In-Service Exam
Skin Lesions - 2003





In a 70-year-old man with rhinophyma, which of the following is the most appropriate management?

(A) Oral administration of isotretinoin
(B) Topical administration of 5-fluorouracil
(C) Tangential excision and healing by second intention
(D) Staged excision and coverage with a full-thickness skin graft
(E) Excision and coverage with a forehead flap

The correct response is Option C.

In this 70-year-old man who has rhinophyma, the most appropriate management is tangential excision of the affected skin, followed by healing by second intention. Rhinophyma, or sebaceous hyperplasia of the nasal skin, is a sequela of acne rosacea that typically occurs in men older than 60 years. It has not been linked to alcohol abuse. The skin lesions are not considered premalignant, and occult basal cell carcinoma is rarely associated. Tangential excision by shaving, dermabrasion, or laser therapy is recommended for management of rhinophyma; the wound will heal by second intention.

Oral retinoids, such as isotretinoin, have not been shown to be effective in improving symptoms associated with rhinophyma. Topical 5-fluorouracil is appropriate for treatment of premalignant tumors and superficial skin malignancies. Skin grafting or flap closure would be unnecessary because the dermal appendages are preserved following tangential excision.

References
1. Roberts TL, Pozner JN. Aesthetic laser surgery. In: Achauer BM, Erikson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby Ð Year Book, Inc; 2000;5:2457-2486.
2. Weinstein C, Roberts TL. Aesthetic skin resurfacing with the high-energy ultrapulsed CO2 laser. Clin Plast Surg. 1997;24:379-405.
3. Zarem HA, Lowe NJ. Benign growths and generalized skin disorders. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:141-159.

A 65-year-old man undergoes surgical excision of a morpheaform basal cell carcinoma with a diameter of 1.5 cm from the right cheek. Pathologic examination of tissue obtained from the lesion shows one positive margin. Which of the following is the most appropriate management?

(A) Observation
(B) Topical application of 5-fluorouracil
(C) Radiation therapy
(D) Cryosurgery of the involved margin
(E) Repeat excision

The correct response is Option E.

Because untreated positive margins have been shown to result in clinical recurrence in 16% to 42% of patients, the involved margins should be immediately re-excised under frozen section or Mohs' micrographic chemosurgery. Morpheaform basal cell carcinoma is an aggressive subtype with indistinct margins. As a result, it may be difficult for patients to observe changes in the affected area, and rapid growth may result in compromise of vital structures.

Topical application of 5-fluorouracil, radiation therapy, and cryosurgery do not contribute to the treatment of positive margins.

References
1. Goldberg DP. Assessment and surgical treatment of basal cell skin cancer. Clin Plast Surg. 1997;24:673-686.
2. Richmond JD, Davie RM. The significance of incomplete excision in patients with basal cell carcinoma. Br J Plast Surg. 1987;40:63-67.

A patient with which of the following disorders is a candidate for surgical rejuvenation of the aging face?

(A) Cutis laxa
(B) Ehlers-Danlos syndrome
(C) Elastoderma
(D) Progeria
(E) Werner's syndrome

The correct response is Option A.

Of the disorders listed above, only patients who have cutis laxa should be considered for elective cosmetic surgery. Cutis laxa is a disorder in which patients have a defect of elastic tissues, more specifically a nonfunctioning elastase inhibitor or degenerative elastic fibers, resulting in the appearance of coarsely textured, drooping skin over the entire body. The condition is often diagnosed during the neonatal period or in early childhood; associated conditions include congenital heart disease, emphysema, and pneumothorax. Affected patients are prone to developing aneurysms and hernias. Although the effects of cutis laxa slowly worsen over time, there are no inherent difficulties with wound healing, and patients may consider periodic surgical procedures to correct skin laxity.

Patients with Ehlers-Danlos syndrome, a disorder of collagen cross-linking, have fragile hyperelasticity of the skin, joint hypermobility, and aortic aneurysms. Because wound healing is poor, elective surgical procedures should not be performed. Elastoderma is a disorder of unknown cause characterized by pendulous skin laxity initially involving the trunk and extremities that progresses to encompass the entire body. Elective surgery is contraindicated because wound-healing mechanisms are unknown. Progeria, which is a disorder of childhood, involves laxity and irregular contouring of the skin and is associated with rapid progression and a shortened lifespan. Cutaneous features of Werner's syndrome, an autosomal recessive disorder, include induration, plaques, variable pigmentation, and facial aging; alopecia, atherosclerosis, cataracts, and short stature are also associated. This disorder also has been linked to poor wound healing, and surgical procedures should not be performed to correct the prematurely aging face.

References
1. Adams WP Jr. Discussion - the role of plastic surgery in congenital cutis laxa: a 10-year follow-up. Plast Reconstr Surg. 1999;104:1179.
2. Kumar S, Sehgal V, Sharma RC. Cutis laxa. J Dermatol. 1996;23:721.
3. Nahas FX, Sterman S, Gemperli R, et al. The role of plastic surgery in congenital cutis laxa: a 10-year follow-up. Plast Reconstr Surg. 1999;104:1174-1178.

Which of the following skin conditions is associated with a disorder of lipid metabolism?

(A) Acrochordons
(B) Dermatofibroma
(C) Keloid
(D) Sebaceous hyperplasia
(E) Xanthelasma

The correct response is Option E.

Approximately 50% of patients with xanthelasma palpebrarum have familial dyslipoproteinemia. Xanthelasma palpebrarum usually presents in the fourth to fifth decade of life and is characterized by multiple soft yellow periorbital plaques that may coalesce. Findings can be unilateral or bilateral. The lesions should be surgically excised or ablated with liquid nitrogen, trichloroacetic acid, or a carbon dioxide laser; however, the rate of recurrence is high.

Acrochordons are simple skin tags that usually develop in patients older than 10 years.

Dermatofibromas are common skin tumors that affect the trunk and upper and lower extremities. These lesions are typically no larger than 2 cm and are more common in women.

A keloid is an abnormal scar that extends beyond the site of the initial injury.

Patients with sebaceous hyperplasia have yellow lesions measuring 2 to 6 mm on the face.

References
1. Harris AO, Levy ML, Goldberg LH, et al. Nonepidermal and appendageal skin tumors. Clin Plast Surg. 1993;20:115-130.
2. Morganroth GS, Leffell DJ. Nonexcisional treatment of benign and premalignant cutaneous lesions. Clin Plast Surg. 1993;20:91-104.