he is sick uh I don't know he got but um he asked me to teach today so I told him I would because I like to teaching you guys you guys are my favorite class I've had this semester hey anybody else likes Skittles I don't have any for you but there's there's they say this they said all the Skittles Taste the same the color just tricks your brain to tasting different is that true anybody heard that they all taste the same I I don't know the science but I think everybody's T are a little bit different I know it's stud shown it's different with age which is why when you're a kid you don't like vegetables and when you get older you're like oh I like salads and stuff like that like your T CH I don't know I don't know the the science behind skle but anyway we'll get into the lecture for neop all the different types of Skittles who we're going to be talking about all the stuff I I say um we're discussing beny NEOS we don't go too too deep in the weeds oh yeah one more thing if Mr boo on the lectures that he teaches if he tolds you ah don't worry about the slide I'd worry about it just because uh he doesn't WR a t um uh some of the students told me they said hey uh just let you know Mr boot said don't worry about Fitzpatrick was that me the Fitzpatrick skin and then there was a question on it so I'm trying to get that question back for you as well um I had to withdraw because after I submit the paperwork they kind of publish and I was like hey don't don't publish yet I'm trying to um change it up and I'm trying to get that questiona you um that's the only one I'm taking not cuz I don't want everybody be like well you didn't talk about this thing this too so I'm like oh well it is what it is but the the two people that told me thank you for that and for future reference on this block if he told you don't worry about it I probably still study it anyway just because it could be on the test um until he writes questions I I me I don't know we'll see what happens all right for the classification of benign plasms it just kind of breaks down I'm not going to test you on this slide and you can trust that um but here we go subia keros most common Bine cutaneous neoplasm you guys know I like to test on most common those are low hanging fruit and I'm not saying I'm going to ask you a question on what's the most common Bine cutan plasm but if I do happen to ask you that it's going to be one of the easy questions for you to get so ideology as you can see right there prolifer proliferation of imature Cal sites possible reaction sun exposure so there's some studies that show possible the more sun exposure you get the more seate cares you can get typically ra from m to become a popular rotus I have seen these CO as well um I'm not saying they completely join forces and margin stuff like that but if a person is more prone to getting these and they have a lot of s exposure they can get so many to where they look like they're connected sever your keros keratosis common presentation middle-aged elderly there's a theory like I said the reason it's coming in from uh middle HL ladies because over their lifetime they have sun exposure and it takes time for them to develop um continue uh greater number in lighter skinn individuals the theoretically because they take more some damage as well because they don't have as much melanin tends to be hereditary um as you can see right there on the bowl stuck on greasy appearance that's what you see on the pantess and that that's what you will see if I ask you a question about these in the vignette if I tell you uh a person comes into the um Clinic complaining of of these lesions that look on stuffy like like they're stuck on your skin greasy like you can feel PE them off I'm more likely going to talk about seate keratosis if the person's middle aged or elderly and they have them all over the skin and it says that they have chronic sun exposure uh location areas space back chest those are all areas you can get in you can get them anywhere um usually Pro to Sun exposed areas and Sous areas potential none when doubt biopsy now you're going to see that that phrase uh no mum potential but went in doubt the reason it says that is because all these benign lesions are going to be benign right that's that's the title of this lecture but you're not going to know if they're benign if you're confused about the diagnosis or you're unsure in clinic so if there's any doubt in your brain of the diagnosis you should biopsy it so you can get the determinative diagnosis does that make sense to everybody now when it says Milan potential none of course it's going to be none but when you're in a clinic it's a little bit different when you're looking at a lesion and you the PA support historian it's better to be safe than sorry so if you have to biopsy biopsy it that's the safest way to figure out what it is and get a definitive diagnosis and see if it is benign because in dermatology everything looks like everything else um so we'll keep going this is a little chart SK versus melanomas gives you a little differentiation in pictures but it also give you some key terms in the uh in the verbiage as well when biopsy out as you can see right there you can use a hands lens you'll you'll get more practice with a hands lens when you get to phase two it's called a dermoscope when you're doing your Dermatology rotation they'll give you a little dermoscope uh to use but you have to turn it back in when you're done with rotation it to every student it's just a little light microscope that you can put on the skin to get magn magnific magnified a magnified appearance um SKS preserve a uniform appearance over their entire surface it's one of the keys when you're dealing with melanomas they can have a high podge of or I should say a varities of different textures on the same Legion