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lthough most benign lesions will remain benign, it is important to be aware of lesions (eg, actinic keratoses) that have malignant potential. Many benign lesions are quite bothersome to patients and require treatment. The more you understand and can recognize the patterns of skin disease, the better you are equipped to help your patients.

Pigmented Nevi

       Pigmented nevi, the most common of all neoplasms, may arise at any age but most often form at 2–3 years of age and at puberty. They consist of collections of normal melanocytes (an epidermal cell that produces pigment). There are several types of pigmented nevi. Junctional nevi occur as smooth, hairless, brown (light or dark) macules that can be slightly elevated, are usually multiple, and can appear anywhere on the body. Intradermal nevi are the dome-shaped, skin-colored moles that are commonly found on the scalp, hand, and neck of adults. They can also become pedunculated (ie, attached by a stalk). Halo nevi are pigmented nevi that develop a ring of peripheral depigmentation, usually formed in a perfect circle. Over time, they will clear up (ie, involute).

A patient with seborrheic keratoses. Photo by Robert A. Norman, DO, MPH.

Blue nevi appear benign, congenital, or spontaneous and present as blue-gray or blue nodules. They are commonly located on the head, neck, forearm, or hand.
       Normally, pigmented nevi require no treatment. However, pigmented nevi that exhibit any of the following warning signs should be investigated: an irregular border, an irregular distribution of pigment, onset after age 40, change in size or color, pain, irritation, pruritus, infection, bleeding, or crusting. A biopsy followed by a pathology exam is the recommended procedure if any of these warning signs is present. When the diagnosis of benign pigmented nevi is in doubt, surgical excision is usually appropriate.

Hemangiomas

       Hemangiomas are usually benign tumors made up of blood vessels. They typically occur as a slightly elevated area of skin and are somewhat purple or red in color. Up to 80% of hemangiomas are found on the head or neck, but they can occur anywhere on the skin or even on internal organs. There can be a single lesion or a dominant primary lesion with smaller associated hemangiomas. They can be superficial, appearing flat and somewhat red in color, deep beneath the surface of the skin and somewhat blue in color, or a combination of both. Treatment for hemangiomas usually begins when they occur, likely in the patient’s youth. Treatment is rarely performed on nursing home patients. However, treatment options include surgical excision, laser treatments, steroids, and/or alpha-interferon therapy.

Seborrheic Keratoses

       Seborrheic keratoses are extremely common lesions that are seen mainly on the trunk, face, and proximal extremities. These lesions are dark brown or black papules that appear to be stuck on the skin. Cryosurgery or electrocautery are treatment options. A shave biopsy should be performed on any suspicious lesion to rule out melanoma.

Actinic Keratosis

       Actinic keratosis is a keratotic, 3–6mm, red or brown papule. It is most often found on sun-exposed areas of fair-skinned individuals. These lesions usually persist if untreated and may present with symptoms of burning or stinging. Twenty percent of patients with multiple actinic keratoses develop squamous cell carcinoma. Reduction of sun exposure and use of sun protection (eg, sunscreen, protective clothing) may reduce development of new lesions. Treatment for superficial lesions may include cryosurgery, electrodesication with curettage, and/or topical 5-fluorouracil (5-FU) cream.

Sebaceous Hyperplasia

       Sebaceous hyperplasia appears as yellow nodules that may have a central pore. The number of sebaceous glands remains constant as a person ages, but the glands increase in size and become more visible, particularly in chronically sun-exposed skin. Paradoxically, sebum production decreases over time, contributing to the dry skin seen in normally aged as well as photo-aged skin. It is important to distinguish sebaceous hyperplasia from nodular basal cell cancer. In contrast to basal cell cancer, the sebaceous gland is not translucent and does not have telangiectatic blood vessels. Nevertheless, when in doubt, it is always best to perform a biopsy.

Solar Lentigines

       Solar lentigines are brown patches that are smooth and found on sun-exposed areas. Differential diagnoses include seborrheic keratosis, ephelides, nevi, and melanoma. Treatment options include chemical peels, bleaching creams, and cryotherapy.

Favre-Racouchot Syndrome

       Favre-Racouchot syndrome includes a variety of primarily sun-induced skin changes—nodular elastosis (with cysts and comedones) and sebaceous hyperplasia. Superficial vascular changes result in erythema and telangiectasias. Irregular melanocyte distribution via alteration in pigmentation may manifest as multiple areas of hyperpigmentation, hypopigmentation, and scattered lentigines.

