Intradermal naevus is the most common pigmented skin lesion commonly called “mole”. It frequently increases in size with time and age. They appear as skin nodules and vary in size, thickness and pigmentation. Some of them may have a few follicles of hair. Although they rarely turn malignant, it is prudent to check for signs of malignant change including change of pigmentation, ulceration and bleeding. The treatment of these lesions is dependent on the size and location.
When it is small and flat or near to vital structures like the eyelashes, they may be removed with laser vapourization. However if it is large and thick, generally excision and direct closure is the method of choice to ensure complete removal. The tissue should be sent for histology if there is any suspicion of malignant change.
Xanthelesma frequently occur around the eyelids. They appear as yellowish plaque like lesions on the medial aspect of the upper or lower eyelids. These plaques consist of foam cell deposits which contain lipid substance. When the lesion is small, direct excision and closure is the treatment of choice. However when the lesions are large and confluent, serial excision and sometimes skin grafting may be required. There is a small significant risk of recurrence (about 10%) because they may have subcutaneous extension.
Congenital naevi are pigmented lesions or moles, which are present at birth. They can vary significantly in size. They increase in size and thickness in proportion to the growth of the child. When the lesion is thick or large, it is frequently associated with growth of hair, thus called Congenital Hairy Naevus. The treatment is dependent on the size and location. When it is small, a simple excision and closure is done. When the lesion is large and near to vital organs like eyes and nose, serial excision or skin grafting may be the method of choice in order not to distort the normal anatomy of the eye or nose. There is 3-15% risk of malignant change in a lifetime for large congenital naevus particularly the ones on the midline of the trunk.
Syringoma, Milia, Seborrhoeic Keratosis, Age Spots, Skin Tags and Viral Wart
There are many skin lesions or blemishes that seem to appear with time and ageing. The common lesions among the younger patients include syringomas, milia or sebaceous hyperplasia due to oily skin condition. They commonly occur around the eyes and appear like white or skin coloured nodules (seeds) on the skin. Among the older age group, seborrhoeic keratosis and multiple skin tags in the neck and face are common. The seborrhoeic keratosis appears as thick brown patches of on the skin on the face and neck. Skin tags are skin coloured smooth fleshy lesions attached to the skin and usually pedunculated. Viral warts tend to have an irregular surface and verrucous appearance.
All these lesions are amenable to removal using a carbon dioxide laser vapourization. The procedure is done under topical anaesthetic cream. Local anaesthesia may be used as a supplement for some if the lesion is large and discrete. The procedure takes about 30-60 mins depending on the number of lesions to be removed. Post laser treatment, an antibiotic ointment is applied over the wound to promote healing without infection. Multiple scabs will develop over the next few days. Patients are advised to keep wound clean and dry to allow the faster healing. The average recovery time is about 1 week.
Basal Cell Carcinoma, Squamous cell carcinoma, Malignant Melanoma
The 2 most common common skin cancers in Asians are Basal Cell Carcinoma and Squamous Cell Carcinoma. Malignant Melanoma is more common in western population and end to be more aggressive in behavior.
Basal cell carcinoma appears as skin nodules with non-healing ulcers and raised pearly edge. They tend to bleed when traumatized. In Asians, about 70% of them are pigmented. These cancers are slow growing and localized. A wide excision with clear margins is sufficient treatment. When the defect is small, direct closure is done. When the defect is large, a skin flap or skin graft may be required.
Squamous cell carcinoma appears as more fleshy nodules on the skin. The surface tends to bleed when traumatized. When the lesion is large, it can invade into deeper tissues and spread to the lymph nodes. The treatment of choice is a wide excision with 5-10mm margin to get surgical clearance. If the lymph nodes are enlarged in the field of drainage, a dissection of the lymph nodes in the neck, axilla or groin will be required. Frequently the defect is covered with a skin graft or flap because the size of defect is too large to close primarily. Adjuvant treatment with radiotherapy or chemotherapy may be required.
Malignant melanoma frequently presents as a pigmented lesion, which increased in size quite suddenly and associated with pigmentation changes. It may also be associated with ulceration of the skin and lymph node enlargement. An incisional or excisional biopsy is recommended if there is any suspicion of malignant change. Surgery is the mainstay of treatment. A wide excision with 5 – 20mm margin, depending on the stage or thickness of the melanoma, is recommended. The defect is resurfaced with skin grafts or reconstructed with skin flaps as necessary. A sentinel node biopsy in the field of drainage is done for the purpose of staging. If a positive node is found, a dissection of the lymph nodes in the neck, axilla or groin would be necessary. Post-operatively, chemotherapy or immunotherapy may be helpful in some cases.