Types of benign neoplasms of the skin. Mole-like skin lesions

Each of us has some kind of neoplasm on the skin. To moles or warts that do not show themselves and do not spoil the appearance, people, as a rule, are indifferent. But the skin can also be a place where cancer cells begin to develop, and due to the fact that it is easily injured, the risk of cancer increases many times over.

We will consider the most common benign and malignant skin neoplasms in this article.

Neoplasms on the skin: types

All neoplasms that occur on human skin can be divided into two groups: congenital and acquired.

The first include the so-called moles or, in other words, nevi, as well as birthmarks (the same nevi, but measuring more than 2 cm²). As a rule, they all have a rounded shape, the color is from flesh to dark brown, sometimes they rise slightly above the skin, but they can also be completely flat.

Causes of acquired neoplasms on the skin

An acquired neoplasm on the skin most often occurs due to any metabolic disorders, a decrease in immunity, as well as infection with the human papillomavirus.

Most of the newly emerged outgrowths are located, as a rule, on the neck, in the armpits, in the groin, but there are also many of those that are localized on the chest, back, face, hands and soles. There are neoplasms that have arisen in the nose, on the auricle, on the eyelids and similar “atypical” places.

Let's consider them in more detail.

Hard and soft fibroids

A metabolic disorder causes a neoplasm on the skin in the form of a hard or soft fibroma. They consist of connective tissue (from fibrobast cells), which, growing, form rounded seals resembling a pea. Fibroids may also have a stalk. The skin over the neoplasm, as a rule, does not change, but when it is large, it may acquire a red or bluish tint.

Most often, the factors provoking the occurrence of fibromas are advanced age, hereditary predisposition, as well as prolonged mechanical or chemical effects on a specific area of the skin (this can be friction against clothing, increased skin moisture, etc.).

And sometimes a malignant tumor is hidden behind a fibroma. To prevent this, with an outgrowth that has arisen on the skin, you should contact a dermatologist and conduct a tissue biopsy. With a growing fibroma or in cases where it spoils the appearance of a person, benign skin tumors are removed, since their conservative treatment is not successful.

The most successful way to remove fibromas is radio wave destruction, which does not leave scars, is painless and does not require the use of anesthetics. The duration of this operation is only a few minutes.

What are keratomas

The following acquired neoplasms on the skin, the types of which we are considering, are keratomas - benign growths caused by the rapid growth of the upper (horny) layer of the epidermis. Most often, these tumors occur in people over 50 years of age.

Doctors call exposure to ultraviolet radiation and hereditary predisposition the reasons that provoke the occurrence of keratoma. That is, if the ancestors had a similar neoplasm on the skin, then it is extremely harmful for the descendant to be in direct sunlight.

As a rule, a keratoma first appears as a grayish or coffee-colored spot. At the same time, its surface often peels off. Over time, it grows and becomes covered with a crust, which can come off, which can cause slight bleeding and soreness. Keratomas can occur in several places at once, and exactly where the skin is most often exposed to sunlight.

Keratoma is mostly just a cosmetic problem. But in order to avoid the risk of its degeneration into squamous cell carcinoma, it is worth showing the neoplasm to a dermatologist.

What causes xanthomas

Benign neoplasms of the skin - xanthomas - is another manifestation of metabolic disorders. In this case - lipid (fatty). Often these disorders affect people with gallbladder disease. Therefore, having discovered a xanthoma, you should consult a therapist and do an ultrasound of the abdominal cavity.

In medicine, 5 types of these tumors are distinguished. They can develop as white, firm nodules (such as eruptive xanthoma), tumor-like nodules (tuberous xanthoma), or indurations formed by fusion of nodules in the lower layers of the skin (infiltrative xanthoma).

Most often, these formations are located on the buttocks, in the area of \u200b\u200bthe joints, on the feet or hands, as well as on the skin of the eyelids (this tumor is described as xanthelasma).

As a rule, the treatment of the underlying disease helps to get rid of the appearance of new xanthomas, and the old ones are removed with a laser.

Neoplasms resulting from infection with a virus

A benign formation that has a viral nature is papillomas, genital warts and warts. They are small bulges of flesh or dark color, located on a thin stem. The surface of the papilloma is usually uneven, resembling a cauliflower.

Papillomas and condylomas can be both multiple and single. Most often, these neoplasms are located on the skin of the face or trunk, but they can occur on the mucous membrane of the mouth, nose, and even internal organs of a person.

Unremoved papillomas tend to increase in number and develop papillomatosis. In some cases, these neoplasms can grow to enormous sizes.

The transmission of the virus occurs through sexual contact (we are talking about genital warts), as well as in the home.

Due to the high susceptibility to injury, papillomas, condylomas and warts should be removed. This is done on an outpatient basis, with a radio wave scalpel. Often, along with surgery, doctors also prescribe antiviral agents (Genferon, Viferon, Proteflazid, etc.).

Malignant neoplasms of the skin: melanoma

If the neoplasm you have has changed its color, size and shape, has become denser, itches and bleeds, you should definitely see an oncologist to eliminate the risk of developing skin cancer.

One of the most common malignant neoplasms is melanoma. Its development is associated with an active effect on age spots or moles of ultraviolet radiation, as well as with frequent skin injuries. By the way, the highest risk of such a rebirth is observed in fair-skinned people over 40 years old.

This tumor is usually located on the neck, head or limbs of a person. In order to distinguish between a nevus and melanoma, one should remember some of its features. So, a malignant formation, as a rule, is larger than an ordinary mole, its shape is asymmetrical and has uneven, jagged edges, and tubercles, depressions and sores appear on the surface. Around the melanoma, the skin also changes, painful sensations and itching appear. The degree of skin pigmentation also changes.

Basalioma

Basalioma, a common skin cancer, gets its name from the cells that are involved in causing it. This pathology accounts for almost 70% of cases of skin oncology.

Basalioma has been growing for several years and, fortunately, does not tend to metastasize. Most often it is located on the face and can be multiple. Outwardly, this is a round or oval spot that has different shades of pink. With the development of the tumor, small vessels may appear on it, as well as erosive areas covered with crusts. With aggravation, erosion turns into an ulcer, sometimes reaching 10 cm in circumference, along the edges of which a roller is clearly visible.

Squamous cell skin cancer

Spinalioma, a squamous cell carcinoma, has similar symptoms. This is a tumor of the epithelium, manifested in the form of a red plaque with scales on the surface. Most often it occurs in older people on the face, back of the hand or on the mucous membranes.

This neoplasm on the skin is prone to metastasis to nearby lymph nodes, and in some cases lesions of bone tissues and lungs have also been noted.

Unlike basalioma, squamous cell carcinoma develops rapidly. As a result of infection, it often causes pain.

For the treatment of these malignant tumors, all methods known in oncology are used. With small sizes, surgical removal of skin neoplasms is performed. Radiation therapy, cryogenic destruction (in other words, freezing of the tumor with liquid nitrogen), laser coagulation and chemotherapy are successfully used. The choice depends on the structure and localization of the tumor, as well as on the condition of the patient.

A strict rule should be followed, according to which, at the slightest doubt in the diagnosis, a histological examination of the neoplasm is necessary.

There are several histological classifications of skin neoplasms. We considered it expedient to present an abbreviated histological classification of the World Health Organization in 1996 |42|.

Malformations, tumor-like processes and benign tumors of epi-dermis

Papillomatous malformation.

epidermal cyst.

Papilloma.

Seborrheic wart.

Common wart.

Pseudocarcinomatous hyperplasia.

Clear cell acanthoma.

Keratoacanthoma.

Cystic epithelioma.

Precancerous conditions of the epidermis,neoplasms with locally destructivegrowth

Senile keratoma.

Skin horn.

actinic keratosis.

Verruciform carcinoma (Gottron's carcinoid, giant condyloma of Bushke-Leve and matte, verruciform opidermodysplatia of Levandon-Lutz).

Leukoplakia.

Bachalyu cell carcinoma (basalioma).

Cancerin situ

Bowen's disease.

Extramammary Paget's cancer.

Eritronla.chiya Keira.

Squamous cell carcinoma: keratinizing, non-keratinizing stage I-III

hair follicle tumors

Comedonal nevus.

Extended time of Winner.

Tricholemmal (hairy) cyst.

Trichofolliculoma.

Trichoadenoma.

Trichoepithelioma (including desmoplastic).

Trichoblastoma.

Trichoblast fibroma.

9. Acanthoma of the hair follicle.

Tumor of the funnel of the hair follicle (follicular keratoma).

Cylinder with piloid differentiation.

Tricholemma.

Pilomatricoma.

Mesenchymal tumors of the hairfollicle

Trichodiscoma.

perifollicular fibroma.

Tumors of the hair follicle with locally invasive growth and malignancyvein tumors of the hair follicle

Basalioma with piloid differentiation.

Malignant pilomatricoma.

Malignant tricholemma.

Malformations, benign andmalignant tumors of the sebaceous glands

1. Malformation of sebaceous jelly:; (non-nus Yadassohn).

Adenoma of the sebaceous glands, including Muir-Torre syndrome.

Basalioma with sebaceous differentiation.

Cancer of the sebaceous glands.

Malformations and benignsweat gland tumors

Eccrine hydrocystoma.

Syringoma.

Eccrine poroma, including simple hydradenoma.

Syringoadenoma (protocoar, papillary, mixed).

Eccrine acrospiroma (syringolitis).

Eccrine spiradenoma.

Cylinder with glandular differentiation.

Chondroid syringoma.

Hydradenoma (papillary, glandular cystic, light cell).

Tumors with locally destructive growthvolume and malignant tumorsexcretory glands

Basalioma with glandular differentiation.

Malignant analogues of benign tumors.

Primary sweat jelly cancer) (adenocystic, mucinous, microcystic, adnexal, ductal).

Aggressive papillary adenocarcinoma of the fingers.

Unclassified tumors.

Complex structure malformations epidermis, pilosbaceous complex, complex tumor structure with locally destructive growth (basaliomas complex structure). malformations andvascular tumors

Malformations: capillary, lymphatic, venous, arterial, complex structure - focal and diffuse.

Benign tumors: capillary, cavernous, arteriovenous hemangiomas

Lymphangioma.

Tumors of the transitional type: hemaigio- ■-zhdothelioma.

Malignant tumors: Kaposi's sarcoma, angiosarcoma, lymphangiosarcoma.

Perivascular tumors: hemanpupericytoma, glomus tumor and their malignant counterparts.

Tumors of the melanocytic system

Intradermal, borderline, mixed nevus.

Large and giant congenital nevi.

Nevus Spitz.

Galonevus.

Blue nevus.

Dysplastic nevus (dysplastic nevus syndrome).

Malignant melanoma in situ.

Superficial spreading melanoma.

nodular melanoma.

Melanoma of the malignant lentigo type.

Acrolentiginous melanoma.

Fibrous, fibrohistiocytic andmuscle tumors

Fibrous hamartoma of childhood.
Digital (ribromatosis of childhood.

Plexiform fibrohistiocytic tumor.

Giant cell fibroblastoma.

Atypical fibroxanthoma.

Juvenile xanthogranuloma.

Reticulohistiocytic granuloma.

Fibrous histiocytoma.

Bulging dermatofibrosarcoma.

Myxoid fibrosarcoma.

Leiomyoma of the skin from the muscles that raise the hair.

Skin leiomyosarcoma.

Tumors of adipose tissue

Lipoma: angiolipoma, myolipoma, chondroid, fusiform, pleomorphic.

Hibernoma.

atypical lipoma.

Liposarcoma.

Neurogenic tumors

Post-traumatic neuromas.

Limited solitary neuroma.

Schwannoma.

Neurofibroma and its variants.

Tumors of peripheral nerve sheaths (perineural fibroma, myxoid and cellular neurothekeoma).

Granular cell tumor.

Malignant tumors of peripheral nerve sheaths.

Merkel cell tumor.

Lymphoproliferative diseasesskin

Benign lymphocytic pro- proliferation

Reaction to insect bites.

Angiolymphoid hyperplasia with eosinophilia.

actinic reticuloid.

T-cell pseudolymphomas of the skin (lymphocytic infiltration of Jessner-Kanof).

T-cell lymphomas of the skin

Fungal mycosis.

Lymphomatoid papulosis.

B-cell pseudolymphomas of the skin (benign Befverstet lymphadenosis, skin lymphocytoma, Spiegler-Fendt sarcoid).

Clinical classification of tumorsskin

Clinical manifestations are an important diagnostic factor, since the color, shape, growth dynamics of the element and its localization, as well as the age of the patient, can provide a preliminary idea of the origin of the neoplasm. However, it is not always possible to determine the nature of the process using a visual assessment, since some of the neoplasms may have a similar clinical characteristic, but a different histological structure; others, on the contrary, with different clinical manifestations have a similar morphological structure, and finally, some of the neoplasms do not have pathognomonic clinical signs and are a histological finding.

Grouping neoplasms based on their clinical signs can to some extent outline the range of suspected nosological forms and help in making a preliminary diagnosis.

Skin color flat tumors: flat viral warts, leukoplakia.

Flat pigmented Tumors: nevi, usually intraepidermal but may be dysplastic, lentigo, café-au-lait spots, histiocytoma, Mongolian spot, melanoma (superficially spreading type).

Towering tumors of the bodycolors: viral warts, soft fibromas (papillomas), nevi, usually intradermal type, cysts, lipoma, keloid scars, basal cell carcinoma (usually scleroderma-like variant), squamous cell carcinoma, molluscum contagiosum, xanthogranuloma.

Elevated brown tumorscolor: viral warts, nevi, seborrheic keratomas, soft fibromas (papillomas), actinic keratomas, basal cell carcinoma, mela-

noma, squamous cell carcinoma, keratoacanthoma.

Elevated tumors of redcolors: hemangiomas, actinic keratomas, pyogenic granuloma, glomus tumors, senile or "cherry" angiomas.

Towering tumors of blackcolors: seborrheic keratomas, nevi, pyogenic granuloma, melanoma, blue nevus, thrombosed angiomas or hemangiomas.

In the preliminary diagnosis of the nature of the proliferative process, the fact that many neoplasms predominate in certain age groups of patients can also help. This group includes molluscum contagiosum and viral warts, since it is often necessary to differentiate them from skin tumors.

skin rashes in children: viral warts (most common), molluscum contagiosum, intradermal nevi, hemangiomas, café-au-lait spots, pyogenic granuloma, Mongolian spot, xanthogranuloma.

Tumors and tumor-like pro-skin processes in adults: viral warts (plantar warts are the most common), nevi, cysts, soft fibromas (skin papillomas, acrochords), sebaceous gland hyperplasia, histiocytoma (dermatofibroma, sclerosed hemangioma), keloids, lipoma, pyogenic granuloma.

Tumors and tumor-like processesskin lesions in the elderly: seborrheic keratomas, actinic keratomas, capillary hemangiomas, basal cell carcinoma, squamous cell carcinoma, leukoplakia.

In establishing the origin of a particular neoplasm, its location also plays a certain role. Below are examples of the localization of the most common neoplasms in the practice of a dermato-cosmetologist.

Hairy part of the head: seborrhea-

keratomas, epidermal and pilar cysts, pevus, follicular keratomas, papillomas, basal cell carcinoma and squamous cell carcinoma, sebaceous nevus, cylindroma, syringocystadenoma.

Ear shells: seborrheic and actinic keratomas, basal cell carcinoma, squamous cell carcinoma, nevus, keloids, epidermal cyst, nodular chondrodermatitis, hibernoma, gouty nodules, Lyme disease, keratoacanthoma.

Face: seborrheic and actinic keratomas, sebaceous hyperplasia, lentigo, milia, nevi, basal cell carcinoma and squamous cell carcinoma, lentiginous melanoma, flat warts, trichoenithelioma, fibrous papules of the nose, keratoacanthoma, pyogenic granuloma, Spitz nevus, hemangioma, adenoma sebaceous glands, hydrocystoma of apocrine and eccrine glands, trichilemmoma, trichofolliculoma, Merkel cell cancer, nevus of Ota, atypical fibroxanthoma, angiolymphoid hyperplasia with eosinophilia.

Eyelids: soft fibromas, seborrheic keratomas, milia, syringoma, xanthelasma, basal cell carcinoma.

Neck: soft fibromas, seborrheic keratomas, epidermal nevi, pilar cysts, keloid.

