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Langerhans cells: antigen-presenting cells in stratum
spinosum
Dermis
Made up of two layers (superficial to deep): papillary and
reticular
Cell types: fibroblast, macrophage, and mast cell
Papillary dermis
Similar thickness to epidermis; intertwines with rete
ridges of the epidermis
Type III collagen > type I
Site of collagenase activity, terminal networks of
Meissner corpuscles and capillaries
Reticular dermis: majority of the dermal layer
Mostly type I collagen bundles with elastic fibers
between
Contains hair roots, sebaceous and sweat glands,
receptors, and blood vessels.
Tissue components
Collagen: provides tensile strength.
*Type I to type III—4:1 ratio in adult skin
Immature scar type I to type III—2:1 ratio in adult
skin
Elastin
Interdigitates with collagen; composed of fibrillin
protein
Important in skin recoil and decreases with aging
Ground substance
Noncellular component of extracellular matrix with
fibers
Composed of glycosaminoglycans (hyaluronic acid
and proteoglycans)
BENIGN LESIONS
EPIDERMAL LESIONS
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Epidermal nevus (linear nevus)
Present at birth or early childhood
May be associated with developmental delays and other
neurologic and MSK abnormalities
Clinical presentation: tan or brown warty papules in linear
array
Anatomic location: trunk and extremities
Treatment: excision, laser therapy (CO2), topical therapies
less effective
Inflammatory linear verrucous epidermal nevus
Present at birth or early childhood
Clinical presentation: erythematous, scaly papules in linear
array, pruritic
Anatomic location: on one extremity along lines of Blaschko
Treatment: excision or laser therapy (pulsed dye laser)
Seborrheic keratosis
Derived from basal layer of epidermis. Cystic inclusions of
keratinous material
Present in middle age around fifth decade
Clinical presentation: waxy, tan to black, stuck-on papules
Anatomic location: anywhere except palms, soles, mucous
membranes
Treatment: cryotherapy, curettage, excision
Actinic keratosis: most common premalignant skin lesion
Rate of transformation to SCC ~0.6%-16% per year
Clinical presentation: erythematous, scaly papules; actinic
cheilitis if on lips
Anatomic location: sunlight-exposed areas (scalp, ears,
face, and hands)
Histologically characterized by dyskeratosis, atypia in basal
layer of epidermis
Treatment: 5-fluorouracil (FDA approved), imiquimod 5%
(Aldara), cryotherapy, photodynamic therapy
Verruca vulgaris
Common wart: caused by human papillomavirus (HPV).
Clinical presentation: scaly, rough appearance often with
thrombosed capillaries.
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Anatomic location: variable. Lesions arise from stratum
granulosum.
Treatment: cryotherapy, imiquimod, candida antigen,
salicylic acid, or excision.
Cutaneous horn
Clinical presentation: well-circumscribed cone with
hyperkeratosis.
Most commonly arise from actinic keratosis; SCC present in
up to 20% of lesions.
Anatomic location: sun-exposed areas.
Treatment: excisional biopsy with careful evaluation of
lesion base.
Leukoplakia
Associated with chronic inflammation/irritation (alcohol or
tobacco).
*May degenerate into SCC.
Clinical presentation/anatomic location: mucosal lesion;
cannot be wiped away.
Treatment: removal of irritant, biopsy may be warranted.