with SK they tend to be uniform throughout the entire Legion now I'm not saying that every lesion looks the same on their entire body what I'm telling you is with that particular lesion on the texture it's usually uniform throughout that particular lesion U melanomas have smooth surface and colors so can that SK they can have different colors usually it's some type of shade of brown um I have seen them very very dark though need differential diagnosis uh at the surface so as you can may have guessed you want to look at it through AB dermoscope you want to compare the structures on the in in the entire Legion to make sure it's uniform and when in doubt you want to cut it out so you can send it to send out to pathology the recurred hostess management no treatment needed because it's denying now if you have to treat it um you can use some of these methods liquid nitrogen Cur curage save and may recur after treatment now these lesions can grow uh back after you cut them out but a lot of times will happen is if you cut these out new ones will occur because if you're cutting it off an area that has a lot of sun exposure and of elderly they going to get them again and again and again um but since they're benign if the patient has no problem with them and they're not inflamed or anything like that you don't have to cut them out you need just give them reassurance if you want um on the other hand if their subate keratosis gets inflamed from rubbing on belts or clothing or something like that maybe it's on the collar and it's very large they can get inflamed and if they are currently get inflamed you can remove them as well hosis is excellent Moma in dark lesions um what I mean by that is when subate keratosis get very very dark and you're concerned like it's darker than the rest of lesions like a this one cuz you'll notice you you'll notice it when we talk later about the melanoma lecture if one aerosis is darker than the rest on the on his entire back or or his shoulders you be like well that one's really really dark and it's standing out to me I'd like to I'd like to remove it just to make sure it's not anything malignant that's something you can do and just make yourself and the patient feel better the Lesser Trot sign is a sudden appearance of multiple SKS so what I mean by that is the typical appearance of these is middle age elderly on sun-exposed areas hereditary tendency right but if they're completely normal one year and you come back they come back the next year and all of a sudden they have a cluster of sub perosis on some part of their body that wasn't at all there the year before that sudden appearance is concerning that can be a sign of internal malignancy now I'm not I'm not giving you specifics on where the internal malignancy is but that has shown to be a thing um with internal Delancy now I'm not saying all internal elegancies are going to show up with the Lesser trail out sign of a bunch of separate characteristics but if you have a patient that's completely normal with no SK and then you come back for the year followup and then there's a cluster them out of the blue from nowhere you're like okay that that's a little abnormal I mean it's it's uncommon for you to get them all at once um so we're going to forther evaluate does that make sense everybody cool there's some videos if you want to watch uh treatment procedures I'm not going to test you on treatment procedures but if you want to watch they're on YouTube and you can just check them out you can just Google that as well on YouTube and then um you'll see these procedures varant variations and appearance all these right here are different sub keratosis which is why it can easily look like melanoma if one's darker than the rest so you kind of want to talk to the patient see how long it's been there and then figure it out if you want to remove it these are different sub kosis on a person's back that as you can see they're different shades they're different sizes the textures are a little bit different but if you look at each individual one with the dermoscope what you should see is a uniform pattern throughout that particular Legion like the surface should be a uniform texture uniform color now as you can see the different C kosis compared to every other Legion they may be a little bit darker a little bit bigger but that's completely normal but throughout that particular solitary Legion when you're looking at a dermoscope it should have around the same shade and it should be the same uniform texture of the of the lesion this one right here shows one that's inflamed that's what I was talking about if there's one that's particularly inflamed um this one happens to be on a female's back and any guesses why this one get inflamed right the back of the BR St right that's where it may hook um this one's getting particularly inflamed so if that one continues to get inflam bleeds and scav up you can remove it for comfort and anytime you remove anything from the body you always want to send that pathology so they can make sure it is the diagnosis that you were talking about and make sure it is deny difference sub kosis as you can see right there there's multiple in one location and they're kind of close together which is what I was trying to tell you if you get them growing large enough and close enough they kind of look like they coales even though they don't really join margins or anything like that you just have a lot this is the next thing we're going to be talking about sub I'm sorry stucco keratosis this is a vascular insufficiency uh condition xerosis just means dry skin I think we talked about in the previous block as well theine proliferation of kosy is more common in elderly lighter skin patients with peripheral edema because it's a vascular insufficiency issue right you can see these