Lips and mouth area: Fordyce's disease, lentigo, telangiectasias, pyogenic granuloma, squamous cell carcinoma, granular cell tumor of the tongue, peripheral osteoclastoma of the jaw, verrucous carcinoma, white nevus, lentiginous melanoma.

Armpits: soft fibromas, epidermal cyst, molluscum contagiosum, lentigo.

Chest and back: seborrheic keratomas, angiomas, nevi, actinic keratomas, lipoma, basal cell carcinoma, squamous cell carcinoma, epidermal cyst, keloid, lentigo, café au lait spots, melanoma, hemangioma, histiocytoma, multiple steatocystoma, cyst, go-

any nevus, nevus of Ito, Becker's nevus, Paget's disease.

Groin area: soft fibromas, seborrheic keratomas, molluscum contagiosum, warts, Bowen's disease, Paget's extramammary carcinoma.

Sex organs: warts, molluscum contagiosum, angiokeratoma (in the scrotum), epidermal cyst, miliary papules of the penis (on the edge of the glans penis), squamous cell carcinoma, Queyre's erythroplasia, Bowen's disease, penile cyst in the median suture, verrucous carcinoma , papillary hydradenoma on the labia majora.

Upper limbs: warts, seborrheic and actinic keratomas, lentigo, myxoid cyst (in the proximal parts of the nail), squamous cell carcinoma, glomus tumor (in the area of the nail bed), blue nevus, acral and lentiginous melanoma, pyogenic granuloma, recurrent fibroma of the fingers in children, post-traumatic fibroma, xanthoma, Dupuytren's contracture.

Feet: warts, nevus, blue nevus, acral and lentiginous melanoma, seborrheic keratomas, verrucous carcinoma, eccrine poroma, Kaposi's sarcoma.

Shoulders and shins: seborrheic and actinic keratoses, lentigo, warts, histiocytoma, squamous cell carcinoma, melanoma, lipoma, xanthoma, Kaposi's sarcoma.

16.2. Benign tumors of the epidermis

Seborrheic keratomas are a very common type of epithelial tumors in the elderly. The number of keratomas in this case can vary greatly - from single to several hundred, especially in people with oily skin. The abundance of seborrheic keratomas can sometimes be a manifestation of paraneoplasia.

Rice. 16.1. Seborrheic keratomas on the face.

Clinical manifestations. Seborrheic keratomas are most often localized on the face, neck, scalp, back and upper chest, less often on the forearms, shins and lower body (Fig. 16.1). Usually their diameter does not exceed 1 cm, rarely reaches 3 cm or more. Rashes of yellow, brown, sometimes black color predominate. Keratomas have an oval shape with a warty surface, rise slightly above the level of the skin, are covered with a thin fatty film, for which they got their name. A characteristic symptom is white, brown or black keratotic plugs (pseudocorneal cysts).

Stages of development. At an early stage, small papules practically do not rise above the skin surface and are often pigmented. Their surface is dotted with multiple small thimble-like depressions. At later stages of development, keratomas transform into warty plaques that rise above the surrounding skin in the form of a nail head.

Pigmented nevi exist for a long time, have a smooth surface and elastic consistency. Flat warts are observed in the

mostly in children and young people, appear suddenly, often in large numbers. Melanoma is rare and usually characterized by rapid growth with induration at the base.

Treatment. With typical clinical signs of seborrheic keratomas and there is no doubt about the diagnosis, you can immediately begin to remove them. In this case, surgical excision, laser destruction, electrosurgery, cryodestruction and other methods are used, the simplest of which is curettage followed by cauterization with a 35% trichloroacetic acid solution or electrodesiccation.

When the number of keratomas is in the hundreds, applications of a 5% solution of fluorouracil or 30 % prospidin solution, and inside appoint aromatic retinoids (isotretinoin or acitretin) at a dose of 20-40 mg / day for 2-4 months.

If there is doubt about the diagnosis (pronounced superficial hyperkeratosis, hyperpigmentation, condition after mechanical trauma), keratomas are subjected to histological examination.

Soft fibromas (papillomas, acro-chords). Perhaps the largest group of patients who seek treatment for skin neoplasms are people who want to get rid of papillomas. The favorite localization of papillomas is the neck, axillary areas and the skin under the mammary glands, less often they are found in other parts of the body. Most papillomas occur in middle-aged patients, often with disorders of the endocrine system.

Clinical manifestations. Papillomas are usually flesh-colored, their size varies from a few millimeters to the size of a pea. Occasionally there are soft large solitary papillomas up to 1-2 cm in diameter (Fig. 16.2). In case of injury or torsion of a thinner base with a feeding vessel, papillary

crowbars become inflamed, undergo thrombosis, as a result of which they acquire a black color.

Papillomas are characterized by slow growth, but during pregnancy they often rapidly increase in size and number.

Filiform warts are located on the fingers of the hands, resembling a skin horn. Seborrheic keratomas are usually larger, dark in color, and have a warty surface. Neurofibromas are quite large, more often localized on the skin of the back, have a hereditary character; single elements are not an indicator of a systemic disease.

Treatment. Papillomas are removed due to their possible trauma and secondary infection, as well as for aesthetic reasons. There are many ways to remove papillomas, the simplest of which is cutting off with scissors. With subsequent coagulation of the bleeding vessel.

cysts. There are several types of cysts: epidermal, hairy (sebaceous) and milia.

Rice. 16.2. Papilloma on the elbow.

Clinical manifestations. The epidermal cyst is localized on the face, auricles, neck, back and scalp (Fig. 16.3). An epidermal cyst arises due to the formation of a closed cavity and its filling with horny masses and skin.

Rice. 16.3. epidermal cyst.

Rice. 16.4. Giant hair cyst.

Rice. 16.5. Milia on the eyelid.

fat. The cyst wall is relatively thin and represents an inverted full-thickness epidermis, which can be easily damaged. In this case, the content of the cyst penetrates the dermis and causes

inflammatory reaction of the type of foreign body granuloma and soreness.

Hairy cysts are more common in women and are multiple smooth, dense, dome-shaped nodules 0.5 to 5 cm in diameter (Fig. 16.4). They are distinguished from epidermal cysts by the structure of the capsule, in which there is no granular layer, and the nature of keratin, which has a homogeneous fat-like consistency, in contrast to the laminar characteristic of epidermal cyst keratin. Damage to the cyst is accompanied by inflammation and severe pain.

Milium is a miniature retention cyst that looks like a yellow-white papule 1-2 mm in diameter containing keratin (Fig. 16.5). Favorite localization milia - eyelids, cheeks and forehead. Milia occur in people of all ages and occur spontaneously or as a result of trauma.

Differential diagnosis. The lipoma has a larger size, dense texture, lobed structure, less clear boundaries. The dermoid cyst superficially resembles the cysts described above and is usually represented by a single element; histological examination of the dermoid cyst reveals hair, remnants of eccrine and sebaceous glands. Mucosal cysts are usually clear, pea-sized or smaller, located on the lips. Synovial cysts are spherical, transparent, pea-sized and localized around the joints on the fingers and toes.

Treatment. The success of therapy depends on the location and number of cysts, as well as on the quality of the operation, since in case of incomplete removal of the capsule, the cyst may recur.

Removal of a separate cyst with a diameter of 1-3 cm is performed by excision with a scalpel, followed by suturing. The operation can be performed in two ways: either by dissecting the skin along the entire diameter of the cyst with far

the most complete removal of its capsule, or a small dissection of the cyst and squeezing out the contents. The latter technique is the simplest to perform and is carried out fairly quickly.

Multiple cysts on the scalp are removed in a different way. First, a cyst incision is made 3-4 mm long, then the contents of the cyst are squeezed out with a curette. The capsule is removed with surgical forceps through the incision.

If during the operation a solid tumor is found instead of a cyst, it is completely excised and sent for histological examination.

Removal of milia is performed by a preliminary puncture with a needle, followed by evacuation of the contents using a comedo extractor. Another removal method is surface electrodesiccation of elements.

Keratoacanthoma is a rapidly growing epithelial tumor with a centrally located massive accumulation of horny masses surrounded by a high ridge. The favorite localization of keratoacanthoma is the face and upper limbs (Fig. 16.6).

Rice. 16.6. Keratoacanthoma.

Clinical manifestations. The tumor resembles squamous cell carcinoma, but unlike it often spontaneously

regresses 6-9 months after the onset. Although this tumor is not usually regarded as a primary malignant neoplasm, the frequency of malignancy of keratoacanthoma, according to some authors, reaches 60%. In this case, the main sign of malignancy is prolonged bleeding of the bottom of the ulcer after rejection of the horny masses and the appearance of a seal at the base of the element.

The most common type of elements is solitary. Less common are atypical keratoacanthoma (giant, mushroom-shaped, centrifugal, multinodular, etc.), constantly appearing throughout the patient's life. They do not have a favorite localization.

There are 3 stages of keratoacanthoma development: growth stage, stabilization stage and regression stage. At the stage of growth, a small papule that suddenly appears acquires a rich red color, its diameter reaches 1–2 cm within several weeks. There are no subjective sensations. During the stabilization of the keratoacanthoma, the growth of the element stops and a crater-like depression is formed, filled with gray horny masses. At the stage of regression, the horny masses are separated and the tumor completely regresses, leaving an inconspicuous atrophic scar.

Treatment usually carried out 2-4 months after the appearance of the neoplasm, when there are no hopes for spontaneous regression. If necessary, excision or curettage is performed, followed by cauterization, cryodestruction, less often, aromatic retinoids are prescribed orally.

16.3. Precancerous tumors of the epidermis

Precancerous neoplasms of the epidermis, which are often encountered by dermatocosmetologists, include

Rice. 16.7. Actinic keratomas on the dorsum of the hand.

Rice. 16.8. Skin horn.

actinic keratomas and leukoplakia; very rarely, radiation dermatitis and xeroderma pigmentosa occur, which we will not talk about. actinic keratomas occur mainly in older people, more often in fair-skinned men who have been in the sun for a long time. UVB radiation is of particular importance for the development of these elements.

(280-320 nm). The danger of actinic keratomas lies primarily in the fact that in 20-25% of cases they can transform into squamous cell carcinoma.

Clinical manifestations. Actinic keratomas are multiple elements up to 1.5 cm in diameter, having the appearance of flat or slightly raised papules above the skin surface. They often coalesce into brown plaques and are covered with hard, keratinized scales. Actinic keratomas are usually located in areas exposed to prolonged sun exposure (face, ears, neck and shoulders) and slowly, over the years, increase along the periphery and into the depth of the epidermis (Fig. 16.7).

The proliferative, hyperkeratotic form of actinic keratomas is the cutaneous horn. It got its name because of its resemblance to the horn of an animal (Fig. 16.8). It should be taken into account that elements in the form of a skin horn can also be a manifestation of seborrheic keratomas, viral warts, squamous cell carcinoma, basalioma and keratoacanthoma.

Usually actinic keratomas persist for years, but spontaneous disappearance of elements is also possible. Sudden growth of keratomas may indicate transformation into squamous cell carcinoma.

Differential diagnosis. Unlike seborrheic keratomas, actinic keratomas occur in areas that have been exposed to insolation for a long time. Since actinic keratomas often transform into squamous cell carcinomas, any suspicious neoplasms that rapidly increase in size should be removed and sent for histological examination. Discoid lupus erythematosus should also be excluded by histological examination.

Treatment. Before proceeding with the removal of actinic keratomas, it is necessary to resolve the issue of histological

com research. In case of compaction or inflammation of the keratoma, a histological examination is mandatory.

Several methods have been developed for removing actinic keratomas.

Surgical methods include cryosurgery and curettage. Cryodestruction is performed with liquid nitrogen for 7-10 s, after which the elements are destroyed and after 7-10 days the formed crust is rejected.

Another way to remove keratomas, especially large and thickened ones, is curettage followed by cauterization of the wound surface with concentrated trichloroacetic acid or electrocautery. Small wounds heal within 7-14 days; dressings are not required.

Numerous hyperkeratotic elements on the shoulders and scalp can also be removed using mechanical dermabrasion.

Chemical methods consist in applying 5-fluorouracil preparations to multiple surface elements (fluoroplex - 1% solution or cream, efudex - 2% solution and 5% cream) 2 times a day for several months. When the keratoma is localized on the face due to the irritating effect of 5-fluorouracil preparations, the course of therapy usually lasts no more than 2 weeks and only on limited areas of the skin 164]. Another method of treatment with 5-fluorouracil is pulse therapy, when the drug is applied 2 times a day for 2-4 days every week for 3-4 months until the complete disappearance of actinic keratomas. An alternative to 5-fluorouracil in the treatment of actinic keratoses is a medium chemical peel with trichloroacetic acid and Jessner's solution (see Chapter 8).

With widespread actinic keratomas, the use of roaccutane 10-20 mg per day for 1-2 months can become an effective conservative treatment.

The skin horn is removed in the same way

similar to actinic keratomas. If a tumor transformation is suspected, removal is performed together with the base of the skin horn, followed by a histological examination.

Leukoplakia- a form of dysplasia of the mucous membranes, develops as a result of smoking, insolation, and also due to chronic diseases of the mucous membranes, such as recurrent actinic cheilitis and presenile or senile atrophy of the vulva.

Clinical manifestations of leukoplasty cues - well-defined flat whitish single or multiple plaques on the mucous membranes of the external genitalia, vagina, lips and oral cavity (Fig. 16.9).

Clinically, the following variants are distinguished: Tappeiner smokers' leukoplakia, flat leukoplakia, verrucous leukoplakia, and erosive leukoplakia.

Rice. 16.9. Leukoplakia in the oral cavity.

Tappeiner's leukoplakia is the most mild. After

the patient quits smoking, the elements most often regress on their own. Flat leukoplakia is a continuous whitish film tightly attached to the underlying tissue. Verrucous leukoplakia is characterized by isolated flat papules with a warty surface. Erosive leukoplakia is regarded as a complication of the flat or verrucous form of the disease, which most often (up to 50% of cases) undergoes malignancy. Other forms of leukoplakia become malignant much less frequently.

Differential diagnosis. Lichen planus on the mucous membranes of the cheeks and the red border of the lips is represented by whitish papules, similar to leukoplakia. The diagnostic difference from leukoplakia is that on the surface of the papules of lichen planus, a characteristic Wickham grid is determined. In addition, elements in lichen planus are localized not only on the mucous membranes, but also on the skin. In this case, papules take the form of shiny polygonal elements with a central umbilical depression and are localized on the flexion surfaces of the wrist joints and forearms, the anterior surfaces of the legs, etc. In difficult cases, it is necessary to take a biopsy for histological examination.

Atrophic sclerotic lichen in the vulva area does not have the compaction at the base characteristic of leukoplakia and can spread beyond the mucous membranes, to the skin of the inguinal and perianal areas; Often patients are worried about severe itching. An accurate diagnosis can often only be made by histological examination.

Treatment. In men who smoke, small plaques of leukoplakia occur mainly on the lower lip. For successful therapy, a complete cessation of smoking is necessary, since even this step can lead to the complete disappearance of leukemia.

coplakia. Any irritating toothpastes and hard toothbrushes should also be avoided and photoprotective lipsticks should be used.

To eliminate small persistent elements, electrosurgical methods are used, less often cryodestruction. In torpid cases, it is possible to prescribe roaccutane 10-20 mg/day for 1-3 months.

16.4. Malignant tumors of the epidermis

Malignant neoplasms of the epidermis in terms of prevalence occupy one of the leading places among all human tumors. Most of them are either basal cell or squamous cell carcinoma, less often malignant melanoma. In many ways, their appearance depends on skin type. Thus, the annual incidence of non-melanoma malignant tumors on the skin of white people in the United States is 230 per 100,000 population, while among African Americans it is only 3 per 100,000 population [33, 70].

Basal cell carcinoma(basalioma, basal cell epithelioma) can occur at any age, but is most often recorded in patients older than 60 years.

Epidemiology. In regions with high solar activity, populated by people with fair skin, basal cell carcinoma accounts for 75% of all malignant skin tumors. Thus, in Western Europe, the frequency of registration of various forms of basalioma (per 100,000 population) is 40-80, in Russia - 20.3 in men and 27.3 in women, in the south of the USA - 300, and in Australia - more than 1600, and over the past 15 years, incidence rates in these countries have doubled. In the USA alone, basaliomas are found annually in more than 500,000 people.