Keratoacanthoma
*Rapid growth phase followed by spontaneous
regression
Clinical presentation: firm, dome-shaped nodule
Prominent horn-filled central depression and keratin
with thick epidermis
Difficult to distinguish from SCC
Treatment: simple excision; consider 5-fluorouracil if
multiple lesions
MELANOCYTIC LESIONS
Nevus of Ota/nevus of Ito
Found in patients with Asian ancestry
Clinical presentation: appears at birth as large, blue-gray
patch
Anatomic location
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Ota: areas innervated by first and second branches of
trigeminal nerve
Ito: posterior shoulder and areas innervated by
posterior supraclavicular and lateral cutaneous brachial
nerves
Treatment: laser therapy (Q-switched ruby, alexandrite,
Nd:YAG)
Nevus spilus
Appears at birth
Clinical presentation: tan patch with speckled
hyperpigmented macules and papules
Anatomic location: commonly on trunk and extremities
Treatment: observation, laser therapy (Q-switched ruby,
Nd:YAG); simple excision
Spitz nevus (benign juvenile melanoma)
Appears in childhood or early adulthood
Clinical presentation: pink to brown, dome-shaped, smooth
papules
Anatomic location: commonly located on the head and neck
Treatment: excision with margins to decrease recurrence
risk (range from 1-2 mm to 1-2 cm depending on concern
for melanoma)
May be difficult to distinguish histologically from spitzoid
melanoma
Junctional nevus
Nests of melanocytes located at dermoepidermal junction
Appears in childhood or early adulthood
Clinical presentation: skin colored to brown, evenly
pigmented macule with well-defined borders
Anatomic location: any site
Treatment: observation, simple excision
Compound nevus
Contains both junctional and intradermal components
Appears in childhood or early adulthood
Clinical presentation: skin colored to dark-brown papule
with regular borders
Anatomic location: any site
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Treatment: observation, simple excision
Intradermal nevus
Located entirely within the dermis
Appears in the second or third decade of life
Clinical presentation: appears as a flesh-colored or light tan
papule
Anatomic location: face or neck
Treatment: observation, simple excision
Common blue nevus
Appears during adolescence.
Clinical presentation: blue or blue-black <1 cm papule.
Anatomic location: hands, feet, face and scalp.
Treatment: observation, simple excision.
Cutaneous metastasis of malignant melanoma can
resemble blue nevus.
Cellular blue nevus
Appears after second decade of life
Clinical presentation: blue-black 1-3 cm papule
Anatomic location: buttocks or sacral region
Treatment: observation, simple excision
Atypical (dysplastic) nevus
Patients with dysplastic nevi and a family history of
melanoma in a first-degree relative are at a higher risk of
melanoma, warranting regular skin examinations.
Appear after puberty.
Clinical presentation: atypical pigment, borders, size,
asymmetric.
Anatomic location: anywhere.
Treatment: excision with margins to prevent recurrence.
Sunscreen and avoidance of sunburning/tanning
ADNEXAL TUMORS: SEBACEOUS
GLANDS, HAIR FOLLICLES,
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APOCRINE, OR ECCRINE SWEAT
GLANDS
Hair follicle tumors: located in lower dermis and subcutaneous
fat
Pilomatrixoma (calcifying epithelioma of Malherbe)
Typically seen in younger patients (<20 years old)
Clinical presentation: single, solid subdermal nodule
Positive tent sign—stretching of overlying skin
yields angulated shape.
Difficult to distinguish from calcified masses or
carcinoma.
Histopathology: epidermoid cells with basophilic
and eosinophilic cells.
Anatomic location: head and upper trunk
Treatment: excision (up to 1-2 cm margins); up to 10%
recurrence rate
Trichofolliculoma (hair follicle nevus)
Clinical presentation: <1 cm and skin colored
Anatomic location: on face with thin pale hairs
Treatment: observation, biopsy
Trichoepithelioma
Seen in patients after puberty
Clinical presentation: solitary pink or flesh-colored
papule
May be difficult to distinguish clinically and
histologically from BCC
Anatomic location: if multiple, symmetric distribution
around face and eyes
Treatment: observation, laser, electrosurgical
destruction
Trichilemmoma
Cowden syndrome (multiple hamartoma syndrome):
suspect if patients have multiple such tumors.
Histopathology: glycogen-rich epithelial cells
surrounded by sheaths of cells resembling hair follicles.