little white uh the little white lesions on their skin morphology as you can see right here one once 10 mm they tend to be round they tend to be dry they can't have a stuck on appearance but usually these are not brown like subate characteristics they don't have a greasy appearance to where they look like they they um can be peeled off these tend to be lighter and wider um ankles I me light ankles are a common location for this also the dorsal aspect of the feet you rarely see them on the plantart aspect of the feet it's a different texture of skin and everything like that in addition this is a vascular insufficiency problem so a lot of times lower extremities are going to be commonly affected with this forearms and hands can also be affected as well management not required um or desire you to pour healing so when you cut into these because they're occurring in an issue with a vascular insufficiency problem when you cut into these and you try to remove them you can open a can of worms with problems infection redness poor healing those are all things that can happen so if they're not problem problematic you may want to reassure the patient on the other hand if you have a patient that it's um they're getting larger and they're getting inflamed you can but you want to give them the heads up when you remove these you you maybe opening up the can of worms prosis will recur because they still have a vasular insufficiency problem completely benign just like everything else in this lesson PL this is what they look like don't look like sub keratosis they can have that stuff on appearance when you look at them with the dermoscope they tend to not be the same color at all and with the sub keratosis you notice that it's usually on sun exposed areas something that has chronic sun exposure next we're talking about dermatosis papulo anra smaller SK due to the U due to darker skin tones 2 3 mm Dome shaped papules they can be Brown to Black depending on the person's skin tone hyperic and they can be pedunculated pedunculated just means they have a stock underneath the wide uh surface and female has fance of getting these location cheeks around the eyes and areas where there's sun exposure foration team middle age we can't have a hereditary component more common in African-Americans and Hispanics anybody has more melanin can get these completely B and I'll go back to this I'll just give you example what they look like go back to the stream plan just said what they look like all right management no treatment needed Direct by the patient for cosmesis which just means a better uh cosmetic appearance now these rarely get inl because they don't tend to rub up against clothes or anything like that but outliers being outliers if you you do have one that's getting in flame you can remove it a lot of times these don't get in flame be careful when free freezing because these lesions tend to be in individuals with more melanin they have uh they have darker skin tones right freezing and liquid nitrogen can cause hypopigmentation you definitely want to discuss that with patients before you do that even if they want it small lesions you can use scissor Snips larger lesions you want aning room with a shav or a scissor um biopsy the larger lesions think of it this way the bigger the legion the more blood supply I have seen some Legions be big enough to where they had um a larger blood spy than the smaller ones and it takes a little bit time uh with pressure to keep from the bleeding from um continum and this are pictures I showed you before what's that actor's name the one on seven not B the other one Morgan Freeman you ever seen thatg frean he has those around his eyes all right skin tags Acro Cordon skin colored to Brown I have seen these are very very dark all depends on patient skin tone soft undulated um 1 mm to 1 cm now it say 1 mm to 1 cm in meat but these can be very very large uh depending on how long they've had them location location is areas rubbing eyelids neet gr buts axilla waste those are all areas that can get them but if you have um I have seen them on inframammary folds I have seen them on a on a panis around the abdomen anywhere where there's skin to skin contact and friction you can get these um when these are removed you're not R you're not removing the friction component so they you can get them again and again and again presentation 25% after a 25 the age 25 more common in obese patients you may have yes because skin skin contact they have more skin folds and stuff like that and uh the friction component is still going to be there small lesions may not require anesthesia larg lesions you want to NES tize an excise just like the other lesions the larger the lesion the more blood supply you have to realize that if it's a large lesion you may have to prepare for uh for clotting and blood control so you may have to apply pressure I have seen these um uh cariz with silver nitrate anybody familiar with silver nitrate have silver nitrate s are used to cauterize they damage the skin um sometimes because it's a costic agent and it stops bleeding but it burns the tissue as well um what you should be familiar with silver nitrate if you use them and and there's nothing about silver nitrate sticks on this lecture but I'm just giving you a heads up when you clip these little skin tags off pressure can help with the bleeding if you use silver nitrate the silver nitrate can be absorbed in the skin and it can leak underneath the tissue I saw one guy he got a lesion removed from his forehead and they cized it with silver nitrate and they didn't tell him it was going to leap through his skin and it started draining down the side of his face underneath the skin because um that's the way the lymphatic system works but it can leak into the tissue prognosis for skin tags oh sorry