Answer : Pyogenic granuloma Discussion Pyogenic granulomas may occur in the skin as solitary, raised lesions with hyperemic and ulcerated features. Trauma with superimposed infection and/or inflammation is considered to be the most probable cause of these lesions, which are not true neoplasms. Vascular causes have also been described.Definitive treatment of pyogenic granulomas involves excision with a generous margin of surrounding normal tissue. An alternative effective treatment is to shave off the lesion flush with the skin and coagulate the base. ref - Schwartz's Principles of surgery 9th ed Pyogenic granuloma is a misnomer for an exuberant outburst of highly vascular granulation tissue at the site of previous relatively trivial trauma. They usually occur on the fingertips. These lesions are very friable, bleed easily, and may grow rapidly. They respond to curettage or simple excision. Histologic confirmation of the diagnosis is necessary because of occasional confusion with aggressive malignant lesions, such as ulcerated, amelanotic, malignant melanomas. ref - Sabiston 19th ed vol 3, Chp 70 Differential Diagnosis 1) Actinic keratosis and cutaneous horns • Actinic (solar) keratoses: These are single or multiple discrete scaly hyperkeratotic rough-surfaced areas,usually less than 1 cm diameter. Theyare seen on sun-exposed sites,especially the dorsal aspects of the hands, face and neck. They are most common in those with a fair skin. Histologically, they show hyperkeratosis, abnormal keratinocytes with loss of maturation and dermal elastosis. Actinic keratoses may regress spontaneously. However, they can progress to squamous cell carcinoma( 20 % risk according to - Weedon's Skin Pathology, 3rd Edition ) Treatmentis normally by cryosurgery, but certain lesions may be best treated with curettage, excision or by applying 5%5-fluorouracil cream (Efudix) twice daily for 2-4 weeks or 3% diclofenac gel (Soloraze) twice daily for 60-90 days. A cutaneous horn may occasionally develop in actinic keratoses. It is treated by excision or curettage. ref- Dermatology an illustrated color text in short, there is an actinic keratosis behind every cutaneous horn ( sounds familiar ... but i am sure it has never been said in the context of cutaneous horn ) 2) Acrochordon aka cutaneous skin tag or fibroepithelial polyp An acrochordon (plural acrochorda, and also known as a (cutaneous) skin tag, or fibroepithelial polyp) is a small benign tumor that forms primarily in areas where the skin forms creases, such as the neck, armpit, and groin. They may also occur on the face, usually on the eyelids. Acrochorda are harmless and typically painless, and do not grow or change over time. Though tags up to a half-inch long have been seen, they are typically the size of a grain of rice. The surface of an acrochordon may be smooth or irregular in appearance and is often raised from the surface of the skin on a fleshy stalk called a peduncle. Studies have shown existence of low-risk HPV 6 and 11 in skin tags hinting at a possible role in its pathogenesis. ref - wiki The tag is usually the same color as skin, or a little darker ( and that's how u can differentiate it from a wart )it's more common as one gets older and in people who are overweight or who have diabetes. ref - A.D.A.M. Medical Encyclopedia. A very famous skin tag is the accessory tragus aka preauricular skin tag Accessory tragi result when a branchial arch or cleft fails to fuse or close properly. Defects occur unilaterally or bilaterally and may have accompanying facial anomalies.Noted at birth and persists asymptomatically for life. Usually, it is an isolated, congenital defect. Rarely, there may be other associated branchialarch abnormalities or other genetic syndromes present. The presence of preauricular tags are associated with urinary tract abnormalities such as vesicoureteral reflux. Accessory tragi are a feature of Goldenhar syndrome, Treacher–Collins, and VACTERL syndrome, among others. Solitary, uncomplicated lesions may be tied off shortly after birth but otherwise can be excised during childhood for cosmetic purposes. Screening urinary tract ultrasonography is recommended by some authors. ref - COLOR ATLAS & SYNOPSIS OF PEDIATRIC DERMATOLOGY, section 1 - cutaneous findings in new born The other skin tag,i call it - skin tag vulgaris, becos atleast one is present in 50% of adult population and doesn't generate a lot of press. An excerpt from, COLOR ATLAS & SYNOPSIS OF PEDIATRIC DERMATOLOGY, section 11..... Age Adolescence and adulthood. Gender F = M. Incidence 50% of all adults have at least one skin tag Although totally benign, skin tags can be associated with acanthosis nigricans and, in this context, can suggest an underlying malignancy or insulin-resistant state. DIFFERENTIAL DIAGNOSIS The differential diagnosis includes a pedunculated dermal or compound melanocytic nevus, neurofibroma, seborrheic keratosis, or wart. Miscellaneous Seborrheic keratosis - although not seen clasically on the lip, i will cover it in the interest of completeness synonyms - senile wart, basal cell papilloma Clinical features - Seborrhoeic keratoses occur on any body site, being most frequent on the face and the upper trunk. The first evidence is slight hyperpigmentation. They are usually asymptomatic but may be itchy. The most common appearance is that of a very superficial verrucous plaque which appears to be stuck on the epidermis, varying from dirty yellow to black in colour and having loosely adherent, greasy keratin on the surface. The shape is round or oval and multiple lesions may be aligned in the direction of the skin folds. The size varies from 1 mm to several centimetres. The smallest lesions occur around follicular orifices, particularly on the trunk. On the eyelids and major flexures, SKs may be pedunculated and less keratotic. The rapid development of large numbers of SKs can occur in patients with an inflammatory dermatosis or in association with underlying malignancies where it is known as the sign of Leser–Trélat. The neoplasms most commonly associated with this skin manifestation include stomach and colon cancer and in some patients it may be associated with the development of acanthosis nigricans. On the hand and face, seborrhoeic keratoses can be mistaken for melanocytic lesions. It may be difficult to distinguish superficial seborrhoeic keratoses from lentigo maligna and pigmented AK. More florid examples may be pedunculated or acanthotic, smooth-surfaced, domed and heavily pigmented, but in contrast to melanocytic naevi do not reflect light and usually have plugged follicular orifces on the surface, giving an almost cerebriform appearance. Most seborrhoeic keratoses have fewer hairs than the skin they arise from. ref - Rook's textbook of Dermatology, Chp 52
thanks it interesting to have only the images, we exercice our capacity to analyse the lesions. I think that the same lesion with the anamnestic would permit to fine the diagnosis(developing in 1 to 3 weeks, +/- traumatism +/- a peripheric collar around the lesion)