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Clinical presentation: smooth skin-colored papules
Anatomic location: found on scalp or other hair-bearing
regions
Treatment: laser therapy (CO2), electrosurgical
excision, or simple excision due to similar appearance
with BCC and trichilemmal carcinoma
Eccrine tumors
Cylindroma
Appears in early adulthood
Multiple may indicate AD Brooke-Spiegler syndrome or
multiple cylindromatosis
Clinical presentation: solitary, firm, smooth pink
nodules
Anatomic location: often located on scalp
Treatment: laser therapy (CO2),
electrodessication/curettage, or simple excision
Eccrine poroma
Clinical presentation: firm, popular, or nodular lesions
surrounded by rim of hyperkeratosis; may appear
pedunculated
Anatomic location: most commonly palms and soles of
feet
Treatment: simple excision
Syringoma
Appears in early adulthood, more common in women
and with Down syndrome
Clinical presentation: small yellow-pink papules. May
be confused with xanthelasma or trichoepithelioma
Anatomic location: most commonly periocular region
(eyelids, upper cheek) but may involve trunk, neck, or
extremities
Treatment: laser (CO2), electrodesiccation, snip/simple
excision
Eccrine spiradenoma
Appears in young adults
Clinical presentation: painful, slow-growing, blue-purple
nodule
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Anatomic location: head, neck or trunk
Treatment: simple excision if symptomatic; laser (CO2)
for smaller lesions
Eccrine hidrocystoma
Dilated and obstructed sweat ducts histologically
Clinical presentation: skin colored to blue translucent
firm papules
Swell in heat/humidity; regress in cooler/dry climate
Anatomic location: temples, cheeks, periorbital area,
forehead
Treatment: puncture to release pressure
Sebaceous tumors
Nevus sebaceus (of Jadassohn)
Appears at birth or early childhood.
Most commonly develops secondary benign adnexal
tumors, most common malignant lesion (~2.5% cases)
that develops within is a BCC (~1% cases).
Clinical presentation: appears as yellow/orange, waxy,
smooth plaques prior to puberty and rough, verrucous,
orange plaques after puberty.
Anatomic location: most commonly found on scalp.
Treatment: observation, complete excision.
Sebaceous hyperplasia
Appears in middle-aged or older adults
Clinical presentation: appears as shiny, small
umbilicated, yellow-white papules
Anatomic location: most common on face
Treatment: cryotherapy, electrodesiccation, or laser
(pulsed dye, Er:YAG, CO2), may be excised due to
similar appearance with BCC
Sebaceous adenoma
Appears in middle age
*May be associated with Muir-Torre syndrome—an
autosomal-dominant syndrome associated with
multiple keratoacanthomas, marked increase in
visceral neoplasm
Clinical presentation: smooth, yellow papules
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Anatomic location: located primarily in head and neck
Treatment: simple excision
Apocrine tumors
Apocrine cystadenoma (aka hidrocystoma)
Contains brown or blue tinged fluid
Clinical presentation: appears as a single translucent
nodule
Anatomic location: most common on face
Chondroid syringoma
Histology: sweat gland (epithelial) and cartilaginous
elements (mesenchymal)
Treatment: excisional biopsy
Syringocystadenoma papilliferum
Appears during childhood
Clinical presentation: may be associated with nevus
sebaceus
Anatomic location: most commonly found on scalp
Treatment: excision; ablative laser
SMOOTH MUSCLE TUMOR
Leiomyoma
Abnormal proliferation of smooth muscle.
May become painful on exposure to cold/pressure.
Clinical presentation: smooth, pink to red-brown papules or
nodules.
Treatment: laser (CO2), excisional biopsy.
Malignant degeneration to leiomyosarcoma is rare.
CYSTS
Epidermal inclusion cyst (epidermoid cyst)
May be incorrectly called a sebaceous cyst; however, not
sebaceous in origin.
Appears in adulthood.
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Clinical presentation: fluctuant, flesh-colored, wellcircumscribed nodules.
Dilated punctum may be visible; may express foulsmelling keratinous debris.
Anatomic location: commonly found on face, neck, and
trunk.
Treatment: excision if uninfected; if infected, incision and
drainage with interval excision.
Dermoid cyst
Appears at birth or early childhood
Clinical presentation: firm, deep-seated nodules
*Anatomic location: most commonly found on
supraorbital ridge, lateral brow, nasal midline
Treatment: excision
*Midline nasal mass differential diagnosis: dermoid
cyst, glioma, meningocele/encephalocele
CT or MRI prior to excision to determine
intracranial extension
Pilar (trichilemmal) cyst
Appears in adulthood
Clinical presentation: smooth, mobile, keratin filled
Anatomic location: most commonly found on scalp
Treatment: excision if uninfected; if infected, incision and
drainage with interval excision
FIBROUS LESIONS
Dermatofibroma
Appears in adulthood
Clinical presentation: brown-red papule with dimple sign
(sinks when squeezed)
Anatomic location: most common lower extremities
Treatment: intralesional corticosteroids, simple excision
Angiofibroma
Clinical presentation: skin colored to pink firm papules
Anatomic location: most commonly on nose
Treatment: simple excision for cosmesis
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