Etiology. There are many hypotheses for the origin of basalioma.

genetic hypothesis. In recent years, using the methods of molecular biology and embryology, the gene for the nevoid banal cell syndrome, located on chromosome 9q22.3, has been found. This gene is similar in many respects to the Drosophila itatch gene. The latter takes part in the segmental development of the insect, controls its growth and regulates its shape. Mutations in this gene were found in a number of patients with basalioma [15, 52]. Among other genetic factors, skin color is important: basalioma develops primarily in patients with fair skin.

UV radiation. It has been established that increased skin insolation can provoke the development of basal cell carcinoma. It is no coincidence that most of the tumor elements are localized in open areas of the body (face, neck, hands).

ionizing radiation. A radiation dose of approximately 10 Gy significantly increases the risk of developing basal cell carcinoma |36]. On average, the latent period can last up to 25 - 35 years, and in some cases, tumors can develop much faster.

carcinogens. Prolonged intake of food or drugs containing inorganic arsenic salts can lead to the development of basalioma and other tumors.

Chronic skin diseases. Basalioma can develop against the background of chronic skin diseases, ulcers that do not heal for a long time, in the area of traumatized scars or in places where the skin comes into contact with the prosthesis. At the same time, these factors often provoke the appearance of squamous cell carcinoma.

Surprisingly, for many years the main cause of the occurrence of basalioma - the most common human tumor - remains a mystery.

that the development of basalioma is due to malignancy of the basal cells of the epidermis. Indeed, upon microscopic examination, tumor cells look small, have a rounded shape, basophilic, resemble basal cells, which in the form of islets, lobules or strands are introduced into the dermis from the epidermis (Fig. 16.10). However, immunohistochemical studies have shown that basalioma develops from pluripotent epidermal cells of either the basal layer or the inner root layer of the hair follicle. The patient must be warned about this.

♦ Excision. Most dermato-oncologists prefer this approach to treatment. In this case, not only the entire tumor is completely excised, but also areas of apparently healthy skin, departing from the edge of the neoplasm by 5 mm, and in the case of a scleroderma-like form - by 1 cm. It is optimal to use microscopic control of the edges of the surgical

logical wound, because due to the jagged irregular contour of the basalioma, it is possible to miss the growth of the tumor in the deep parts of the skin.

Micrographic methods of excision of neoplasms (Mohs microsurgery) lead to positive results in more than 99% of cases. This method is primarily used for recurrent basaliomas, for surgical wounds that must be closed with a flap or graft, for large basaliomas with bone invasion, for basaliomas localized in risk areas, for example, in the nasolabial triangle, in areas of the eyes and ducks, with a sclerosing form of basalioma, when it is difficult to determine the boundaries of the tumor. Mohs microsurgery is hardly necessary when removing single small tumors, since it is a very expensive method.

Cryodestruction. An alternative to surgical excision is deep cryodestruction, especially when the tumor is localized on the eyelids and nose, as well as in superficial basalioma. In the experienced hands of a qualified surgeon, this method is optimal for the treatment of elderly patients. The technique of cryosurgery is described in Chapter 7. Immediately after the procedure, the tumor ulcerates and often bleeds, but as it heals, an acceptable cosmetic result is achieved.

Curettage and electrodesiccation. In case of localization of small (up to 1 cm in diameter) or superficial basaliomas on the trunk or upper limbs, curettage can be applied followed by cauterization or electrodesiccation. The disadvantage of this method is the impossibility of histological control over the edges of the tumor, which makes it unsuitable for the removal of scleroderma-like basalioma. Pro-

The healing process also takes longer and the cosmetic results are worse than with other methods, so it is better not to use electrosurgical methods in areas with a high risk of visible scarring (in the nasolabial triangle, near the eyes and auricles). ).

Radiation therapy. Irradiation of basalioma at a dose of 3-5 Gy 4-5 times a week at a total dose of 50-60 Gy achieves good therapeutic and cosmetic results [15, 36]. Radiation therapy is carried out in fractions, with the capture of the adjacent apparently healthy skin by 0.5-1 cm. The required penetration depth is estimated according to biopsy or ultrasonography data. Radiation therapy is especially effective in patients older than 60 years, when the risk of radiation-induced tumors is minimal or when patients are afraid of surgery. In difficult cases, with large basaliomas, prospidin is additionally prescribed intramuscularly or intravenously, 100 mg daily; for a course of 3.0-3.5 g | 4].

With multiple superficial basaliomas localized on the trunk, applications of 5-fluorouracil are sometimes used, but after that, relapses often occur. A number of studies have also shown the effectiveness of 5-fluorouracil with epinephrine in the form of a gel, as well as interferon a-2b injected into the tumor. The ratio of basaliomas and squamous cell carcinoma varies from 5:1 to 10:1.

Etiology. Squamous cell carcinoma originates from fairly well differentiated epithelial cells. As in the case of basalioma, a number of etiological factors contribute to the development of squamous cell carcinoma:

constant exposure to the sun on the skin;

human papillomavirus (types 16, 18, 31, 33, 35 and 45);

x-ray exposure;

exposure to carcinogens (resins, oils);

treatment with immunosuppressants;

genetic factors (xeroderma pigmentosa).

Clinical manifestations squamous cell carcinoma change according to the degree of malignancy. There are several types of squamous cell carcinoma.

Squamous cell carcinoma with cutaneous horn is a tumor nodule with severe hyperkeratosis at the apex in the form of a cutaneous horn.

Nodular squamous cell carcinoma is a rapidly growing single node, in the center of which an ulcer rapidly develops, and along the periphery - a dense raised ridge with a reddish tinge (Fig. 16.15). This is the most malignant type of squamous cell carcinoma.

Squamous cell carcinoma with exophytic growth often occurs in patients with Bowen's disease as a loose nodule that bleeds easily (Fig. 16.16).

The verrucous form of squamous cell carcinoma clinically resembles a wart and is also often induced by the human papillomavirus.

Etiology. The nevoid cells in melanocytic nevi are of dual origin. First, when migrating into the epidermis from the neural fold during embryonic development, melanocytes do not reach it and remain in the dermis. Secondly, melanocytes can transform into nevoid cells directly in the epidermis. Genetic predisposition, hormonal effects and UV radiation have the most important etiological significance in the appearance of mSlanocytic nevi. The position of the nevoid cells within the dermis determines the type of nevus, which usually ends with involution and fibrosis after several stages of development (Fig. 16.22).

The borderline type of melanocytic nevi is characterized by the accumulation of nevoid cells at the border of the epidermis and dermis in the region of the dermoepidermal junction.

A complex type of melanocytic nevi combines features of borderline and intradermal nevi.

Intradermal type of melanocy-

Nevus cells are characterized by nests of nevoid cells in the dermis, where the nevus continues to grow or goes dormant. As they sink into the dermis, nevoid cells lose their ability to synthesize melanin and the melanocytic nevus loses pigmentation.

Clinical manifestations. Some melanocytic nevi are already present at birth, but most appear during adolescence. At this time, their number reaches a maximum; the appearance of new melanocytic nevi is possible in adulthood, but it is quite rare. In this case, special attention should be paid to nevi that appeared after prolonged insolation or during pregnancy. According to clinical manifestations, melanocytic nevi are subdivided as follows.

♦ Congenital nevi are found in 1% of newborns. They vary in size (from tiny to gigantic), light brown to black in color, and appear as a spot, but often become bulging and covered with hair. The occurrence of congenital nevi is probable.

associated with impaired differentiation of melanoblasts. There are three types of congenital nevi: small (less than 1.5 cm in diameter), large (1.5 to 20 cm) and giant (more than 20 cm). The latter, when localized in the head and neck region, are often combined with damage to the meninges. The risk of developing melanoma depends on the size of the nevus: the larger it is, the greater the likelihood of malignancy. For example, with large and giant congenital nevi, the probability of transformation into melanoma during life (especially in children under the age of 10 years) is 5-15%, with small ones - 0.8-4.9%. The risk of malignancy is also associated with the localization of the congenital nevus: it is highest on the trunk and minimal on the lower and upper extremities.

Compound nevi usually appear as papules or nodules less than 1 cm in diameter, round or dome-shaped, with a smooth surface and dark coloration (Fig. 16.23). Large elements resemble warts or papillomas, protrude significantly above the skin surface and are covered with hair. Complex nevi do not have a favorite localization. Borderline nevi are represented by flat formations ranging in size from 2 to 10 mm, light or dark brown in color, round or oval in shape, with clear, even borders. Deprived of hair, they are located on the trunk, palms, soles and external genitalia and very slowly change size and color. Intradermal nevi are common moles that are found in almost all people, and their number can reach several dozen. Distinctive features of these formations are persistent hyperpigmentation, clear boundaries, soft consistency and the absence of inflammatory

Rice. 16.23. Complex melanocytic nevus.

phenomena. They usually become noticeable between the ages of 10 and 30 and never regress on their own. Over time, intradermal nevi can take on a warty shape, undergo fibrosis, and lose pigmentation.

Rice. 16.24. Nevus Spitz.

♦ Spitz's nevus is a round, firm, reddish-brown nodule most commonly found on the face in children (Fig. 16.24). Characterized by a benign course and rapid

Rice. 16.25. Blue nevus.

Rice. 16.26. Multiple halonevuses on the back.

height. Spitz's nevus is also called benign juvenile melanoma, emphasizing the fact that in some cases, a histological examination shows a picture similar to that of melanoma.

The blue nevus got its name because of the gray-blue hues (Fig. 16.25). The nevus occurs as a separate papule or node of dark blue, gray or black color, has a dense texture with clear boundaries without hair. Blue nevus is most often localized on the face, buttocks, shins, feet, soles. There are several clinical varieties: simple blue nevus, cellular blue nevus, combined blue and non-cellular nevus.

The halonevus (Sutton's nevus) is an element surrounded by a depigmented corolla. Not infrequently, a lot of halonevus can appear at the same time. In children and adolescents, they are located mainly on the trunk (Fig. 16.26). Depigmentation is caused by destruction of nevoid cells by immune cells. Halonevus usually resolve spontaneously. The reason for the development of halonevus is unknown, but, apparently, the mechanism of their development is similar to that of vitiligo.

Becker's nevus, a rare variant of nevi, usually develops in boys as unilateral lesions on the upper back or chest (Fig. 16.27). Initially, they become hyperpigmented, later covered with hair.

Nevus of Ota is also called a dark cyanotic orbitomaxillary nevus. A typical localization of this formation is the face (the area of innervation of the first and second branches of the trigeminal nerve). Nevus of Ota consists of one large or many dark bluish spots merging with each other, located in the area of the cheek, upper jaw, zygomatic arch, with pigmentation spreading to the sclera and the inner surface of the buccal mucosa (Fig. 16.28 ).

The nevus of Ito has a similar histological picture with the nevus of Ota, but is localized along the neck and shoulder.

Dysplastic nevi can be sporadic or hereditary, single or multiple, often larger than 7 mm in diameter, with irregular margins and uneven pigmentation (Fig. 16.29). Dysplastic nevi often occur in adulthood, localizing mainly on the upper half of the trunk and extremities (Fig. 16.30). It is estimated that 2 to 8% of people have one or more dysplastic nevi. In persons with dysplastic nevi, the risk of their transformation into melanoma is sharply increased.

In the USA, it was decided to use the name "atypical nevus" instead of the term "dysplastic nevus".

Patients with dysplastic nevi should avoid prolonged exposure to the sun and be constantly monitored by a dermatologist or oncologist.

Differential diagnosis. Freckles are represented by patchy

Rice. 16.27. Nevus Becker on the shoulder.

brown rashes on areas of the skin exposed to sunlight. Lentigo is manifested by multiple, often merging hyperpigmented spots and occurs in people over 40 years of age. Seborrheic keratomas are densely packed verrucous elements with keratin crusts.

Rice. 16.28. Nevus of Ota.

Rice. 16.29. Dysplastic nevi. ;

Rice. 16.30. Melanoma developed from a dysplastic nevus.

mi. Hemangioma develops from vessels and is sometimes pigmented. Dermatofibroma is usually located on the lower extremities in the form of a knot of dense consistency, often with pigmentation. Pigmented basalioma is often located on the face, has "pearl" blotches, rapidly increases in size, and ulcerates. Melanoma has a different color and contours, quickly increases in size, can become inflamed, ulcerate and bleed.

Epidermal nevi are a malformation of the epidermis and are usually present at birth or develop during infancy. Epidermal nevi, as a rule, increase in parallel with the growth of the patient without any changes and regression. There are several types of epidermal nevi.

♦ A unilateral nevus is characterized by a unilateral lesion in the form of verrucous, often pigmented papules, which, when localized on the extremities, are elongated along their length, and on the trunk they can occupy an entire segment

(FIG. 16.31).

Linear verrucous epidermal nevus, the most common of the group of epidermal nevi, manifests itself as linear limited grouped warty rashes on the surface of the skin.

Nevus ILVEN (English abbreviation, translated as inflammatory linear verrucous epidermal nevus) is characterized by red, scaly and itchy papules arranged in a line. Permanent inflammation is not associated with trauma or infection.

Rice. 16.31. Unilateral epidermal nevus.

Rice. 16.32. Comedonal nevus.

Comedonal nevus is characterized by follicular papules, the central part of which is expanded and contains a horny plug (Fig. 16.32).

Epidermolytic ichthyosis is manifested by generalized, often symmetrical rashes on the trunk and extremities.

Often, the epidermal nevus is so large that it occupies an entire area of the body. After their excision, relapses are often observed.

An epidermal nevus in the area of the scalp is called a nevus of the sebaceous glands (Fig. 16.33). It can also be located on smooth skin, on the face and neck in the form of a yellow plaque with a rough surface, on which there is no hair. The preference for surgical excision (taking into account the size and localization) is due, firstly, to the fact that full-thickness removal guarantees the absence of secondary seborrhea, which can be a complication of incomplete removal of deeply located sebaceous glands when using me- method of dermabrasion, and secondly, a more favorable cosmetic result.

Principles of treatment of nevi. When choosing the tactics of managing patients with nevi, it is convenient to adhere to the classification of nevi proposed by N.N. Trapeznikov et al. . This classification was created taking into account the risk of developing melanoma from nevi.

and predetermines appropriate therapeutic measures, being a good guide for the doctor. According to this classification, two main groups of neoplasms are distinguished: melanomonogenic nevi and some non-nevoid skin formations; melanoma-prone nevi and skin lesions.

Rice. 16.33. Nevus of the sebaceous glands.

Most nevi, especially in children, do not require any intervention. Their excision is indicated if malignancy is suspected, if they cause discomfort and for aesthetic reasons.

In addition, it is desirable to excise the Spitz nevus, since the exact cause of its occurrence still remains unknown. The tactics of treatment of multiple halonus infections depends on the nature of the central nsvus that has appeared for the first time: if it is benign, then the rest do not need to be removed. If malignancy is suspected, all halonevus should be excised. Previously, it was not recommended to remove melanocytic nevi located in places prone to injury as a preventive measure, but now the attitude towards their excision has changed dramatically.

The group of melanoma-prone nevi and skin lesions includes borderline pigment nevus, blue nevus, Ota and Ito nevi, giant congenital nevus, and dysplastic nevus. It has been proven that melanoma-dangerous nevi are much less common than melanoma-dangerous formations. However, if they are present, regular monitoring is necessary, a careful collection of a family history for the presence of dysplastic nevi or melanoma, patients are given recommendations for protection from insolation; elements must be photographed. At the slightest suspicion of malignancy, a biopsy of the nevus and a histological examination of the material should be performed. Taking biopsy specimens of low-risk formations by tangential excision or the curettage method is not recommended. Excisional biopsy is indicated for small (up to 1.5 cm in diameter) formations and when they are located in those parts of the body where the skin reserve makes it easy to tighten the wound, for example, on the trunk. Incisional excision is performed rarely and only in cases where, for anatomical reasons, it is not

complete excisional biopsy is possible.

Therapy for melanomonogenic melanocytic and epidermal nevi should be individualized. Not only the cosmetic effect, but also, ultimately, the result of therapy depends on the chosen treatment tactics. For this purpose, surgical, electrosurgical methods, laser therapy, cryodestruction and dermabrasion are used. In surgical treatment, the optimal excision margin is a distance from the nevus of 0.2–0.3 cm on the trunk and 0.1–0.2 cm on the fingers, face, and neck 115,281.

