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Benign Skin Tumors

Examination of a skin tumor is for determination not only of malignancy or benignancy but also of the skin component from which the tumor derives. A tumor may originate from epidermal keratinocytes, from cells of
appendages such as those in sweat glands, or from neural crest cells or mesenchymal cells including dermal
fibroblasts. The epidemiology, pathology and course of tumors vary depending on the origin of the cells. This
chapter classifies benign skin tumors into the subtypes below.
A: Epidermal tumor
F: Neural tumor
J: Adipocellular tumor

B: Follicular tumor
C: Sebaceous tumor
G: Hemangiomas/vascular malformations
K: Myogenic tumor
L: Osteogenic tumor

D: Sweat gland tumor

H: Fibrous tumor
M: Hematopoietic tumor

E: Cyst
I: Histiocytic tumor

A. Epidermal tumors
Epithelial tumors originate mainly from epidermal keratinocytes.

1. Seborrheic keratosis (SK)

Synonyms: Senile warts, Senile verruca
Outline
A

benign verrucous tumor occurs, most frequently on the

face, head or trunk of men and women middle aged and
older. It derives from keratinocytes in the epidermis or
infundibular hair follicle.
Elevated, sharply demarcated, grayish-brown to blackish-brown nodules of 1 cm to 2 cm in diameter occur.
Cryotherapy, laser therapy and excision are the main
treatments.
When multiple, itchy, SK rapidly occurs on the whole
body within 6 months after the onset of SK, it is called
Leser-Trlat syndrome. It may be accompanied by internal malignancy.
Clinical features
Seborrheic keratosis (SK) appears in people in their 20s and is
seen in nearly everyone in their 80s or older. Flat-topped papules
of 1 cm to 2 cm in diameter, varying in color from brown to
blackish brown occur on the face, head and trunk (Figs. 21.1-1
and 21.1-2). The palms and soles are unaffected. The surface of
the papules is keratotic and often papillary or granular, resembling clay adhered to the skin. Itching and pain are not usually
present. As the synonym senile warts suggests, SK occurs as a
skin aging change. Senile freckles often elevate to form SK.
Pathology
There is upward intraepidermal proliferation of basal cells and
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Clinical images are available in hardcopy only.

Fig. 21.1-1 Seborrheic keratosis (SK).

Multiple, flatly elevated, brown or blackishbrown keratotic papules of 1 cm to 2 cm in diameter on the back of an elderly man.

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Benign Skin Tumors

suprabasal cells (exophytic lesion). The ratio of proliferative cells

to normal cells varies. Dysplasia is not present, but melanin pigmentation occurs in each proliferative cell to a varying degree
(Fig. 21.2). Pseudohorn cyst formation presents as milia-like cyst
by dermoscopy.
Clinical images are available in hardcopy only.

Differential diagnosis
The disease should be differentiated from actinic keratosis,
Bowens disease (papular type), basal cell carcinoma, squamous
cell carcinoma, keratoacanthoma, follicular tumor, syringoma,
flat warts, verruca vulgaris and lentigo simplex.

Clinical images are available in hardcopy only.

Treatment
Treatment is not necessary except when there are cosmetic
concerns or suspected malignancy. The lesions do not disappear
spontaneously but increase in number with age. If necessary,
cryotherapy, laser therapy or surgical removal is conducted.

2. Clear cell acanthoma

Fig. 21.1-2 Seborrheic keratosis (SK).
The skin lesion resembles clay adhered to the
skin. The surface of the lesion is keratotic and
papillary.

Clear cell acanthoma is usually a solitary, elastic, firm, domeshaped or flatly elevated small tumor whose diameter is up to 2
cm. It may be pedunculated, fungiform or papillomatous. The
surface is smooth, granular or velvety. The color is usually rose
pink, but it may be brown to blackish brown in some cases. The
pathogenesis is unknown. There is a question of whether clear
cell acanthoma is a genuine tumorous lesion or a reactive lesion
that accompanies inflammation. Histologically, epidermal cells
containing clear cytoplasm (clear cells) proliferate.

3. Warty dyskeratoma
In warty dyskeratoma there are verrucous or flatly elevated
tumors of 1 cm to 2 cm in diameter that tend to keratinize at the
center. The condition is largely asymptomatic, although tenderness and pain are present in some cases. Basaloid cells proliferate
pathologically toward the dermis directly above which cleavage
appears. Warty dyskeratoma clinically resembles Dariers disease
but is a different disease.

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Fig. 21.2 Histopathology of seborrheic keratosis (SK).

The epidermis proliferates and elevates above the
normal skin surface. Pseudohorn cysts form
(arrows).

MEMO
Sudden development of numerous seborrheic keratosis lesions, usually,
with pruritus, is called Leser-Trlat sign. This sign implies the presence
of internal malignancy. Therefore, systemic investigation must be
made for such malignancies when dermatologists see this phenomenon.

Leser-Trlat sign

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A. Epidermal tumors

4. Porokeratosis
Outline

round, brown keratotic lesions with elevated

rims occur on the extremities, trunk and face.
The disorder is asymptomatic. There is transformation to
squamous cell carcinoma in rare cases.
Characteristic pathological features called cornoid lamella are observed.
Excision and cryotherapy are the main treatments.