about that excise uh they won't regrow but you don't take away that friction com right so they're going to get more potential completely benign but anytime you remove anything you want to send it off pathology to confirm that it's nine this is what it looks like looks like some guy's sco on the top but I you got skin tags right there all right there's an axilla and this one is very large what should you think about with this uh very large um skin tag large blood supply right so if you remove this and you have to be prepared what happens if this doesn't stop bleeding like what are you going to to do and you can only apply so many silver nitrate s and in addition silver nitrate s only work when um when you don't have cooling blood because like I've seen some Legions cut off and it's bleeding very very very very fast it may have Mi may have miit the blood supply and you're like okay spilling up too fast I can't silver nitrate it because it's not effective unless silver nitrate is applied to uh live tissue does that make sense so nitrate does not work on a pool of blood you're not going to be able to cariz tissue you got to think about that I have seen individuals get stuff removed um the elliptical incision couldn't be closed properly and they keep Ling so they called it an ambulance before thankfully it wasn't me it was another new provider but um things happening you have to have a plan ABC to to best take care of the patient a larger lesion you should also consider if if it's covering a large surface area sting them out to Dermatology or something like that to where it's uh more specialized hands and in closing regions as well whenever you do an elliptical you should always examine the surface tension of the skin because if it's very tight skin it's not going to close very easily so always kind of feel the skin make sure it's very pliable and stretchy so that you can have enough um laxity to where you can close the legion does that make sense to everybody cool cool drat fibrom fibrous reactive process to trauma a lot of times I um you get these to unknown trauma now it says in the beef they get these from trauma but when you ask patient they're not going to be like oh I did this and then this thing formed they don't usually come to you until it's already been there for several weeks and then they're like hey I don't like this can you remove it and then you go from there continue on collection of fiberblast ands andyes so it's a collection into different cells if when you send it off to pathology peric or Tender early and becomes asymptomatic so at the first sign of trauma for example if if they get them I I've seen these a lot on individuals that shave their legs uh the reason I say individuals is because different people shave their legs with that being in mind when they shave and they n themselves or something like that that can be the trauma that starts the process to form these D fibras now a lot of times when they first start off they can be itchy and they can be a little U tender when you're pressing on them but after a few weeks they become non- tender whatsoever and then you get this reaction if you squeeze uh if you squeeze the lesion around it it tends to Dimple into the skin I'll show you a picture in just a sec morphology 3 to 10 mm I haven't really seen them bigger than that but um depending on how big the TR is they theoretically can get bigger retract benath skin with compression which is dimpling and when I say compression I mean cor compression around the sides like you're squeezing a pimple or something like that it'll depress into the skin location anywhere on extremities and trunk interior legs most common shaving and anywhere the person shaves they can get these lesions shoulders upper back as well now I'm not saying that the person shaves on their shoulders or upper backat but anywhere there's trauma on the skin as you may have seen in the past slide you can get from bug bites as well they don't resolve spontaneously so these will not go away on their own if the patient wants them are removed you ask a reason why and then if you feel it's just why you can go ahead and do it punch biopsy uh or you can remove these with punch biopsies just remember that punch biopsies if you use them for larger lesions when you close these these are not like an elliptical Legion it's a circular so when you close them up they tend to have uh dog ears at the end which is tented skin at the ends of the uh at the ends of the uh incision once you suture it up conservative Crow surgery to decrease the color but it does not get rid of the lesion completely it just changes the surface color you will still have the histiocytes and the Fib blasts underneath the tissue that cause dimpling and these are completely benign just like everything else s this is what they look like they can PUD a little bit from the skin this individual is a lighter or a fair skin patient and the lesion itself is a little bit darker once again this is another example CHS a little ruler so you can uh document the size and when you compress the tissue along the sides it tends to Dimple into the skin this is not to be confused with neurofibromas which you give digit pressure directly on it with dermatomas you diagnose them by squeezing on the side and they tend to Dimple into the skin all right hyperopic scars are keloids these tend to be raised they can be red or hyperpigmented which means darker than the rest of the skin they can be firm or shiny hypertropic scars differ from keloids because keloids tend to grow beyond the bord of the incision uh borders for example I shouldn't say incision I shouldn't say trauma for example if they have a tear in the skin hyperopic scar will be confined to the wound site where choid will go beyond the wound site for hypertropic scars they can