In case of epidermal nevi, in addition to excision, injections of corticosteroids directly into the elements are sometimes used or 5-fluorouracil I is applied externally! combined with tretinoin.

The only correct approach to the treatment of melanoma-dangerous nevi is their excision along with the surrounding skin and subcutaneous tissue. When nevi are localized on the trunk and extremities (except fingers), the incision is made by stepping back from the edge of the nevus in all directions by 0.5-1.0 cm. The location of the elements on the fingers, auricle, face allows limiting this distance to 0.2 -0.3 cm. Histological examination of the removed nevus is obligatory.

With nevi of Ito and Ota, patients should be under dispensary observation (examination every 3 ms). Surgery is usually not indicated.

The optimal approach to a giant congenital melanocytic nevus is to remove it. It is usually performed in the first 2 weeks of a child's life using curettage or dermabrasion, or a series of resections or excisions followed by wound closure with a 115| skin flap.

When deciding whether to remove a congenital nevus of small or medium size, you should first discuss it with the patient or with

Rice. 16.34. capillary hemangioma.

Connective tissue nevi are rare, appear as smooth multiple papules or flesh-colored plaques. With the predominance of collagen, connective tissue nevi have a flesh color, in the case of a predominance of elastin, they become yellowish. An example of connective tissue nevi can be nevi in the form of cobblestones ("shagreen" spots) in tuberous sclerosis.

16.8. Vascular nevi

Vascular nevi include hemangiomas characterized by proliferation of endothelial cells in vessels, as well as vascular malformations without proliferation of endothelial cells (for example, in various forms of flaming nevus).

Hemangiomas. IN Depending on the depth of location, clinical manifestations and localization, the following types of hemangiomas are distinguished: superficial, cavernous, mixed (there are signs of both superficial and cavernous hemangioma), arachnid, in the form of port-wine stains, , capillary, in the form of venous "lakes" and angiokeratoma.

Superficial hemangiomas. IN this group includes capillary (strawberry nevi), arachnid and senile hemangiomas.

Capillary hemangioma (strawberry nevus) is a node or plaque of red or dark red color of soft consistency, localized most often on the head and neck. The size of a capillary hemangioma varies from 1 to 10 cm. It appears during the first year of life as a red, flat, pinhead-sized nodule that grows rapidly (Fig. 16.34). The girls get sick

Rice. 16.35. Capillary-cavernous hemangioma.

3 times more often than boys. Complete resolution of the elements in 50% of children occurs by the age of 5, and by the age of 12 they disappear in 97% of children.

In the case of an increase in size and spread to the subcutaneous tissue, a cavernous type of hemangioma, or giant hemangioma, is formed (Fig. 16.35).

Spider hemangioma (stellate hemangioma) consists of a small superficial central arterio-

Rice. 16.36. Spider hemangiomas.

ly the size of a match head with even smaller vessels extending radially from it - "spider legs". Most often, spider-like hemangiomas are localized on the face and trunk (Fig. 16.36). Sometimes they can be observed in large numbers in pregnant women or in patients with chronic liver diseases. Capillary senile hemangiomas occur in young people, as well as in mature and elderly people (Fig. 16.37). They are also called cherry hemangiomas, as they are bright red flat or raised papules with a diameter of 2-3 mm or more. Capillary hemangiomas are localized on

Rice. 16.37. Capillary senile hemangiomas.

trunk and do not disturb patients, except when they are injured and bleed.

Cavernous and mixed hemangio- We. Deep hemangioma is also called cavernous. Cavernous hemangioma is a malformation of the venous and lymphatic vessels of the skin, subcutaneous tissue and looks like a tumor-like formation of a soft spongy consistency. Mixed hemangiomas are formed as a result of changes in superficial and deep vessels.

Neck hemangioma is a red vascular formation located on the back of the neck below the edge of the scalp. It does not disappear with age and is practically not amenable to modern methods of therapy. Since the posterior surface of the neck is also a characteristic localization of neurodermatitis, it should be taken into account that the erythema remaining after its treatment may be a symptom of a neck hemangioma that has existed for many years and was not noticed by the patient.

Venous hemangioma (varicose varicose veins) - a soft formation of dark blue or purple color, flat or slightly raised above the level of the skin, localized on the face, lips, auricles. It is more common in people over 50 years of age and practically does not bother patients (Fig. 16.38). Weak pulsation of the venous hemangioma on the lower lip distinguishes it from the convoluted segment of the anterior labial artery.

Angiokeratoma are dark red, keratinized, pinhead-sized papules that resemble warts and come in three types. Mibelli's angiokeratoma occurs on the dorsum of the fingers And stop, as well as on the knees of girls; Fabry's angiokeratoma affects the lower half of the torso of men (Fig. 16.39, a); Fordyce angiokeratoma, the most common form of angiokeratoma,

Rice. 16.38.

located on the scrotum (16.39, b). Mibelli and Fordyce angiokeratomas are not treated.

Fabry angiokeratoma (diffuse angiokeratoma) is a skin manifestation of a systemic disorder of phospholipids, in which they accumulate both in the skin and in the internal organs. Patients usually die before reaching the age of 50 due to the deposition of phospholipids in the blood vessels, heart and kidneys.

Flaming nevus (port wine stain) detected in 0.3% of children at birth. This malformation of the vessels of the dermis has the appearance of reddish spots of various sizes, often localized on the cheeks, forehead, upper eyelids, limbs, and often disfiguring these areas (Fig. 16.40). The color of the nevus intensifies when the child cries. The flaming nevus increases in proportion to the growth of the body, never disappears on its own and acquires a darker color with age with the appearance of papules and nodes on the surface of the spot. If the nevus is located above the eyelid, it may communicate with the underlying underlying hemangioma in the meningeal space, which can sometimes lead to epileptic seizures, for example, in the Sturge-Weber-Crabbe syndrome. There are four clinical forms of flaming nevus:

the nevus of Unna is localized in the back of the head, eyelids and above the bridge of the nose;

Sturge-Weber-Crabbe syndrome includes a nevus, localized along the branches of the trigeminal nerve, with malformations of the vessels of the eyes and meninges;

Klippel-Trenaunay syndrome includes a nevus with malformations

Rice. 16.39. Angiokeratoma.

a - Fabry type; b - Fordyce type.

Rice. 16.40. Flaming nevus.

vessels of soft tissues and bones in the form of hypertrophy of one limb;

Cobb's syndrome includes a flaming nevus with malformations of the vessels of the spinal cord, which leads to neurological disorders.

Differential diagnosis. Venous asterisks are small cyanotic telangiectatic formations localized on the legs and face, less often on other parts of the body. If desired, they can be removed by the same methods as spider hemangiomas.

Hereditary hemorrhagic telangiectasias (Osler-Rendu disease) are located on any part of the body or internal organs in the form of small red vascular spots or papules with a tendency to bleeding. This disease is characterized by a triad of symptoms: numerous elements on the fingers and palms, on the red border of the lips, mucous membranes of the mouth and nasal passages; gastrointestinal and nosebleeds; burdened family history.

Treatment hemangiomas, especially superficial ones, are the subject of numerous discussions. Color, size, depth, localization of hemangiomas and associated aesthetic problems are factors that must be considered in each specific case of the disease. Alertness in hemangiomas, especially large ones, is due to two reasons. Firstly, the very presence of a hemangioma on the skin worries parents, especially if it is located in open areas. Secondly, if the hemangioma is localized near the eye, nose, mouth, neck, external genital organs and in the anus, then it can cause dysfunction of these organs.

Some dermatosurgeons believe that all types of superficial and cavernous hemangiomas should be removed, others believe that they should be left alone and wait for spontaneous involution. The latter are based on the data of a number of authors who showed that by the end of the first year of life, the growth of most hemangiomas stops, about 85% of hemangiomas disappear without leaving noticeable scars by the age of 7 years. Other arguments in favor of refusing therapy are that the hemangiomas remaining in the child after 5-7 years may look better than the scars left after excision of the hemangioma, as well as the high cost of treatment. In this case, camouflage cosmetics can be recommended (see Chapter 4).

Nevertheless, early treatment of small, superficial or cavernous hemigiomas has the following advantages. First, they can be eliminated completely or almost completely. Secondly, there is no evidence yet that the therapy provoked an increase in hemangiomas. Thirdly, the treatment performed reduces the fear of parents and relatives regarding the course of hemangiomas. After a competently performed operation, there are no noticeable scars, in any case, they look no worse than if the hemapgioma remained intact.

In case of cavernous or mixed hemangioma, different methods of treatment are used: surgical excision, ligation of the central vessel supplying the hemangioma, broad-spectrum antibiotics, administration of corticosteroids into the lesion. Oral corticosteroids are considered the treatment of choice for complicated hemangiomas. If hormonal therapy is ineffective, high doses of drugs based on ingerferon are used.<х-2Ь.

With a flaming nevus, pulsed liquid dye or copper vapor lasers with a wavelength of 585 nm are most effective. This energy is selectively absorbed by oxyhemoglobin molecules, which leads to the destruction of capillaries with minimal damage to surrounding tissues. The best results are achieved in early childhood. Recently, the use of selective pulsed phototherapy has become an alternative to laser therapy. The essence of the method lies in the use of pulsed broadband irradiation in the wavelength range from 515 x 1200 nm. The wavelength, energy, duration of pulses and the interval between them are selected individually. Other treatments for flaming nevus include high-dose oral or intralesional corticosteroids, surgical excision, interferon injections, em-

arterial bolization and laser therapy. Melanoma affects people of all skin colors, but most often Caucasians living in countries close to the equator.

Melanoma is a disease mainly of mature people (average age is about 45 years) and people with fair skin. Wu lit! in the age group from 20 to 60 years, superficially spreading and

Etiology melanoma has not yet been established. Nevertheless, among the main risk factors, the association between intense sun exposure, sunburn, as well as a large number of atypical melanocytic nevi and the occurrence of melanoma attracts attention |9, 12, 59, 701. Other risk factors shown in fig. 16.41.

In addition, any of the following changes in nevi or other pigmented lesions can also be a precursor to their transformation into melanoma [9, 70]:

asymmetry (asymmetry) of the shape and distribution of the pigment;

edges (borders) become irregular or jagged and often bleed (bleed);

melanoma can have a different color: in addition to the typical brown, its surface can become

Rice. 16.41. The main risk factors for the development of melanoma. Explanation I! text.

shades of blue, grey, pink, red or white. With any change (change), the formation must be examined again; the diameter (diameter) of most melanomas exceeds 6 mm, but the small size of the formation does not exclude the possibility of a malignant nature. Thus, the signs of the development of melanoma by the initial letters of English words are (Asymmetry, Borders, Bleed, Change, Diameter).

Clinical manifestations of melanoma.

There are four main clinical variants of melanoma.

♦ Superficial spreading melanoma accounts for approximately 39-75% of all melanomas of the skin and has two phases of development: horizontal and vertical. Superficially spreading melanoma is a flat or raised patch that may develop from an already existing nevus and grow slowly over several years (Fig. 16.42). The tumor has clear contours and a dense consistency. In the future, rapidly growing nodules or hypopigmented areas may appear on the surface of the neoplasm. The most common localization of superficial melanoma is the back. Often, in men, tumors are also observed on the skin of the head, neck, chest, abdomen, and in women - in the thighs and legs. Mortality in this form of melanoma reaches 31 %.

Nodular melanoma occurs in 15-30% of skin melanoma cases, mainly in men, and is often localized in the trunk region. The development of the nodular form begins immediately with a phase of vertical growth, so it is called deep penetrating melanoma (as opposed to superficially spreading). Clinically, this form of melanoma presents as a dark blue or black pedunculated nodule or polyp, often ulcerative and bleeding (Fig. 16.43). Mortality in nodular melanoma reaches 56%.

Lentiginous malignant melanoma. Malignant lentigo, existing for a long time, can transform into lentiginous malignant melanoma (Fig. 16.44). This variant of melanoma occurs in 10-13% of patients. Lentiginous melanoma often affects the skin of the face in older people who have been exposed to insolation for many years. It is characterized by two stages of development - a horizontal one lasting 10, 20 or more years and a vertical one, at which invasion into the dermis occurs.

Clinically, lentiginous melanoma is a flat spot with blurred edges of a loose consistency of brown or black color.

The tumor is characterized by slow growth, however, in the vertical growth phase, rapidly growing nodes form on the surface and, at the same time, rapid metastasis occurs. Mortality in lentiginous melanoma reaches 10%.

♦ Acral lentiginous melanoma accounts for approximately 10% of all melanomas. The favorite sites for acral melanoma are the palms, soles, and nail beds (Fig. 16.45). In the latter case, pigmentation of the proximal part of the nail is observed - a symptom of Hat-

Rice. 16.42. Superficial spreading melanoma.

Rice. 16.43. nodular melanoma.

chinson, characteristic of melanoma. This form is often diagnosed late and therefore has a poor prognosis.

Rice. 16.44. Malignant lentigo with irregular contours and pigmentation.

Rice. 16.45. Acral lentiginous malignant melanoma.

The course of most forms of melanoma usually has two stages (Fig. 16.46) - horizontal and vertical. The horizontal stage is characterized by the proliferation of malignant melanocytes within the epidermis. Later, malignant cells penetrate the dermis, and the process passes into the stage of vertical growth.

Local invasion by tumor

cells are assessed using the Breslow method, based on measuring the distance (in millimeters) between the granular layer of the epidermis and the most deeply located identified melanoma cell.

Another method for assessing melanoma invasion is the Clark grade classification.

Because melanoma tends to recur, all areas of the skin should be carefully examined, including the scalp, palms, soles, and perineum. If there are suspicious lesions on the skin, similar to recurrent melanoma, atypical nevus and/or subcutaneous metastases, a biopsy is necessary. If the lymph nodes are enlarged, they are biopsied either by excision or aspiration with a thin needle with further histological or cytological examination.

The minimum scope of studies of patients with melanoma also includes chest x-ray (if necessary, computed tomography is performed to assess the presence of possible tumor nodes) and determination of the level of liver enzymes in the blood. Abdominal/pelvic computed tomography may be required if a mass is found in the abdominal cavity or symptoms of metastatic lesions of internal organs are present.

Differential diagnosis. The clinical diagnosis of melanoma is sufficient

Rice. 16.46. Stages of the chalk noma. The thickness of the skin layers according to the Breslow method. 1 - subcutaneous fat layer; 2 - dermis; 3 - epidermis.

but difficult for a doctor of any specialty. Erroneous diagnoses are 10-20%. Therefore, we indicate neoplasms on the skin that resemble melanoma:

Melanocytic neoplasms: melanocytic nevus, especially dysplastic and recurrent; nevus Spitz; blue nevus.

Vascular neoplasms: angiokeratoma; thrombosed or injured hemangioma; pyogenic granuloma; venous hemangiomas; Kaposi's sarcoma; glomus tumor.

Epithelial neoplasms: pigmented basalioma; seborrheic keratomas, especially inflamed ones; common warts with hemorrhages, pigmented hydrocystoma; pigmented actinic keratomas; pigmented tumors of the skin appendages.

Other neoplasms: dermatofibroma.

The complexity of diagnosis lies not only in the clinical, but also in the histological similarity of the tumor with

other lesions, eg, dysplastic nevus, Spitz nevus, combined nevus, recurrent nevus, halonevus, partially regressed melanocytic nevus, acral nevus, genital juvenile nevus, congenital nevus, deep penetrating nevus, old lanocytic nevus, injured melanocytic nevus, melanocytic proliferation in the epidermis.

Forecast in melanoma depends on the thickness and depth of penetration of the tumor. It can be good (with a tumor thickness of less than 1.5 mm), doubtful (1.5-3.5 mm) and bad (more than 3.5 mm). Below are the indicators of 5-year survival of patients depending on the depth of penetration of melanoma .

Rice. 16.47. Flattened, superficially spreading melanoma with a good prognosis.

Rice. 16.48. Thick, proliferating nodular melanoma with a poor prognosis.

Except In addition, the so-called prognostic index is used to assess the prognosis, which reveals the ratio of the mitotic index to the tumor thickness and reflects the likelihood of the risk of melanoma metastases of medium thickness. When evaluating the mito-

tic index counts the number of mitoses per 1 mm2.