Clinical images are available in hardcopy only.

Scattered,

Clinical features
An elevated keratotic eruption, round or oval in shape, occurs
on the extensor surfaces of extremities and on the trunk and face
(Fig. 21.3). Atrophy occurs at the center of the lesion, which
becomes slightly concave. Porokeratosis begins as a blackishbrown papule, gradually enlarging centrifugally. It is asymptomatic, it progresses slowly, and it does not subside. It maya
aggravate and progress to Bowens disease or squamous cell carcinoma. Despite the disease name, the eruptions are not associated with the sweat pores. Porokeratosis is divided by morphology
into the six subtypes below. Pathologically, the most frequently
seen type is disseminated superficial porokeratosis, which occurs
on sun-exposed areas of the body.
Porokeratosis of Mibelli: This is the classic porokeratosis, in
which small multiple eruptions up to 2 cm in diameter occur
symmetrically on the extremities and face.
a
b
Linear porokeratosis: The onset is between birth and early
infancy. The eruptions are arranged in band-like or linear pattern.
Localized porokeratosis: A large, solitary, localized eruption
occurs.
Disseminated superficial porokeratosis: Multiple, disseminated, small eruptions coalesce.
Disseminated superficial actinic porokeratosis: Multiple eruptions occur on sun-exposed areas of the body, particularly the
extensor surfaces of extremities in adults.
Porokeratosis palmaris et plantaris disseminata:
a Small
b kera-c
totic papules occur multiply on the palms and soles.
Pathogenesis
Porokeratosis is induced by epidermal clones that cause localized dyskeratosis. It may be triggered by sunlight, external injury
or aging. Some cases are autosomal dominant.
a
b
c
d
Pathology
Acanthosis and hyperkeratosis are found at the periphery of
porokeratosis. The rim of the lesion is elevated, and there is
cornoid lamella, a column of incompletely keratinized cells that
stain more brightly than the peripheral horny cell layer. Underneath the cornoid lamella, the granular cell layer is absent (Fig.

Clinical images are available in hardcopy only.

Clinical images are available in hardcopy only.

Clinical images are available in hardcopy only.

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d

Clinical images are available in hardcopy only.

Fig. 21.3 Porokeratosis.

a, b: Porokeratosis of Mibelli. The eruption is
keratotic, with an elevated rim and a diameter of
about 2 cm. c: Disseminated superficial actinic
porokeratosis. d, e: Disseminated superficial
porokeratosis. The eruptions are 5 mm in diameter and slightly elevated at the edge.

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Benign Skin Tumors

lesion

normal area

21.4). Thinning of the epidermis accompanied by parakeratosis is

present in the concave center of the lesion.
Treatment
Excision, electrical coagulation, cryotherapy, dermabrasion,
and administration of retinoids are the main treatments. Porokeratosis is chronic and intractable.

Fig. 21.4 Histopathology of porokeratosis.

The cornoid lamella (arrow) around the lesions
can be observed by the naked eye as an elevated
rim of the skin lesion.

B. Follicular tumors
1. Trichofolliculoma
Small, smooth-surfaced, dome-shaped tumors or papules
5 mm to 10 mm in diameter occur, most commonly in the nasal
region and its peripheries (Fig. 21.5). Trichofolliculoma is characterized by small keratotic cavities with several immature woolly
hairs at the center. The pathogenesis is unknown. Trichofolliculoma is considered a benign tumor in which the entire follicle
including the inner root sheath, outer root sheath, and dermal hair
papilla differentiates.

Clinical images are available in hardcopy only.

2. Trichoadenoma
Fig. 21.5 Trichofolliculoma.
There is a small keratotic concavity at the center
of the lesion. Many fragile young hairs are present.

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Hyperplasia, Adenoma,
Epithelioma

MEMO

Benign tumors in skin appendages are classified by the degree of cellular differentiation.
In order of least abnormal (most differentiated) to most abnormal (least differentiated),
they are hyperplasia, adenoma and epithelioma. When the degree of cellular differentiation is lower than that of epithelioma, the
tumor becomes a blastoma or malignant
tumor. A tumor that has components of all
three germ layers (ectoderm, mesoblast,
endoblast) is called a teratoma. The diagnostic name epithelioma may also be used for
malignant tumors such as basal cell epitheliomas, which are synonymous with basal cell
carcinomas.

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A firm, solitary, elastic nodule 1.5 cm or less in diameter

appears, most frequently on the face. It is thought to be a tumor
whose morphological differentiation falls between that of trichofolliculoma and that of trichoepithelioma. The border
between the normal dermis and trichoadenoma is clear. There are
multiple keratin-containing cyst(s) and solid masses of cells in
the dermis.

3. Solitary trichoepithelioma
This is a benign tumor derived from hair germs that differentiate into various hair components, such as hair follicles, outer root
sheaths, and hairs. Small, firm but elastic tumors of 2 mm to 5
mm in diameter and normal skin color occur around the nose,
eyebrows, upper lip, and chin. It is nonhereditary. Solitary trichoepithelioma histopathologically consists of a small keratincontaining cyst(s) and basaloid cells, and there is proliferation of
dermal stroma. It may be difficult to distinguish from basal cell
carcinoma; however, in most cases of solitary trichoepithelioma,

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