occur any place kids most commonly on the shoulders and chest but any skin surface I've seen them frequently on patients with pierced ear loes anybody seen uh anyone that get their ears pierced and I'm not saying you particular one of them but you see someone's um ears pierced and then they get these little bulges on the back of their airloads that's what these are the kids clinical presentation predisposed individuals wounds with secondary infections wounds overheal with hypertrophic scars it tends to soften over time but they can be puic or painful long term and that's a case by case depending on how the incision or the trauma heals hyp scars and kids management there's no Universal treatment interly uh but the ones below are routinely effective treatment now you're going to have to if you decide to treat these in clinic you're going to have to figure out what works best for the patient because there's no one treatment plan that works for all of them a lot of times you get inal steroids direct injected directly into them sometimes they use cryotherapy especially for color changes if it's not too big just remember if it's a dark Darkly pigmented individuals use cryotherapy it can cause hypopigmentation of the skin cic and gel sheeting has been shown to be beneficial but it's hit Miss just like everything else in Regional 5fu that's that that's that uh that top treatment that you can give um that has shown benefits and then lasers as well now none of these are 100% the reason I say that is because you have to brief the patient on every every one of these treatment options before you give it and you have to go through the informed consent just like everything else in addition when you're damaging these tissue um the reason you get hypertrophic scars and chids is from initial trauma anyway right when you're removing these or giving these any treatment it can the body can respond to more trauma and they can get bigger hosis um so abnormal so history of abnormal healing should avoid trauma to the skin what I mean by that is if you have individuals that you see hypertropic scars in or coming in and or they have kead on their shoulders or that you should let them know hey I I noticed you have this you should probably avoid any trauma to your skin if possible um because you're prone to getting these and these are hard to treat can recurve treatment stops continue collagen production because they can get bigger and bigger and bigger looking potential as you may get and this is back of an ear someone that gets their ear pierced they get these chids in the back of their ear kind of hard to treat I've seen interal steroids be beneficial and I've seen other ones that get interal steroids and there's no benefit at all in addition I have seen these remove surgically because they're so big and then they recur because it's trauma to the skin it's kind of like a never ending cycle with these here's another example right here overgrowth of tissue and it's beyond the borders of the the initial trauma that's a choid the kids the uh back of the shoulder the shoulders and the back are very common areas to get these now here's a keid on a hyperpigmented individual can anybody tell what the initial TR was so it looks like surgery so as you can see at the end right there towards the right the little dots are where the stitches work and the chids are not necessarily form on the initial incision but more so where the stitching was another example on the chest or example on the chest this is a just remember with any dermatologic condition if it's severe enough it can be debilitating and you have to go over their mental health as well all right next one we be talking about is C aanta relatively common benign of helal tumor these tend to be solitary uh smooth Dome shaped red or popular tumor they can have rapid expansion to 1 to 2 cm and a distinctive Central hyper carotic core as you can see in this in this picture it's a distinct hyper carotic core in the middle location of these is the most common anywhere that set exposure it can be um on the hands as well and the arms face check trunk these are face chest and trunk these are all areas that can you can get these lesions as well now with these the thing you want to remember especially for pants is these are often indistinguishable from Squam cell carcoma clinically and histologically so you're going to want to remove these even though you suspect her aoma because you have to be sure and they can look very very similar on appearance so you're going to want even though the biopsy report will come back that these are benign you don't want to chance it because you don't want to miss schoc carcinoma management excision for cosmetic and functional diagnosis s pathology to rule out SW carcoma if there's multiple and recurrent you can use 5 Fu or methotraxate now the reason I say that is I don't mean oh you see a bunch of Paras let's give methotraxate or 5 Fu you want to remove a couple just to make sure that the diagnosis is Squam carcinoma now whenever you put um five F you it damages abnormal skin so it's um something that's very effective when you have multiple because you can put it all over the area and it won't damage the normal skin it'll damage the abnormal skin which is why it's useful at get getting rid of these but you should definitely have on record that you biopsy a couple of these so you can make sure that they're CR hels there's an example one large hyper carotic core there's another example right here these can look differently he can be on different locations this one's very very large on the top of the year you're going to want to make sure your biopsy make sure it's not swam cell and I'm not saying that you should tell individuals hey you have swam cell don't put anything in the record that you have not a confirmatory