There are also other prognostic factors, the most important of which are as follows.

tumor thickness. Breslow tumor thickness assessment is the most important prognostic factor, but requires the participation of highly qualified histologists. It should be noted that melanoma, which is localized only in the epidermis, metastases are not typical. Examples of flattened and thickened tumors are shown in Figs. 16.47 and 16.48.

Floor. Men have a worse prognosis than women.

Tumor localization. In melanomas located on the back, shoulders, neck and scalp, the prognosis is worse than in other localizations.

melanoma type. In nodular and acral melanomas, the prognosis is worse than in superficially spreading and lentiginous melanomas, even in cases where tumors have the same thickness.

Ulcer formation. Some oncologists regard melanoma ulceration as an unfavorable prognostic factor.

Treatment. The main method of treatment is the complete excision of melanoma only in the conditions of an oncological hospital, therefore, without considering the details of the operation, we note only the general points of therapy.

When removing melanoma with a thickness of 1 mm or less, not only the tumor itself is excised, but And apparently healthy tissue, retreating 1 cm from the tumor. With a tumor thickness of more than 1 mm, excision is performed with a capture of 2-3 cm from the edge of the tumor, in case of relapse or with a long-term melanoma - 5 cm (Fig. 16.49). The localization of the tumor is also of great importance. Melanoma on the face

it is possible to excise in such a volume as it is done on the body.

If the lymph nodes are involved in the tumor process, then their excision can stop the development of metastasis, but will not lead to an increase in the patient's life expectancy. Prophylactic excision of local lymph nodes is performed in some oncology centers in the treatment of intermediate or thick tumors, but the results obtained are rather contradictory.

In the case of excision of melanoma with a high degree of malignancy without metastases, various schemes of chemotherapy and immunotherapy are used. The rationale for immunotherapy is that melanoma is an immunogenic tumor and has a higher chance of spontaneous remission than other tumors. The appearance of T-cell infiltrates may indicate melanoma regression. In addition, the appearance of vitiligo in patients with melanoma is a good prognostic sign indicating the beginning of the development of an immune response to melanocytes, including malignant ones. A number of techniques have been proposed that force immune cells to fight malignant melanocytes. For example, it has been shown that nonspecific immunostimulation with BCG or Corinebacterium parvum vaccines leads to some regression of the tumor process. However, in general, this technique does not increase the life expectancy of patients and does not lead to a prolongation of the remission of the disease.

Another method is the combination of radiation therapy or surgical excision with local microwave hyperthermia. Although this method reduces the frequency of relapses, it does not increase survival.

Very high doses of recombinant IFN-ce-2b preparations in patients with severe melanoma increase the 5-year survival rates from 37 to 46%. Interferon

Rice. 16.49. Borders of excision of a melanoma.

used intravenously daily for 4 weeks at the rate of 20 million IU per 1 m 2 of the skin surface, and then subcutaneously 3 times a week for a year at the rate of 10 million IU per 1 m 2. The disadvantages of this technique are the high cost and the possibility of systemic toxic effects. Another modification of immunotherapy, the treatment with activated lymphocytes (lymphokine-activated T-lymphocytes infiltrate the tumor), is under study.

In case of detection of metastases, intensive radiation therapy, polychemotherapy, regional perfusion chemotherapy, immunotherapy, hyperthermia are carried out.

It should be noted that today none of the methods and schemes of cytostatic therapy can completely cure the disease, but is exclusively palliative. Nevertheless, in a number of cases, excision of isolated metastases in internal organs in combination

with polychemotherapy can lead to a decrease in relapses.

The most predictable feature of melanoma is its unpredictability. Despite even seemingly successful therapy, it should be borne in mind that melanoma can recur even after 8 and 10 years. Therefore, patients operated on for melanoma should regularly visit an oncologist in order not to miss a recurrence of the disease. M. Wood and P. Bani. In the terminal stages, polychemotherapy is prescribed, i.e. several cytostatics from different groups at once.

TESTS

1. Indicate the age category of patients for which hemangiomas are typical:

a) children b) adults

b) teenagers; d) old people.

2. Indicate the age category of patients, which is characterized by the occurrence of basal cell and squamous cell carcinoma:

a) children b) adults

b) teenagers; d) old people.

3. Flat pigmented tumors do not include:

a) lentigo;

b) soft fibromas;

c) superficially spreading type of melanoma;

d) histiocytoma;

e) keratoacanthoma.

4. Of the listed removal methods for multiple large seborrheic keratomas on the face, it is preferable to use:

a) electrocoagulation;

b) cauterization of ferezolsm;

c) cryodestruction;

d) applications of 5% fluorouracil;

e) laser destruction.

5. A 50-year-old patient has a tumor-like formation in the dorsum of the nose: a red tumor with a diameter of 1 cm rising above the skin surface with a crater-like depression in the center filled with gray horny masses. The edges of the tumor are dense, even, without telangiectasias. Itching and pain are absent. A year ago, a similar element appeared on the cheek, but regressed on its own, leaving a small atrophic scar. Specify the presumptive diagnosis:

a) basalioma;

b) epidermal cyst;

c) nodular melanoma;

d) keratoacanthoma;

e) seborrheic keratoma.

6. Distinguish the following clinical

forms of basal cell carcinoma. except:

a) nodal;

b) nodular;

c) superficial;

d) scleroderma-like;

e) ulcerative.

7. Of the listed neoplasms of the epidermis, precancerous ones include:

a) erosive leukoplakia;

b) epidermal cyst;

c) nodular melanoma;

d) actinic keratomas;

e) seborrheic keratomas.

8. Malignancy is more often exposed to:

a) leukoplakia of Pap-Payner smokers;

b) flat leukoplakia;

c) verrucous leukoplakia;

d) erosive leukoplakia;

e) listed above.

9. Indicate the localization most typical for basalioma:

a) shins;

b) torso;

d) the scalp.

10. Of the listed forms of basalioma, it is more often transformed into squamous cell carcinoma:

a) nodal; d) metatypical:

b) ulcerative; e) cystic.

c) pigment;

11. Of the listed methods of treatment of the nodular form of basalioma, the highest efficiency is:

a) systemic intake of cytostatics;

b) radiation therapy;

c) microscopically controlled surgery;

d) curettage;

e) cryodestruction.

12. Of the listed types of squamous cell carcinoma, the greatest malignancy and metastasis is characterized by:

a) nodal;

b) skin horn;

c) squamous cell carcinoma with exophytic growth;

d) verrucous;

e) all of the above.

13. In patients aged 70 years with a large squamous cell tumor, lo-

calcified in the area of the upper eyelid, it is preferable to use:

a) surgical excision;

b) cryodestruction;

i) polychemotherapy;

d) radiation therapy;

e) curettage.

14. A 40-year-old patient has a neoplasm in the shin area that appeared more than 2 years ago, which is often injured during shaving of hair: a slightly raised brownish knot 5 mm in diameter; when the knot is squeezed with fingers, it is slightly pulled inward. Specify the probable diagnosis:

a) epidermal cyst;

b) melanocytic nevus;

c) keratoma;

d) keratoacanthoma;

e) dermatofibroma.

15. Melanocytic nevi do not include:

a) nevus Spitz;

b) halonevus;

c) nevus ILVEN;

d) nevus of Ito;

e) comedonic nevus.

16. Of the listed melanocytic nevi, the highest risk of transformation into melanoma has:

a) intradermal nevus;

b) Becker's nevus;

c) halonevus;

d) dysplastic nevus;

e) nevus Igo.

17. In a 47-year-old patient, a "mole" in the area of the right shoulder, which has existed for more than 30 years, after a long rest at the sea, began to grow rapidly, itch and bleed. The element slightly rises above the skin surface, 1.5 cm in diameter, irregularly shaped, black in the center and yellow-brown along the periphery; small hemorrhagic crusts along the border of the element. Specify the presumptive diagnosis:

a) nevus Spitz;

b) dermatofibroma;

c) superficial spreading melanoma;

d) superficial hemangioma;

e) psoriatic plaque.

18. Indicate the predominant localization of the pathological process of CTCL:

a) the stratum corneum of the epidermis;

b) the basal layer of the epidermis;

c) epidermis and papillary dermis;

d) reticular layer of the dermis and hypodermis;

e) lymph nodes.

19. Immunopathological reactions in patients with CTCL are mainly carried out by:

a) B- and T-lymphocytes;

b) B-lymphocytes, Langerhans cells, melanocytes;

c) T-lymphocytes, Langerhans cells, epitheliocytes;

d) fibroblasts, epitheliocytes, T-lymphocytes;

e) plasma cells, epitheliocytes, B-lymphocytes.

20. Indicate the cells whose predominant proliferation in the skin is observed in CTCL:

a) T-helper lymphocytes;

b) T-killer lymphocytes;

c) B-lymphocytes;

d) Langsgans cells;

e) T-suppressor lymphocytes.

Right answers. 1a; 2g; 36; 4c,d; 5g;66; 7a, d; 8g; 9g; South; Pv; 12a; 13g; 14d; 15c,d; 16g; 17c; 18c; 19c; 20a.

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Tutorial

Sergei Nikolaevich Akhtyamov, Yuri Sergeevich Butov

PRACTICAL DERMATO-COSMETOLOGY

Head editorial T.P. Osokina Editor L. V. Pokrasina Artistic editor S.L. Andreev Technical editor N.A. Birkina Corrector L.P. Kolokoltseva

LR No. 010215 dated 04/29/97. Handed over to the set 06/25/2003. Signed for publication on 11.08.2003. Paper format 70xl00"/i6. Office paper No. I. Typeface Time. Offset printing. Printing convention 32.50. Red print convention 95.55. Circulation 5000 copies Order No. 7590ik-.ii

State Enterprise of the Order of the Red Banner of Labor, publishing house "Medicine". 101990, Moscow, Petroverigsky per., 6/8.

Printed from the original layout at the Federal State Unitary Enterprise Smolensk Printing Plant of the Ministry of the Russian Federation for Press, Television and Radio Broadcasting and Mass Communications. 214020, Smolensk, st. Smolyaninova, 1.

The largest organ of the human body - the skin is prone to the appearance of all kinds of neoplasms. Among them may be habitual moles, nevi, benign formations or dangerous oncological tumors.

Any change in the skin carries a potential threat - under certain circumstances, neoplasia may degenerate into. Therefore, seeking the advice of a specialist will be the right response to the transformation of existing formations or the emergence of new ones.

Classification of skin tumors

Neoplasia that occurs on the skin surface is divided into:

benign neoplasia,
precancerous tumors.

benign

Formations that have slow growth, do not invade other tissues and do not allow metastasis, are defined as benign. They are not dangerous to human life, but they can become so.

Neoplasia should be in the field of attention of the patient himself, and if they begin to grow, change color, or other new characteristics of their vital activity are observed, you should immediately see a doctor.

Benign formations include:

.
The nodule appears on the skin, more often in those areas that are open. The tumor originates in the connective tissue. Mosquito bites or injury to a skin area can serve as a provocation. The nodes are pigmented and usually do not progress in development.
.
A slight elevation on the skin that has a bumpy surface. The color of the tumor is brownish or black. They are also called senile warts because they often appear in older people.
The formation occurs due to a violation of the localization of the cells of the basal layer. Appear on the scalp, scalp and in areas that are hidden by clothing.
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The tumor often occurs on the hands and face. A node appears, increases within a month, can reach three centimeters in diameter.
Keratoacanthoma looks like a plaque with a depression in the center filled with keratinized cells. Education itself is able to resolve itself in about a year after the appearance.
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Education can be of any shape, similar to a wart. The surface of the neoplasia is uneven, villous, without hair. May have horny masses that are easily removed.
Papilloma consists of cells of the epidermis. The color of the formation is brownish or grayish. Differ in slow growth.
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The formation consists of melanocytes or nevus cells. Appearance - pigment spots of black or brownish color. Flat papules can appear anywhere on the skin.
These neoplasias are dangerous by degeneration into melanomas. The nevi localized on the genitals, palms and soles are most disposed to such a transformation.
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The tumor is born from lipocytes - cells of adipose tissue. Skin on neoplasia of unchanged color. The texture is soft to the touch.
It can grow up to ten centimeters in size. Lipoma can be as a single or multiple tumor-like formation under the skin.
- refers to vascular tumors.
Neoplasm occurs in the vessels of the lymphatic or circulatory system. These are difficult cases for early diagnosis. Because neoplasia duplicates the structure of the vessel and is not very noticeable at first.
Such neoplasms can occur in the internal organs, and on the skin they settle on its surface or in the fatty layer. The tumor is dangerous because its presence in the vessel impairs its functioning and thus affects overall health.
Often angiomas appear on the face. They look like spots of pinkish, red or bluish color with a flat or bumpy surface.
Distinguish:
- venous cavernous angioma,
- mixed angioma,
- arteriovenous angioma.

Precancerous

Formations that are on the verge of degenerating into malignant tumors are called precancerous neoplasia.

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The tumor occurs in the genital area, on the palms, head. At the initial stage, it looks like a brownish spot, then it degenerates into a flat formation, in which the surface is flaky.
The tumor is five centimeters in diameter. This phenomenon occurs with skin dermatitis, violations of the integrity of the cover, old cysts, from the influence of radiation, carcinogens and ultraviolet radiation.
The disease is dangerously malignant, so it must be treated in a timely manner. If the surface of the tumor is covered with ulcers, the degeneration of Bowen's disease into a form of cancer has already occurred.
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Most often the disease manifests itself in the elderly and fair-skinned people. In exposed areas of the skin under the action of ultraviolet radiation, the degeneration of keratinocytes occurs.
As a result, rashes appear. They may take different forms:
- warty,
- hypertrophic,
- erythematous,
- pigment.
Actinic keratosis can develop into squamous cell carcinoma over time.

Malignant

Cancerous tumors on the skin are aggressive in nature. Neoplasias often grow rapidly in size, grow into nearby tissues, and may metastasize.

The most common types of malignant tumors:

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A plaque that has clear edges of a reddish color with an uneven surface may be squamous cell carcinoma. Over time, an impression appears in the center of the formation, which is first covered with scales, and later a wound forms in this place.
Like other types of cancer, squamous cell carcinoma can grow into other tissues. Actinic keratosis may be a precursor to the disease. Under the influence of ultraviolet radiation, aggressive chemical environments, conditions are created for the appearance of skin cancer.
.
Among the varieties of malignant tumors of the skin is considered the most dangerous. Therefore, one must be attentive to the condition of moles on the body, because under adverse conditions they can turn into melanoma.
There is especially a warning for people whose moles are in places where they can be injured:
- in the crotch
- on the scalp.
Avoid direct sunlight on the skin for a long time.

Photo of melanoma, a malignant tumor of the skin

.
A formation on the skin with a depression in the center, in which the wound is located, bears signs of basal cell carcinoma. In the tumor, blood vessels and a bleeding point are usually visible.
Basalioma is a type of squamous cell carcinoma. Localization of neoplasia in areas of the skin that are usually not covered by clothing. It is provoked by contact with the skin of carcinogens, ultraviolet radiation, and thermal exposure.
.
Cancer is located in the connective tissues. It can protrude above the surface of the skin or be hidden, then it will be visually indeterminate.
If neoplasia stands out on the skin, then the color of the formation is dark brown-blue.
The tumor may be:
- low-grade fibrosarcoma - more dangerous for its consequences,
- differentiated fibrosarcoma - increases in size more slowly, does not form metastasis.
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The transformation of fat cells into cancer cells. The tumor can reach a relatively large size. It looks like a round shape.
It is characterized by an increase in its size at a slow pace. Metastases do not always release. It occurs more often in older people.
.
Reborn angioma into a malignant formation. The disease occurs in immunocompromised people infected with HIV.
Characterized by the appearance of spots, painted purple or lilac. Formations arise on them, which tend to unite with each other. Over time, ulcers appear on their surface.
An aggressive form of cancer. Often fatal.

Diagnostic procedures

If neoplasms appear on the skin, especially if they change, you should consult a specialist for advice. An experienced doctor by external signs will be able to suggest a diagnosis.

At the dawn of human history, epidemics of infectious diseases were the most significant problem. Over the past two centuries, medicine has made significant progress in the treatment of these diseases with the help of vaccinations and antibiotics. In the twenty-first century, diseases of the heart and blood vessels have come to the fore. Only injuries, poisoning and oncological pathologies can compete with them. Tumors can affect any organ, tissue, and even the smallest part of the body - the cell. A wide variety is noted among skin tumors. This organ can equally become a source of both malignant and benign neoplasms. And each has a number of unique features.

