuming. The added economic benefit is that many surgeons bill the procedure as an excision, rather than a shave biopsy. This saves the added time for hemostasis, instruments, and suture cost. The great disadvantage, seen years later is the numerous scallop scars, and a very difficult to deal with lesions called a “recurrent melanocytic nevus”, see recurrent nevus. What has happened is that many “shave” excisions do not adequately penetrate the dermis or subcutanous fat enough to include the entire melanocytic lesion. Residual melanocytes regrow into the scar. The combination of scarring, inflammation, blood vessels, and atypical pigmented streaks seen in these recurrent nevus gives the perfect
dermatoscopic picture of a melanoma[6][7][8][9]. When a second physician re-examines the patient, he or she has no choice but to recommend the reexcision of the scar.

If one does not have access to the original pathology report, it is impossible to tell a recurring nevus from a severely dysplastic nevus or a melanoma. As the procedure is widely practiced, it is not unusual to see a patient with dozens of scallop scars, with as many as 20% of the scar showing residual pigmentation. The second issue with the shave excision is fat herniation, iatrogenic anetoderma, and hypertrophic scarring. As the deep shave excision either completely removes the full thickness of the dermis or greatly diminishes the dermal thickness, subcutanous fat can
herniate outward or pucker the skin out in an unattractive way. In areas prone to friction, this can result in pain, itching, or hypertrophic scarring.

The Pathology Report

A pathology report is highly dependent on the quality of the biopsy that is submitted. It is not unusual to miss the diagnosis of a skin tumor or a skin biopsy due to a poorly performed or inappropriately performed skin biopsy. The clinical information provided to the pathologist will also affect the final diagnosis. An example would be a rapidly growing dome shaped tumor of the sun exposed skin. Despite doing a large wedge incision, a pathologist might call the biopsy keratin debris with characteristics of actinic keratosis. But provided with an accurate clinical information, he/she might consider the diagnosis of a well differentiated squamous cell carcinoma or keratoacanthoma. It is not infrequent for two, three or more biopsies to be performed by different doctors for the same skin condition, before the correct diagnosis is made on the final biopsy.

The method, depth, and quality of clinical data will all affect the yield of a skin biopsy. For this reason, doctors specializing in skin diseases are invaluable in the diagnosis of skin cancers and difficult skin diseases. Specific stains (PAS, DIF, etc), and certain type of sectioning (vertical and horizontal) are often requested by an astute physician to
make sure that the pathologist will have all the necessary information to make a good histological diagnosis.

References

1. ^ http://www.virtualcancercentre.com/investigations.asp?sid=3
2. ^ Saucerization biopsy of pigmented lesions . Clinics in Dermatology , Volume 23 , Issue 6 , Pages 631 - 635 J . Ho , R . Brodell , S . Helms
3. ^ http://escholarship.umassmed.edu/ssp/46/
4. ^ http://www.clinmedres.org/cgi/content/full/6/2/86
5. ^ http://www.aafp.org/afp/20021101/letters.html
6. ^ http://www.springerlink.com/content/u353473367570111/
7. ^ http://www.pathology-skin-rjreed.com/html/recurrent_nevus__c20t3_.htm
8. ^ http://dermoscopic.blogspot.com/2007/11/recurrent-nevus.html
9. ^ http://www.pathology-skin-rjreed.com/congenital_nevust_c7bt2_.HTM

Pseudomelanoma AKA Recurrent Nevus

Pseudomelanoma (also known as a “Recurrent nevus”) is a cutaneous condition in which melantic skin lesions clinically resemble a superficial spreading melanoma at the site of a recent shave removal of a melanocytic nevus.

Problem with the Recurrent Nevus

The melanocytes left behind in the wound regrows in an abnormal pattern. Rather than the even and regular lace like network, the pigments tends to grow in streaks of varying width within the scar. This is often accompanied by scarring, inflammation, and blood vessel changes - giving both the clinical and histologic impression of a melanoma or a severe dysplastic nevus. When the patient is reexamined years later without the assistance of the original biopsy report, the physician will often require the removal of the scar with the recurrent nevus to assure that a melanoma is not missed.

Saucerization biopsy

Also known as “scoop”, “scallop”, or “shave” excisional biopsy, or “shave” excision. A trend has occurred in dermatology over the last 10 years with the advocacy of a deep shave excision of a pigmented lesion. An author published the result of this method and advocated it as better than standard excision and less time consuming. The added economic benefit is that many surgeons bill the procedure as an excision, rather than a shave biopsy.

This save the added time for hemostasis, instruments, and suture cost. The great disadvantage, seen years later is the numerous scallop scars, and a very difficult to deal with lesions called a “recurrent melanocytic nevus”. What has happened is that many “shave” excisions does not adequately penetrate the dermis or subcutanous fat enough to include the entire melanocytic lesion. Residual melanocytes regrow into the scar. The combination of scarring, inflammation, blood vessels, and atypical pigmented streaks seen in these recurrent nevus gives the perfect dermatoscopic picture of a melanoma.

When a second physicians re-examine the patient, he or she has no choice but to recommend the reexcision of the scar. If one does not have access to the original pathology report, it is impossible to tell a recurring nevus from a severely dysplastic nevus or a melanoma. As the procedure is widely practiced, it is not unusual to see a patient with dozens of scallop scars, with as many as 20% of the scar showing residual pigmentation. The second issue with the shave excision is fat herniation, iatrogenic anetoderma, and hypertrophic scarring. As the deep shave excision either completely remove the full thickness of the dermis or greatly diminishing the dermal thickness, subcutanous fat can herniate outward or pucker the skin out in an unattractive way. In areas prone to friction, this can result in pain, itching, or hypertrophic scarring.

See also

* Ballon cell nevus ; Balloon cell nevi are a cutaneous condition characterized histologically by large, pale, polyhedral balloon cells.

* Skin lesion; Most dermatoses present with skin lesions of more or less distinct characteristics. Macroscopically, these original lesions are known as the “primary lesion”, and identification of such lesions is “…the most important aspect of dermatologic examination.” However, these lesions may continue to develop or be modified by regression or trauma, producing “secondary lesions”. Additionally, on the microscopic level, these lesions can also be characterized by a distinct set of vocabulary.