Acrochordons (Skin Tags)

       Acrochordons (skin tags) are fleshy or dark-colored pedunculated papules or nodules on the neck, axillae, groin, chest, and abdomen. They can be painful when they get tangled in necklaces or clothing. Differential diagnoses include verruca vulgaris, nevi, and seborrheic keratosis. Treatment options include snip excision, cryotherapy, and cautery.

Hyperkeratosis

       Hyperkeratosis, which presents as a thickening of the outermost layer of the epidermis, is one of the most common disorders, affecting the foot in particular. Mechanical forces and hereditary factors contribute to the development of hyperkeratosis. The rate of basal cell division generates new epidermal cells and determines how thick the skin will become. Hyperkeratotic lesions occur over bony prominences of the body as well as areas that experience increased friction. When normal skin is exposed to pressure, it can become hyperkeratotic, and it is considered a disorder when symptoms develop.
       Tylomata (calluses) and helomata (corns) are common hyperkeratotic disorders affecting the feet. A corn is defined as a painful, well-demarcated callosity found over a bony prominence of the foot. Soft corns between the toes can lead to maceration and cellulitis. A callus is a broad plaque normally affecting the sole of the foot. The ball of the foot and margins of the heel are more susceptible to hyperkeratotic lesions. Both types of lesions are characterized by their degree of cornification and can be found almost anywhere on the feet. If treatment is delayed, these hyperkeratotic disorders can erode and form ulcers. About 30% of foot ulcers in the elderly are related to eroded hyperkeratosis. Initial treatment involves changing the patient’s shoes in order to decrease unnecessary pressure and friction. Modification of the patient’s gait is important in preventing further deterioration of the foot. Surgery can be performed if the condition persists after conservative treatment.

Lichen Planus

       Lichen planus of the skin is a relatively common disease that can last from months to years. Initially, it presents as a pruritic, somewhat purple in color, papular eruption with a polygonal shape. The extent of pruritus is associated with the type and location of the lesion. Hypertrophic lesions, which are found mostly on the lower legs, are very pruritic. This disease occurs most often in men and women between the ages of 30 and 70 years and tends to favor the inner wrists and ankles. Long-standing lichen planus lesions have a propensity to develop into squamous cell carcinomas. The cause of lichen planus is not known, but it is believed to be an autoimmune disease, possibly caused by a viral infection. Those with the disease usually have a positive family history and an increased risk of being re-infected. Although there is no cure for lichen planus, most symptoms can be treated with antihistamines and topical steroids. Other helpful measures include soothing baths and applications of wet dressings to the affected areas to help reduce the itching. As the disease heals, brown discolorations that result from the lesions eventually fade away.

Warts

       Nongenital warts are estimated to affect about 7% to 12% of the population. Warts present as hard, benign, skin proliferations caused by one or more of the 150 identified types of human papillomavirus (HPV). Common warts (verruca vulgaris) are found more frequently on the hands and knees. These warts range in size from 1mm to more than 1cm and are most commonly caused by HPV types 2 and 4. Filiform warts are long, narrow growths on or around the face. Deep palmoplantar warts are caused mostly by HPV type 1 and appear as small, shiny papules with a well-defined border and a rough surface. These warts tend to grow deeply and cause strong pain in the weight-bearing areas of the body, such as the ball of the foot and heel. Flat warts are called verruca plana because they are only slightly elevated with a flesh-colored, smooth surface. They can range from 1–5mm and develop as groups of warts on the hands and shins from HPV types 3, 10, and 28. Mosaic warts are plaques of warts seen on the palms and soles of the feet.
       The diagnosis of warts is based primarily on clinical findings, although a biopsy can be performed if any there is any doubt in the initial diagnosis. There are a multitude of ways to treat warts. Topical agents are not very expensive or painful and therefore used most often. Topical agents like salicylic acid can be bought over the counter and applied at home to treat warts. Other topical agents can be used to treat warts in the office setting; a commonly used agent is cantharidin, which is an extract from the blistering beetle.
       Prescription medications (eg, cidofovir, imiquimod, podophyllotoxin, and 5-FU) have also been used to treat recurrent warts that are resistant to other therapies. Because warts are resistant to conventional therapies in many immunodeficient patients, alternative medications should be used. Cryosurgery and lasers are two very successful surgical methods that can be performed to remove warts, although they can be painful and leave scars depending on the location and size of the wart. Cryosurgery may have to be repeated over several weeks or months for effective wart removal.