Causes of the variety of skin tumors

Skin is a unique tool given to a person to protect against adverse environmental conditions. Life on the planet has always been dangerous due to visible - the sun, wind, temperature changes - and invisible reasons. The latter are microbes. However, the skin is ideal for protecting against microorganisms as well. The integumentary tissue of a person daily plays an important role in the life of any organism:

protects deeper organs from the influence of the external environment;
acts as a barrier to pathogens;
maintains the internal temperature of the body;
carries information about the environment.

The skin is designed in such a way as to provide the body with reliable protection and the ability to cognize the world around us through touch. This is achieved by having three layers of skin. The topmost layer - the epidermis - is constantly updated. It consists of special cells - keratinocytes. They have a special life path - from the cell of the deepest basal layer to the dead horny scale on the surface of the epidermis. Melanocytes are scattered among the keratinocytes of the epidermis. It is thanks to these cells that the skin acquires a tan under the rays of the sun. Melanocytes are so named for the production of the pigment melanin.

Human skin is made up of three layers

Deeper than the epidermis lies a layer of special intertwined fibers - the dermis. In this layer, there are also nerve endings - Vatter-Pacini bodies, thanks to which a person has a sense of touch. In addition, many vessels pass through the dermis, from which the skin receives nutrition. This is where the hair follicles originate. Each follicle has its own muscle, which is made up of smooth muscle cells. The dermis contains lymphatic vessels, which play an important role in metabolism, as well as two types of glands - sebaceous and sweat.

The skin contains many small formations - glands and nerve endings.

The deepest layer is the hypodermis. It consists of identical cells - adipocytes. Each of them contains fat. The subcutaneous fat layer is a good shock absorber against any external mechanical influences. In addition, a large number of vessels in this layer helps to maintain a constant internal body temperature.

Skin tumors are neoplasms from various elements of the epidermis, dermis and subcutaneous fat. They can be benign, borderline, or malignant. Tumors of the skin are extremely diverse. They are found in both adults and children.

Features of the structure and functioning of the skin - video

Features of malignant and benign neoplasms

All tumors are formed according to a single principle. The reason is the breakdown of genes that are present in every cell and contain all the information about its life path from birth. Altered genes cause skin cells to develop in a vicious way. First, one tumor cell is formed, which then gives rise to others. Each contains the wrong set of genes.

Cancer is formed from genetically modified cells

Benign cells have a number of characteristic features. First, they are outwardly identical to normal ones. Secondly, they are subject to the influence of the immune system and other body signals. Thirdly, they grow very slowly and do not tend to spread to other organs.

Malignant tumors of the skin - the opposite of the previous case. They are greatly changed in appearance, grow very quickly, deprive the body of nutrients. In addition, the tumor is not the only and often not the worst problem. Malignant cells spread through the blood and lymphatic vessels. Each tumor cell can give rise to a focus of secondary growth - metastasis.

Malignant tumors tend to spread through the blood and lymphatic vessels

Benign skin tumors

Benign skin tumors are a common pathology. Most people are familiar with them firsthand. They can arise from any part of the skin. The lifespan of some is limited, others accompany a person for years and decades. Each type of tumor has all the signs of good quality - a characteristic appearance, slow growth and the absence of metastases.

Symptoms and signs of benign neoplasms on the skin - table

Type of benign skin tumor	Time of onset of the disease	Commonly affected sex
	Aged people	Any gender	skin on the face; body skin.	warty formation; the tumor has a broad base or stalk.	Epidermis
seborrheic wart	aged people; boys and girls; children.	Any gender	face; scalp; limbs; covered areas of the skin.	brown spot; the stain is covered with greasy crusts;	Epidermis
Senile keratoma	Aged people	Any gender	face; upper limbs.	dense hearth, covered with gray crusts; round tumor.	Epidermis
	All age groups	Any gender	Exposed areas of the skin	Cone shaped tumor	Epidermis
	mature people; aged people.	Men	head; face; exposed areas of the skin.	rounded outlines; the tumor rises above the skin; a single focus of a grayish-pink color; in the center is a funnel with horny scales.	Epidermis
Gottron's carcinoid papillomatosis	mature people; aged people.	Men	Symmetrical lesions on the lower extremities	the tumor rises above the skin; the tumor is covered with pink outgrowths; thick foul-smelling discharge between outgrowths.	Epidermis
Trichoepithelioma	mature people	Women	skin on the face; wings of the nose; cheeks;	dense outgrowth of pink color; small vessels on the surface of the tumor.	hair follicle
	boys and girls; mature people; aged people.	Women	skin on the face; scalp skin.	grouped small formations; horny scales in the center of the tumor.	hair follicle
	Boys and girls	Women	skin on the face; scalp.	rounded dense tumor; the tumor rises above the surface of the skin.	hair follicle
eccrine poroma	mature people; aged people.	Women	perineal skin	soft education; rounded spherical shape; the tumor rises above the skin.	sweat gland
Papillary syringocystadenoma	children; boys and girls.	Any gender	scalp; inguinal areas; armpit.	the tumor rises above the skin; pink color; uneven surface with outgrowths.	sweat gland
	All age groups	Women	skin around the eyes; rib cage; lateral surfaces of the body.	many nodular formations; round shape; dense brown formations.	sweat gland
Eccrine spiradenoma	Boys and girls	Men	skin on the face; anterior surface of the body.	dense tumor; the tumor rises above the skin; soreness when touched.	sweat gland
Fibroma	All age groups	Any gender	Any area of the skin	dense tumor; pink color; limited mobility.	Connective tissue
Dermatofibroma	mature people	Women	skin of the upper limbs; skin of the lower extremities.	rounded outlines of the tumor; very limited mobility; swelling inside the skin; dark brown tumor.	Connective tissue
	Neonatal period	Any gender	The entire skin	red spots; the tumor rises above the skin.	Blood vessels
Lymphangioma	Neonatal period	Any gender	the entire skin; often associated with hemangioma.	dense spot; the spot is covered with transparent bubbles.	Lymphatic vessels
Leiomyoma	All age groups	Any gender	body skin; limbs.	rounded tumors of the color of normal skin; dense texture of the tumor.	smooth muscle cells

Benign neoplasms - photo gallery

Syringoma is often localized on the face Hemangioma - a benign tumor from the vessels Skin horn often occurs in old age Seborrheic keratoma is covered with fatty crusts Keratoacanthoma rises above the surface of the skin Follicular keratoma develops from cells of the hair follicle Cylinder develops from cells of the epidermis, dermis, skin glands Papilloma - a common skin tumor

Borderline skin tumors

Borderline tumors can also form from any component of the skin - the epidermis, dermis, sebaceous and sweat glands, hair follicles. At the first stage, they behave like benign neoplasms. However, they are not without reason identified by scientists in a separate group. These types of tumors are characterized by a transition to a malignant form with the formation of metastases. That is why they are called precancerous neoplasms.

Symptoms and signs of precancerous skin tumors - table

Type of precancerous neoplasm of the skin	Time of onset of the disease	Commonly affected sex	Favorite places of occurrence of foci of the disease	Features of the appearance of the neoplasm	Cells-source of neoplasm
	All age groups	Any gender	Exposed areas of the skin exposed to ultraviolet radiation	multiple warts; multiple spots with scales.	Epidermis
Bowenoid papulosis	boys and girls; mature people.	Any gender	Crotch	Single or multiple brown outgrowths	Epidermis
	boys and girls; mature people.	Men	Crotch	Multiple pointed outgrowths with horny scales	Epidermis
	All age groups	Any gender	Exposed areas of the body exposed to ultraviolet radiation	foci of thinning of the skin; dark spots.	Epidermis
solar keratosis	mature people	Men	skin on the face; scalp; dorsal surface of the hands; red border of lips.	Multiple outgrowths covered with horny scales	Epidermis
Radiation dermatitis	All age groups	Any gender	The entire surface of the skin	multiple outgrowths with horny scales; crusty ulcers.	Epidermis
	Aged people	Any gender	skin of the body; skin of the upper limbs; crotch.	single or multiple foci; the centers are covered with bloody crusts.	Epidermis
Erythroplasia of Queira	mature people	Men	Perineum and genitals	bright red color of the tumor; velvety surface.	Epidermis
	mature people; aged people.	Any gender	crotch; groin area; armpits.	itchy lesions; uneven outlines; the centers are covered with stratifications of crusts.	Epidermis
	Aged people	Any gender	skin on the face; scalp; neck skin.	a tumor of irregular or rounded outlines; the tumor rises above the surface of the skin; an ulcer may be located in the center of the tumor; the tumor focus may be pigmented.	sweat gland; sebaceous gland; hair follicle.

Borderline skin tumors - photo gallery

Giant condyloma - the result of the influence of human papillomavirus Verruciform epidermodysplasia affects exposed areas of the skin Bowen's disease occurs more often in the elderly Paget's disease often occurs in women Xeroderma pigmentosa - a precancerous skin condition

Malignant tumors of the skin

Any component of the skin can become a source of a malignant neoplasm. These tumors also arise from the transformation of precancerous lesions. Skin cancer has all the signs of malignancy: rapid growth, the ability to penetrate into neighboring structures. In addition, these tumors metastasize to lymph nodes and distant organs. The three most common forms are squamous cell carcinoma, Dubreu's melanosis, and malignant melanoma.

Melanoma - video

An interesting fact: among all malignant tumors of the human body, melanoma is the most aggressive growth and rapid formation of metastases. This malignant formation develops from pigment cells of the skin - melanocytes.

Symptoms and signs of malignant skin tumors - table

Type of malignant neoplasm	Time of onset of the disease	Commonly affected sex	Favorite places of occurrence of foci of the disease	Features of the appearance of the neoplasm	Cells-source of neoplasm
	Aged people	Any gender	open areas of the skin; underlip; crotch.	hearth with horny scales and an ulcer in the center; focus with warty growths.	Epidermis
	mature people; aged people.	Women	skin on the face; neck skin; dorsal surface of the hands.	pigmented focus with uneven outlines; uniform brown coloring of various shades.	Epidermis
malignant melanoma	mature people	Any gender	lower limbs; torso.	hearth with uneven outlines; the tumor is dense; color from brown to black; uneven edges of the tumor; the center is covered with crusts.	Epidermis
	All age groups	Any gender	skin of the upper body; rib cage.	single tumor; smooth or bumpy surface; bluish coloration.	Connective tissue

Malignant tumors of the skin - photo gallery

Squamous cell carcinoma is the most common skin cancer
Dubrey's melanosis is a malignant disease Melanoma is the most malignant tumor Dermatofibrosarcoma is a malignant tumor of the connective tissue

Diagnosis of skin tumors

Correctly establishing the diagnosis of a skin tumor is the task of an experienced dermatologist. The main advantage of malignant neoplasms of this kind is their location on the surface. That is why skin tumors can be recognized at an early stage. For this purpose, the following research methods are used:

Differential diagnosis is carried out with other skin diseases:

Treatment Methods

The treatment method for a specific skin tumor is chosen by a dermatologist. In the case of a benign neoplasm, it will be enough to get rid of the tumor focus itself. Currently, medicine offers a number of virtually painless ways to get rid of a skin tumor:

At one time, the author of these lines had to deal with a benign skin tumor - papilloma. This focus was localized on the back of the foot. At the initial stage, it was dense and resembled a corn. Then growths appeared at this place, at first glance deep into the thickness of the skin, similar in appearance to cauliflower inflorescences. The tumor was painful and all the time experienced friction from any shoe - street, home, work. It was possible to cope with it with the help of liquid nitrogen. In place of the former papilloma, after its falling off, there was not a trace left.

Precancerous skin tumors also need to be removed using one of the listed methods. This event is vital, since a high frequency of the transition of such diseases to malignant ones has been proven. With cancerous tumors, the situation is somewhat different. In this case, the removal of the primary focus on the skin does not always radically solve the problem. Usually, treatment tactics depend on the specific type of tumor and the degree of its spread (the presence of metastases in the nearest lymph nodes and distant organs). To combat the primary focus and metastases, a complex of therapeutic measures is usually used: surgery, X-ray irradiation and chemotherapy.

Surgery for a malignant tumor requires removing, if possible, all malignant cells from the body. To this end, the surgeon excised the neoplasm itself on the skin, adjacent tissues, and nearby lymph nodes (lymph node dissection). Removal of tumor metastases may require a separate operation. X-ray irradiation is one of the effective ways to fight cancer. The radiation beam is directed directly at the tumor. However, adjacent tissues will also be negatively affected by x-rays. They become thinner, change color, inflammation develops (radiation dermatitis). Another way to fight cancer and metastasis is to prescribe chemotherapy drugs that kill malignant cells (Azathioprine, Cisplatin, Cyclophosphamide). These drugs have negative side effects. First of all, against the background of treatment, digestive disorders begin, the composition of the blood changes, and the work of the immune system is significantly inhibited.

Chemo drugs negatively affect the cells of the intestinal villi

Treatment of skin tumors in children and pregnant women is carried out under the supervision of a dermatologist. The choice of treatment method is carried out by the doctor. Removal of the tumor by any agent is acceptable in all categories of patients. The dose of X-ray exposure and chemotherapy for children is calculated individually depending on age. In the treatment of pregnant women, radiation and chemotherapy are not used due to the negative impact on the developing fetus.

Prevention

Prevention of skin tumors is an important aspect of human life. Each person needs to follow a number of recommendations:

Skin tumors have a unique feature. They have a high chance of being recognized at an early stage. A timely appeal to a specialist will allow you to correctly establish the diagnosis and the very nature of the neoplasm. Medicine offers a wide range of modern and virtually painless methods to fix the problem. Using one of them, you can permanently get rid of the disease.

Definition. Skin neoplasms are a heterogeneous group of diseases, consisting of skin tumors, nevi, secondary metastatic tumors, and specific hemodermas.

Tumors are foci of pathological tissue proliferation that continues after the cessation of the action of the etiological factors that caused it. According to the prognosis, tumors are divided into benign, malignant And pre-cancer (precancerous). By origin, tumors can be primary, i.e., arise from the skin's own tissues (skin tumors) and secondary, developing as a result of metastasis of malignant cells of oncology into it.

hygienic diseases of internal organs (secondary metastatic tumors) or proliferation in the skin of pathological cells of malignant diseases of the hematopoietic system (specific haemoderma or skin leukemia).

Benign skin tumors should be distinguished from non-woos(malformations of the skin). The latter are benign formations (both congenital and manifested in different periods of life), which consist of normal cells and structures pathologically coordinated with each other ("tissue deformity"). In some cases, there are mixed neoplasms that have signs of both benign skin tumors and nevi.

Tumors of the skin and malformations of its development are divided into epithelial (derived from the epidermis and appendages of the skin), mesenchymal (developing from connective tissue, adipose tissue, blood vessels) and neuroectodermal (arising from nerves). Pigmented nevi It is customary to call malformations of the skin originating from nevus cells(melanocytes).

Etiology and pathogenesis skin neoplasms have not been studied enough. It is believed that their causes may be hereditary predisposition, ultraviolet, radiation or X-ray radiation, viral infection, chronic skin trauma and exposure to carcinogenic substances, insect bites, metastasis of oncological diseases, and long-term non-healing skin ulcers. In most cases, the etiology of neoplasms is not established. In the pathogenesis of skin tumors, the weakening of the immune function of the skin to monitor tumor cells, caused by immunosuppressive therapy of concomitant diseases, as well as other etiological factors, also plays a role.

Diagnostics neoplasms is based on clinical data, refined by the results of mandatory histological studies.

28.1. BENIGN NEOPLASMS

seborrheic wart

Definition. Seborrheic wart (senile wart, basal cell papilloma) is a benign neoplasm associated with a violation of the differentiation of the basal cells of the epidermis, which is clearly a

a circumscribed raised papule or plaque with a bumpy surface.

Clinical picture usually begins to develop in elderly and senile age. More often there is a lesion of closed areas of the body, face and scalp. Senile warts have the appearance of papules and plaques of a round or oval shape, yellow-brown, sometimes almost black in color, clearly demarcated, rising above the surface of the skin and with a slightly flattened warty surface (resembling a lump of chewing gum glued to a hard surface). The tumor diameter is 0.5-4 cm. Spontaneous resolution of the elements is possible.

Differential Diagnosis carried out with dermatofibroma, pigmented nevi and melanoma.