diagnosis on especially when you're biopsying it to confirm what you can put in the record is what you what you um abnormal lesion you can put C eoma but person that's a little bit harder to take out of the record so I would be careful with what you're diagnosing and documenting the record they can be large and just remember when they're large you have to consider how much tissue is going to be taken out when they remove these lesions they're going to have to reconstruct this individual's uh nasal tissue to make sure it's fully functional because not everything heals by secondary intention what I mean by secondary intention it means cut off a chunk of the skin and let it heal on its own any area that's covered um skin covered cartilage tends to have poor healing with secondary intention so for functionality especially with this individual where it's on the bridge of the nose and lesion prev I probably send this individual to Dermatology a lot of times Dermatology they'll have a individual there A lot of times surgical PA that has surgical experience that knows how to manipulate the tissue and take uh skin graphs from other areas to the area next one we we talk about is cutaneous horn white to Yellow hard carotic can be chical lesion which means conik Sun exposed areas is common men more than female um elderly and Par complex now on this right here it's important the the top line is important now the cutaneous horn itself is a benign Legion like the horn that hard hyper tissue but the base at which it's growing from can be concerning one out of every 20 bases that the cutaneous horn is growing from is Squam cell caromal or Squam cell inside you so it's not the cutaneous horn itself but the base at which it's growing from can be problematic in the future for treatment for these it's going to be exision may use a sha biopsy liquid nitrogen just remember when you're using liquid nitrogen for these you tend to damage the base so keep that in mind as well next thing we talk about Sous hyper plous small ters of enlarged sebaceous glands morphology begin in small yellow capules um surrounding sebaceous gland like appearance as you can see this is an individual cheek as area that can get these Legions and he has a couple on his cheek right there they tend to blend in with the skin if they're not darker than the rest of the patient skin tone location is a common location is going to be the face as you can see in this picture ideology is going to be a collection of mature sebaceous glands CL presentation some damaged areas with a patient that has oily skin a lot of times the individuals are above 30 no treatment is required for these just because by Nature they're going to be benign just like the rest of this lecture but if you do want to remove them you can use a a curette or a shave or electri surgery electric surgery is just electrified blade that cauterizes while cuts take care uh to prevent scarring lesions can extend into the dermis anytime it's past the epidermis like we mentioned before anytime it's past the epidermis and you're cutting into tissue you can leave scars if many lesions you can refer for isoo treatment but then they're going to have to go through that whole dermapal and make sure they get the labs done and make sure they have six months in treatment and stuff like that um so hypas with like tasas May must differentiate from basil cell carcinoma because a lot of times with basil cell carcoma we'll go over that I think in three lectures M Mr boo should teach it delic tasers can be an indicator that's basil cell carcinoma phases do not mean directly basil cell carcinoma but basil cell carcinoma is one of the many conditions that can have AAS so you want to be concerned with that as well you want to use dermoscope to differentiate as well hosis and people with spaceous skin will these will recur over and over and over and this what they can look like a lot of times on the face brow cheeks chin close up with the dermoscope this is what it looks like and this is the initial picture that we showed you this individual has multiple as you can see on his face they don't necessarily have to be close together but I mean they get them in different areas this one looks a little bit different this is under the nasal fold as you can see right here you guys need a break someone said yes right all right let's take uh 10 minutes let started 2 we covered around 60 slides we got about 30 left and make it quick I go to class let me know after the lecture I'll try to slow down next time all right next one we'll be talking about seringa it's a sweat duct tumor probably important to know morphology 13 mm small firm flesh color these tend to be around the eye also the lower Lids clinically they tend to happen with young women any age but can happen around the 20s and 30s at least that's a lot of the times where they come into Clinic uh to get them seen these tend to be asymptomatic and as you can see right there here's a picture of an individual with with stearing over searing all over the lower lid for treatment it's going to be benign so none is required in addition you have risk of scarring uh the young skin what I mean by that is since they're um tissue tends to be around the eye with sering over you want to be careful because anytime you try to treat these if you cause any dysfunction with the lower lid or blinking function period you may be messing with the eye as far as dry eye syndrome and stuff like that so be careful with this for cosmetic removal you can you you can do electrication and cage according to you can also shave with an 11 blade but anytime you are around the eyes anecdotally I tend to refer out to Dermatology if they want treatment for these so you have to be careful but if you have a steady hand and you are comfortable with doing this