Treatment. Surgical excision, laser therapy, electrocoagulation, X-ray therapy, cryotherapy are carried out.

Pigmented nevi

Definition. Pigmented nevi (see color incl., Fig. 34) - a group of benign neoplasms (malformations) developing from cells of the melanogenic system - melanocytes, which are otherwise called nevus cells.

Clinical picture pigmented nevi is diverse. All of them are united by the characteristic color of the rashes (from yellow-brown to black), due to the different concentrations of melanin content. Most often they look like pigment spots of various sizes and smooth flat papules, but they can look like giant plaques with a papillomatous surface. Some pigmented nevi are densely covered with hair.

Some pigmented nevi are melanoma-dangerous, i.e., under appropriate conditions, they can transform into melanoma. The most pronounced ability to malignancy have borderline pigmented nevi, whose melanocytes are located in the zone of the basement membrane of the epidermis. Clinically, they are black or dark gray spots (papules) with a flat, smooth surface, devoid of vellus hair. They can be localized on any part of the skin, but the most melanoma-hazardous are located on the palms, soles and genitals. The beginning malignancy of the pigmented nevus is evidenced by the following

signs for diagnosis malignant lentigo:

1) an increase in the diameter of the nevus, especially with uneven growth of its borders;

2) strengthening or weakening of pigmentation;

3) the formation of pigment spots around the nevus or the appearance of dense papules - "satellites" on its surface;

4) compaction of the nevus or the appearance of infiltration and hyperemia around it;

5) the appearance of pain or itching;

6) an increase in regional lymph nodes.

Differential Diagnosis pigmented nevi is carried out with a senile wart, melanoma and dermatofibroma.

Treatment. In the presence of a melanoma-dangerous nevus or malignant lentigo, surgical excision of the entire neoplasm with surrounding healthy skin and subcutaneous fatty tissue is performed.

Dermatofibroma

Definition. Dermatofibroma (fibroma) is a benign mesenchymal tumor of the connective tissue, which is a hemispherical papule or nodule.

clinical picture. The tumor often occurs in the lower extremities and open areas of the body (in places subject to trauma and insect bites). Fibromas are dense, hemispherical, highly pigmented nodules or nodes protruding above the skin surface, 0.5-3 cm in size. Rashes appear at any age and do not tend to progress. The number of elements from single to multiple.

Differential Diagnosis performed with seborrheic warts, pigmented nevi and melanoma.

Treatment. Surgical excision, laser therapy, cryotherapy are necessary.

Angiomas

Definition. Angiomas are benign neoplasms consisting of altered vessel walls of various types (blood and lymphatic capillaries, venules, arteries, veins).

Clinical picture capillary hemangioma characterized by vascular spots of various sizes, with uneven borders, pink-red or cherry color, turning pale during diascopy. The surface of the spots is flat, even, sometimes slightly elevated. Favorite localization - face.

stellate hemangioma is a miliary red papule, from which vascular branches radiate. It is localized more often on the face - in the area of the nose and cheeks.

Cavernous hemangioma has the appearance of a soft node, from 1 to 5 cm, with a bumpy surface, sometimes falling down on palpation. The color of the formation varies and depends on the depth of its occurrence in the skin. Superficial hemangioma is bluish-red, deep - with a bluish tinge.

Differential Diagnosis performed with Kaposi's sarcoma and other vascular tumors.

Treatment. Surgical excision, radiotherapy, laser therapy, cryotherapy, diathermocoagulation are necessary.

Lipoma

Definition. Lipoma is a benign tumor of adipose tissue originating from fat cells - lipocytes.

clinical picture. The tumor is a soft, often lobular nodule ranging in size from a few to tens of centimeters, often protruding above the surface of the skin. The color of the skin over the lipoma is not changed. Tumors can be either single or multiple.

Differential Diagnosis performed with atheroma, dermatofibroma, secondary metastatic tumors.

Treatment- surgical excision.

28.2. MALIGNANT TUMORS OF THE SKIN

Basalioma

Definition. Basalioma (basal cell epithelioma, see color incl., fig. 35) is the most common malignant epithelial tumor that develops from atypical basal cells of the epidermis and follicular epithelium. It is characterized by extremely slow growth, accompanied by inflammatory infiltration and destruction of the surrounding tissue, as well as the absence of a tendency to metastasize.

clinical picture. It occurs mainly in elderly and senile people. The most common localization is the face, scalp. It is characterized by extremely slow growth, slightly increasing in size over the years. Basal cell epithelioma does not metastasize. It is characterized only by peripheral growth, which destroys the tissues involved. Because of these features, basalioma is called a tumor with locally destructive growth. And in view of the possibility under certain conditions (for example, due to inadequate radiation therapy) of its transformation into a metatypical cancer, some authors refer this tumor to precancroses.

Basalioma begins with the appearance of a dense single flat or hemispherical papule with a diameter of 2-5 mm, slightly pinkish or normal skin color. There are no subjective sensations. The papule grows slowly and within a few years reaches 1-2 cm. At the same time, its central part breaks up and becomes covered with a bloody crust, which, when rejected, reveals easily bleeding erosion or a superficial ulcer. Along its periphery, there is a narrow roller, solid or consisting of individual miliary papules of a slightly pinkish color. Sometimes its color can be pearlescent or dark brown. The resulting ulcer, increasing in size, simultaneously scars in the central part.

Depending on the nature of growth, the basalioma can turn into a large (10 cm or more) flat plaque with a scaly surface; in a mushroom-shaped node significantly protruding above the surface of the skin; into a deep ulcer that destroys underlying tissues, including bones (ulcus rodens, ulcus terebrans).

Differential Diagnosis performed with seborrheic wart, Bowen's disease, actinic keratosis, melanoma, various nevi.

Treatment: surgical excision, radiotherapy, laser therapy, cryotherapy.

Squamous cell carcinoma

Definition. Squamous cell carcinoma (spinocellular epithelioma, squamous cell carcinoma) is a malignant epithelial neoplasm of proliferating atypical keratinocytes that begins in the epidermis and turns into an invasive metastatic tumor.

clinical picture. The disease is 10 times less common than basalioma, in men 2 times more often than in women. The development of the neoplastic process is most susceptible to white-skinned patients living in hot sunny countries (Central America, Australia, etc.). Squamous cell carcinoma can begin on any part of the skin and mucous membranes, most often at the points of their transition into each other (lips, genitals). Initially, a small infiltrate appears, with a slightly elevated hyperkeratotic surface of gray or yellow-brown color. Subjective sensations in the initial period are absent. The size of the tumor, starting from a few millimeters, gradually increases to 1 cm, after which a dense node is already determined, which quickly reaches the size of a walnut. Depending on the direction of growth, the tumor can either protrude above the surface of the skin, or grow into the depths of the tissues, undergoing decay with the formation of an ulcer. The ulcerative-infiltrating variant of the growth of spinocellular epithelioma leads to the destruction of not only the skin, but also the underlying tissues (muscles, bones), and also tends to rapidly metastasize, first to the regional lymph nodes, and then to other organs. The resulting ulcer has extremely dense, slightly raised and everted edges; its bottom is covered with blood crusts and grayish masses, bleeds easily, and sometimes shows white grains ("horn pearls"). There is no tendency for the ulcer to heal, local excruciating pains appear, and then general exhaustion and secondary infectious complications develop.

Differential Diagnosis performed with Bowen's disease, basalioma, actinic keratosis and vulgar warts.

Treatment. They resort to surgical excision of the entire tumor surrounding the skin, subcutaneous adipose tissue, and, if necessary, regional lymph nodes and other tissues involved. X-ray therapy, laser therapy, cryotherapy, drug treatment with cytostatic agents are also used.

Melanoma

Definition. Melanoma (malignant melanoma) is the most malignant skin tumor that develops from melanoma cells (malignant melanocytes) and tends to metastasize rapidly.

clinical picture. Melanoma is much less common than basalioma and squamous cell carcinoma, predominantly in Caucasians exposed to excessive insolation, usually after puberty. The tumor can occur anywhere on the skin, including the nail bed. (melanotic felon, acrolentiginous melanoma), either primary (on unchanged skin) or secondary (in 30% of cases) as a result of malignancy of the pigment nevus, for example, due to its chronic traumatization. In the latter case, the nevus begins to grow exophytically and change its pigmentation (see "Pigmented nevi"). Melanoma is an easily bleeding papule or a flat, slightly raised, dome-shaped or bumpy nodule with a uniform dark brown or black with a bluish tint. Sometimes certain areas of the tumor may be devoid of color, and in rare cases, melanoma does not contain melanin at all. (amelanotic melanoma). Due to early lymphogenous metastasis, first dense pigmented hemispherical papules appear near the primary node, and subsequently multiple pigmented and depigmented papules and nodes scattered throughout the body. Metastases also appear in the internal organs, and, as a rule, earlier than the decay of the primary tumor begins.

Diagnostics. A biopsy of melanoma is strictly contraindicated, so the diagnosis is established on the basis of a characteristic clinical picture, after which the patient with suspected melanoma is sent to an oncology dispensary for specialized diagnosis and treatment.

Differential Diagnosis performed with pigmented nevi, seborrheic wart and dermatofibroma.

Treatment. It is necessary to surgically excise the entire tumor with the surrounding skin, subcutaneous fat, and regional lymph nodes. Polychemotherapy is prescribed to prevent recurrence of the disease.

Kaposi's sarcoma

Definition. Kaposi's sarcoma (Kaposi's disease) is a malignant immune-dependent disease caused by multifocal proliferation in the skin and internal organs of hemo- and lymphocapillary endotheliocytes, as well as perivascular connective tissue cells.

Etiology and pathogenesis. Etiology of multifactorial disease. The involvement of an oncogenic virus (HHV8), local trauma, and genetic predisposition is assumed. The pathological process often develops in immunocompromised patients (old age, previous immunosuppressive therapy, HIV infection) and patients with endocrine diseases.

clinical picture. There are the following clinical forms of Kaposi's sarcoma:

1) classical (sporadic, idiopathic); 2) immunosuppressive; 3) endemic; 4) epidemic (associated with HIV infection).

Clinical manifestations classical Kaposi's sarcomas are characterized by an initial symmetrical skin lesion, usually of the lower extremities, and sometimes of the hands and forearms. More often men of advanced and senile age (after 60 years) suffer. Eruptions are slightly edematous red-brown or bluish-purple spots and papules, which gradually turn into flat infiltrated plaques and painful nodes, against which telangiectasias often shine through. Fresh nodes develop along the edges of the primary foci, merge with them, forming larger bumpy tumor infiltrates of varying degrees of density. Separate elements resolve spontaneously, leaving pigmented, slightly atrophic spots.

The disease has a chronic course and lasts for years, for a long time limited to the defeat of the same parts of the body (feet, shins, hands). The foci eventually become hemorrhagic with an ocher-yellow purplish color, they bleed after a slight injury, as well as ulceration. Ultimately, a pronounced swelling of the surrounding tissues develops around the nodes, causing elephantiasis of the limbs. Rashes disseminate, lymph nodes increase, the skin of the trunk, genitals, face, mucous membranes of the nose and oral cavity, internal organs (gastrointestinal tract, kidneys, liver, lungs) are affected.

immunosuppressive the form of the disease develops in patients who use immunosuppressants for a long time (for organ transplantation, autoimmune diseases, malignant lymphomas, etc.) and clinically resembles the classical form. Withdrawal of immunosuppressive therapy often leads to recovery.

endemic Kaposi's sarcoma has been observed in HHV8 and HIV endemic geographical areas of Equatorial Africa (especially Uganda) in indigenous people. It occurs in young patients (25-40 years old), mostly men, as well as children of both sexes. Clinically proceeds in three variants.

In the first variant, the manifestations of the disease correspond to the clinical picture of the idiopathic form of the disease.

In the second variant of the disease, the process develops in the form of a localized aggressive Kaposi's sarcoma, characterized by the appearance of rapidly increasing, with a tendency to invasive penetration into the subcutaneous adipose tissue, muscles and bones, infiltrated vegetative tumors.

The third, most severe variant of this form of Kaposi's sarcoma is characterized by diffuse lesions of the lymph nodes (sometimes without skin manifestations), frequent ulceration of skin lesions, widespread involvement of visceral organs, and rapid (within 1 year) death.

epidemic Kaposi's sarcoma is one of the clinical diagnostic signs of AIDS, as it occurs in HIV-infected patients (in any period of infection). It usually develops in men aged 25-30 years (more often homosexuals and drug addicts). It is characterized by a pronounced disseminated nature of a large number of rashes that can appear on any part of the body (face, ears, neck, chest, abdomen, palms, soles). Despite unusual localization and a significant number of eruptive elements, skin lesions are clinically consistent with classic Kaposi's sarcoma.

Differential Diagnosis performed with hemangiomas and lichen planus.

Treatment.General therapy includes course use of cytostatic therapy (prospidin 100-200 mg per day, for a course of 3-4 g at intervals between courses of 3-4 months), interferon preparations, and in severe cases - polychemotherapy.

Physiotherapy. Radiation therapy of large nodular elements is used.

Outdoor therapy. Symptomatic therapy (disinfectant ointments) is carried out on ulcerating foci.

Skin lymphomas

Definition. Lymphomas are an extensive group of malignant diseases caused by neoplastic proliferation of cells of the immune system (lymphocytes, their precursors and derivatives).

Lymphoid tissue is widespread in the body and forms lymphoid organs - central (bone marrow, thymus) and peripheral (spleen, lymph nodes, lymphoid tissue of the gastrointestinal tract, broncho-pulmonary lymphoid tissue and skin). Each of these organs can be a source of lymphoma, which begins with the proliferation of malignant lymphoid cells in it. Traditionally, Hodgkin's disease (lymphogranulomatosis) and non-Hodgkin's lymphomas are distinguished. The latter can be nodal (derived from the lymph nodes) and extranodal (arising from any other lymphoid organ, including the skin). Skin lymphomas rank second in frequency of involvement after gastrointestinal tract lymphomas. There are primary skin lymphomas that develop primarily in the skin, and secondary skin lesions in lymphomas of other localizations.

Primary skin lymphomas (see color inc., fig. 36) are tumors of the immune system characterized by the proliferation of T- or B-lymphocytes that have a specific tropism for the skin. In 1975, a unified concept of T-cell lymphomas was proposed, and in 1988, the First International Symposium on Skin Lymphomas officially recognized the existence of primary B-cell skin lymphomas. Among all primary skin lymphomas, 60-65% are T-cell lymphomas, 20-25% are B-cell lymphomas, and 10% are rare forms (NK-cell or indeterminate lines).

The new WHO-EORTC classification (2005) is currently in use for cutaneous lymphomas, based on the WHO classification for lymphoid and hematopoietic neoplasias and the European Organization for Research and Treatment of Cancer (EORTC) classification of skin lymphomas.

According to this classification, T- and NK-cell lymphomas are distinguished, as well as B-cell lymphomas. T- and NK-cell lymphomas include the following: mycosis fungoides and its variants (folliculotropic, pagetoid reticulosis, granulomatous flaccid skin syndrome); Cesari's syndrome; T-cell-

adult leukemia/lymphoma; primary cutaneous CD30+ lymphoproliferative diseases (primary cutaneous anaplastic large cell lymphoma, lymphomatoid papulosis); subcutaneous panniculitis-like T-cell lymphoma; extranodal NK/T cell lymphoma; primary cutaneous peripheral T-cell lymphoma, unspecified (primary cutaneous aggressive epidermotropic CD8+ T-cell lymphoma, cutaneousγ/δ T-cell lymphoma, primary cutaneous CD4+ pleomorphic small-to-medium cell T-cell lymphoma).

B-cell lymphomas include primary cutaneous B-cell marginal zone lymphoma; primary cutaneous lymphoma from the cells of the follicular center; primary cutaneous diffuse large B-cell lymphoma, lower extremity type.

There are also hematological neoplasias from progenitor cells - CD4+/CD56+ hemato-cutaneous neoplasia (blast NK-cell lymphoma).

Clinical picture skin lymphomas is very diverse and depends on the type of proliferating tumor cells (morphological analogues of lymphocytes, lymphoblasts, plasmocytes, plasmablasts, centrocytes, centroblasts or immunoblasts) and the stage of development of the disease, since pathological changes increase over time due to the developing more and more pronounced malignancy neoplastic cells, gradually aggravating the clinical course of the disease.

Cutaneous T-cell lymphomas

Fungal mycosis. Aliber first described this disease in 1806, calling it mycosis fungoides due to the fact that tumor-like elements resembled large mushrooms. Ba-zen in 1876 identified three stages during dermatosis: spotted (erythematous), plaque and tumor. Fungal mycosis usually affects older people. The disease begins with spots that gradually infiltrate, turning into plaques. In the erythematous stage, the disease is manifested by various and uncharacteristic erythema, urticaria-like, psoriasis- and parapsoriasis-like, eczema-like rashes. In some cases, clearly defined erythematosquamous elements appear in sizes from 2-3 cm to 10-15 cm or more. The number of rashes varies from a few to many. They are accompanied by intense itching,

sometimes intolerable. The first manifestations of the disease may spontaneously disappear and reappear after a few months. After repeated alternation of partial remissions and relapses, the spotted stage gradually passes into the second - plaque stage.

It is characterized by the formation of infiltrated plaques of various sizes, yellowish-red or bluish in color, with a lichenified surface. In the area of plaques, and on the scalp and beyond, hair often falls out. Nail plates are deformed, become brittle. The average duration of the spotted and plaque stages is 3-5 years. In some cases, the plaque stage can last for decades.

The third stage of the disease is manifested by tumor-like nodes that can form both in the area of existing plaques and on previously unaffected skin. Localization and number of tumors can be very different. They have a size from plum to orange, a wide or, conversely, narrowed base, soft or doughy texture. Having reached a certain size, they are eroded or deeply ulcerated.

Peripheral lymph nodes in the first stage of the disease are usually not enlarged, in the second stage they often increase, in the third - as a rule. In the tumor stage, dissemination of the process to the internal organs, lymph nodes, bone marrow, and blood is possible.

Currently, the following variants of mycosis fungoides are distinguished: 1) folliculotropic with or without follicular mucinosis(clinically manifested by follicular papules, plaques, tumors caused by perifollicular infiltrates from neoplastic lymphocytes); 2) pagetoid reticulosis(psoriasiform rashes, localized mainly on the distal extremities);

3) granulomatous flaccid skin syndrome(in large folds, infiltrated, devoid of elasticity, folded formations are determined).

The subtypes of mycosis fungoides include the following: bullous, ichthyosiform, hypopigmented, poikilodermic, etc. For more than one hundred and twenty years, decapitated fungal mycosis has been isolated, in which the tumor stage develops immediately, bypassing the spotted and plaque. Currently

in connection with the advent of new research methods, it has been proved that this form of lymphoma does not belong to mycosis fungoides.

Cesari syndrome characterized by erythroderma, enlargement of peripheral lymph nodes, the presence of Cesari cells, which make up more than 5% of all lymphocytes, and in absolute numbers - more than 1000 / mm 3. In addition, itching, palmar-plantar hyperkeratosis, alopecia, onychodystrophy are noted.

Primary dermal CD30+ lymphoproliferative diseases

Lymphomatoid papulosis. In 1968 Macaulay introduced the term lymphomatoid papulosis to refer to a disease that lasted for years, sometimes decades, and was characterized by spontaneously resolving papular elements. Attention was drawn to the fact that in a benign clinical course, histopathological data indicated a malignant neoplastic process. Lymphomatoid papulosis usually begins at age 35-45 with reddish spots that gradually turn into papules that have a smooth surface, may peel or crust. Purpura, necrosis can join the above elements. Elements leave on resolution hypopigmented or hyperpigmented spots, in rare cases - atrophic scars. The predominant localization of lesions is the trunk, proximal limbs; less often involved in the process of the palm, soles, face, scalp.

Primary cutaneous anaplastic large cell lymphoma ranks second in frequency among T-cell lymphomas of the skin. It can occur at any age, although most often in 60-70 years.

The disease manifests itself as single or grouped nodes, often ulcerating, less often - papules localized on the limbs or trunk. Spontaneous remissions are possible.

Subcutaneous panniculitis-like T-cell lymphoma characterized by infiltration of the subcutaneous tissue with neoplastic cells, which is histologically manifested by lobular panniculitis, which determines the clinic of lymphoma. The disease is characterized by solitary or multiple subcutaneous nodules, which in some cases gradually ulcerate. They are localized mainly on the lower extremities. Lesions can be either single or generalized.

This lymphoma proceeds benignly, extracutaneous dissemination is observed in 20% of cases.

Extranodal NK/T-cell lymphoma, nasal type. Adult men get sick more often. The disease is characterized by multiple plaques and tumors mainly on the trunk and extremities, in the case of the nasal form - destructive tumors in the middle part of the face.

Primary cutaneous peripheral T-cell lymphoma, unspecified. Papules, plaques, nodes, often eroding or ulcerating, are characteristic of various variants of this lymphoma.

Cutaneous B-cell lymphomas

Cutaneous B-cell marginal zone lymphoma.

Among primary B-cell lymphomas, it occurs in almost 50% of cases. The disease is represented by papules from pink, reddish to purple, plaques or nodes, localized mainly on the trunk or limbs, especially the upper ones.

Primary cutaneous lymphoma from follicular center cells. Among primary B-cell lymphomas of the skin, it occurs in 30% of cases. The disease is represented by solitary or grouped pinkish papules (from a few millimeters in diameter or more), plaques and tumor-like nodes, localized mainly on the scalp, forehead and trunk.

Primary cutaneous diffuse large B-cell lymphoma, lower extremity type occurs predominantly in older people, mostly women. The rash is represented by rapidly growing reddish or bluish-reddish tumors on one or both lower extremities.

Diagnostics. To diagnose skin lymphomas, in addition to assessing the clinical picture, it is necessary to use the following diagnostic methods in combination: histological (description of the cytological characteristics of tumor cells), immunohistochemical (determination of the phenotype of tumor cells), cytogenetic (identification of chromosomal abnormalities), molecular biological (determination of the clonality of the tumor process). To identify the possible involvement of other organs in the process, skin mapping is carried out,

general clinical and biochemical blood tests, chest x-ray, computed tomography, ultrasound of the abdominal cavity and retroperitoneal space, sternal puncture, lymph node biopsy, trepanobiopsy.

Differential Diagnosis skin lymphoma is carried out with many diseases. In the erythematosquamous and plaque stages, mycosis fungoides is differentiated from eczema, psoriasis vulgaris, focal neurodermatitis, allergic dermatitis, and toxidermia. Differential diagnosis of Cesari's syndrome is carried out with nonspecific erythroderma that occurs with irrational therapy of inflammatory dermatoses (lichen pink, psoriasis, eczema, atopic dermatitis), and toxicoderma. Lymphomatoid papulosis is differentiated from vasculitis and hemoderma. Various lymphomas presenting as nodules should be differentiated from panniculitis.

Treatment skin lymphoma depends on the type of lymphoma and the stage of the disease.

General therapy of T-cell lymphomas. In the initial stage, general strengthening and immunostimulating agents are used (vitamins of group B, preparations of ginseng, eleutherococcus, interferon). In the second stage, phototherapy (PUVA, UVB), radiation therapy (X-ray therapy, fast electrons) is used, cytostatic monotherapy is prescribed (pro-spidin 100 mg daily, for a course of 3-5 g or cyclophosphamide 200 mg daily, for a course of up to 6 g ). In erythrodermic forms of lymphomas, treatment begins with glucocorticosteroids (prednisolone per os 30-40 mg per day or diprospan 1 ml intramuscularly 1 time per week) followed by the addition of prospidin (cyclophosphamide) in the same course dose. In the tumor stage of the disease, radiation therapy and polychemotherapy are used.

External Therapy- symptomatic. Glucocorticosteroid ointments and creams are prescribed for infiltrates, plaques and papules, and disinfectants for decaying nodes (to prevent secondary infection).

Therapy for B-cell lymphomas. Surgical removal of foci and / or radiation therapy are used, with a systemic process - polychemotherapy.

28.3. PRECANCROSIS

actinic keratosis

Definition. Actinic keratosis (solar keratosis, senile keratoma) is a precancerous neoplasm that occurs on skin exposed to chronic insolation and tends to subsequently transform into squamous cell carcinoma.

Etiology and pathogenesis. The disease occurs as a result of long-term regular solar or UV exposure, especially with a wavelength of 280-320 nm, after a 10-20 year latent period. It is believed that UV insolation disrupts the genetic material of epidermal cells, as a result of which they transform into anaplastic cells. (carcinoma in situ). These atypical cells gradually replace normal keratinocytes and lead to impaired keratinization of the epidermis. Transformation into squamous cell carcinoma occurs at the moment when they break through the basement membrane and penetrate into the dermis.

Clinical picture develops, as a rule, at the age of over 45 years on open areas of the body subject to insolation (forehead, scalp, back of the nose, auricles, cheeks, neck, shoulders).

The tumor begins with the appearance of a round, oval, sometimes irregular, reddish, slightly inflamed plaque, against which telangiectasias shine through, and palpation reveals a rough horny surface. In other cases, hyperkeratosis is more pronounced and presents as yellow horny masses. Severe hyperkeratosis can protrude significantly above the skin surface and lead to the development skin horn, which is more common in the region of the eyelids and forehead. Sometimes the senile keratoma is hyperpigmented, outwardly resembling a seborrheic wart.

Actinic keratosis is subject to very slow development, malignancy to squamous cell carcinoma does not occur in all cases and occurs after several years or decades. Clinically, this moment is manifested by increased inflammation, thickening of the plaque and its ulceration.

Differential Diagnosis performed with discoid and disseminated lupus erythematosus, Bowen's disease, seborrheic wart, basalioma.

Treatment. Apply cryotherapy, X-ray therapy, laser therapy, surgical excision.

Bowen's disease

Definition. Bowen's disease is a chronic inflammatory disease caused by the proliferation of atypical keratinocytes in the epidermis, characterized by slow invasive growth and the ability to transform into squamous cell carcinoma.

Etiology and pathogenesis. The disease is an intraepidermal cancer (carcinoma in situ), resulting from the proliferation of atypical keratinocytes. Developing at first only intraepidermally, the tumor eventually breaks through the basement membrane and transforms into squamous cell carcinoma. Bowen's disease occurs, as a rule, in elderly patients, more often in persons who have used external cosmetics or drugs containing carcinogenic substances (for example, arsenic). It is believed that food products containing arsenic compounds (wine, tonic) can also be provoking factors.

clinical picture. Foci of skin lesions can be single or multiple, affecting any areas of the skin, as well as mucous membranes. The most common localization is the skin of the trunk, forehead, temporal region and fingers.

Affected areas of the skin look like rounded or unevenly outlined pink spots or plaques ranging in size from 2-5 mm to 10 cm. They are slightly infiltrated and slightly raised above the skin surface, rough and covered with grayish-white or yellowish scales, scaly crusts or crusts. . After removal of the scales, the plaques appear red, with an eroded, slightly keratinized or papillomatous surface. Of the mucous membranes, mainly the oral mucosa, the glans penis, and the vulva are affected, the altered areas of which demonstrate keratinization.

The disease develops slowly, sometimes the process spontaneously resolves, transformation into squamous cell carcinoma occurs only after a few years. In patients with Bowen's disease, concomitant cancers of the internal organs, especially the lungs, the gastrointestinal tract, and the urogenital system, are often found.

Differential Diagnosis performed with psoriasis vulgaris, nummular eczema, discoid and disseminated lupus erythematosus, actinic keratosis, basalioma.

Treatment. They resort to surgical excision, X-ray therapy, laser therapy, cryotherapy, the use of 5% fluorouracil or 30% prospidin ointment.

Paget's disease

Definition. Paget's disease is an intra-epidermal adenocarcinoma that develops in the area of the nipple and areola of the breast (usually unilateral).

Etiology and pathogenesis. The tumor develops from atypical epidermotropic cells of the ducts of the mammary gland. (Paget cells), has infiltrating growth in surrounding tissues with subsequent metastasis.

clinical picture. Paget's disease occurs almost exclusively in women and usually occurs after the age of 40. The disease begins with a unilateral lesion of the nipple or peripapillary field, on which an itchy, painful, well-circumscribed, erythematous plaque covered with a scaly crust appears. The plaque slowly increases in size and extends beyond the areola, affecting the skin of the mammary gland, while remaining sharply demarcated from healthy skin. At the same time, due to invasive growth, the tumor grows in depth, turning into a painful knot. The process ends with metastasis to nearby lymph nodes and the development of breast cancer.

As a variant of the disease, it also occurs extramammary Paget's disease, which develops from the cells of the ducts of the apocrine sweat glands and therefore affects the anogenital and axillary regions, and occasionally the umbilical region. This pathological process also occurs more often in women and has clinical manifestations similar to the classic Paget's disease.

Differential Diagnosis carried out with eczema of the nipples, psoriasis vulgaris, streptococcal diaper rash, Bowen's disease, basalioma.

Treatment. Surgical excision of the affected area within the involved tissues is necessary.

28.4. SECONDARY METASTATIC TUMORS

Definition. Secondary metastatic tumors are malignant proliferation of tumor cells of oncological diseases of internal organs that enter the skin via the hematogenous or lymphogenous route due to metastasis. Among malignant diseases of the internal organs, cancers most often metastasize to the skin, causing the development of secondary skin carcinomas.

clinical picture. Skin lesions occur in 35% of patients with metastatic tumors of internal organs. Sometimes they are the first symptoms indicating the presence of metastases. According to the depth of location, various parts of the skin can be affected, secondary metastatic tumors can be exophytic, intradermal, hypodermal. They are usually nodules of various sizes, over which the skin varies in color from normal skin to bright red. Subsequently, the nodes can disintegrate forming sluggish ulcers.

Localization of tumors depends on the location of the primary tumor. The skin of the abdomen is more often affected by tumors of the lungs, stomach, kidneys and ovaries. In the skin of the breast, metastases are usually detected in women with breast cancer. On the scalp, metastases of malignant tumors of the lungs, kidneys and breast cancer predominate.

Hematogenous secondary metastatic tumors can occur anywhere on the skin and can be either single or multiple. Their favorite localization is the skin of the abdomen and thighs. Secondary metastatic tumors are introduced into the skin by the lymphogenous route, mainly in breast cancer.

Differential Diagnosis carried out with benign and malignant tumors of the skin, specific hemoderma, erythema nodosum, erythema indurativa, scrofuloderma.

Treatment similar to that of Paget's disease.

28.5. HEMODERMIA

Definition. Hemoderma include skin lesions caused by malignant diseases of the hematopoietic myeloid and lymphatic systems (myelo- and lymphocytic leukemias).

Leukemia can cause the development of a pathological process in the skin due to the proliferation in it of pathological cells of the hematopoietic system, morphologically identical to leukemic cells. Such hemoderma are skin neoplasms and are called specific hemoderma or skin leukemia. In addition, inflammatory reactions can develop in the skin associated with the general toxic-allergic effect of leukemia on the body as a whole due to the disturbances caused by it in the endocrine, immune, nervous and other systems.

These inflammatory reactions are called nonspecific hemodermas or leukemids.

clinical picture. At myeloid leukemias the process can affect any area of the skin. More commonly, the lesions occur on the extremities and are single or multiple, raised, well-defined nodules and plaques that are bluish-red, red-brown, or bluish-gray in color. Sometimes there are nodes, the skin over which has an unchanged color. Elements are characterized by a pronounced tendency to decay with the formation of ulcers of various depths.

Myeloid leukemids are more common than specific myeloid hemoderma and are predominantly hemorrhagic manifestations in the skin and mucous membranes (vibices, blisters with hemorrhagic contents).

Specific hemoderma in lymphocytic leukemia (lymphoid leukemias) occur in 20-50% of patients. Neoplasms are located symmetrically, more often in the face and scalp, but can also occur in any other parts of the body. They are smooth, moderately dense nodes and tumor infiltrates of various sizes, which can sometimes merge with each other reaching the size of an apple. The skin above them may be red-brown or the color of a normal color. Nodular ulceration is rare. Diffuse infiltration of the face, accompanied by periorbital edema, gives it an external resemblance to the muzzle of a lion (leonine facies). Characteristic is the presence of bluish-red or red-brown tumor-like infiltrates in the area of the earlobes. Perhaps the occurrence of infiltrates in the mucous membranes of the oral cavity. Another manifestation of lymphoid leukemias is itchy papular rashes on various parts of the body, reminiscent of those with adult strophulus.