and you get a preceptor to teach you or even a season um clinici at your clinic you can do these if you want if you feel comfortable in clinic anytime you do um any new techniques you should always have preceptor or a season provider to OverWatch just to give you a hand if it gets out of control prognosis after appearance uh stable after I'm sorry prognosis after you remove these you treat these it they tend to be stable and these are benign just like everything else in the seure this is what they look like up close I have had individuals come into the clinic they were unnoticeable uh to most on the naked eye but patients are uh can be very critical of themselves and they want them removed a lot of times I'll refer mod to Dermatology just because if it's anywhere near their eyelid especially the border to where they have problems blinking um it can be problematic next is neuropa the nine tumors that grow on the nerves throughout the body these are not specifically limited to any particular part of the body they can happen anywhere because we have nerves everywhere ideology it's a nerve sheath tumor apology flesh to Pink to White of andun related what was that somebody have phone on all right just refer to OC CH recording don't record stuff on your own hello my name is all right um bu hole sign when you push on the skin uh tend to invaginate through with digital pressure um location can be anywhere clinical presentation they uh tend to be waxy on um a first appearance but they can appear anywhere frequently they appear on adolescence um with different conditions such as one rickland housing or neuro fibromatosis type one they can have an over cropping of these lesions you want to be careful because if they have certain syndromes that predispose the individual to getting these they can have other problems as well the reason I think that's important is because with these neural fibromas if you have an individual that has not been fully assessed the neural fibromas may be the tip of the iceberg and you may be the the Pinnacle provider that diagnoses these individuals and gets them the workup they need with management there's no treatment for these because they're uh benign but they can be bothersome in certain areas that rub so you want to excise these or get a specialist like dermatologist excise as well for prognosis they don't recur after they're removed but a lot of times depending on the severity of the condition they can have them all over the body since it's a nerve sheath tumor if if it's covering a large surface area you're not going to remove all of them followed by nuro and Specialties so uh as we talked about um before the nine but if you have two or more such as bin H or neurofibromatosis type one can become cancerous later on now the subset of the neurofibromas that are in these conditions do not meet the other criteria like we said benign for all these Legions if you have a syndrome that's causing the outbreak of the neuroone on the body these subsets can become cancerous and can be concerning this is what they look like it can look like as well and this is an example of a person with a lot of them on their body and you're not going to remove all these nerve sheet tumors it's going to be if you remove all these is going to be moving a lot of the surface area of their tissue and it's going to be very stressful for their body they can be grouped together as well and they can be very very large so the larger they are the more blood supply that they may have you have to control the bleeding and anytime you remove any lesions you should always consider the blood supply and you have to control it next thing we be talking about is CH angomas most common vascular malformations you know the ubiquitous and people older than 30 what what if you don't know what ubiquitous means is can be all over their skin morphology 0.5 to 5 millimeters they tend to be deep red papules and these can bleed if they're ever Nicks or anything like that Trunks and proximal extremities are the common areas that are affected by these and you can have few too many this is an individuals front of their torso treat can be unnecessary but if you want to remove these you can use a shave or shave excision you can use electricy to cize as you cut a lot of times if these are niit they can bleed a lot especially if they patient Nicks them on their own since these can occur anywhere if you nick them with like a razor while shaving they can bleed and a closeup of what they can look like also how small they can be in compared to other lesions as you can see in the center of that picture it's a larger one you can have the very small ones throughout the skin and this is what it looks like that corner is how it looks like under a microscope next one we talk about is tasas these are dilated blood vessels you can have anywhere on the body on the skin even the GI system they are not limited to to the outer skin you can get them pretty much anywhere and it's just a term for permanently dilated small blood vessels they can be a diameter of 1 mm appear at single strands or they can get grouped um which will show you a next slide of spider angomas they can accompany a variety of diseases the reason I say that is because a lot of times even though tases can be a diagnosis especially if you can't correlate with anything else there are several different conditions that will predispose an individual to getting to Lang patients spangas is one of the types as you can see right there there's a picture of it they tend to have have arterials that tend to Fan out from the center for treatment for these you can use Electro desiccation or laser and if it's anywhere on the face depending on the bleeding component and stuff like that and risk I usually refer this out anecdotally but if you're comfortable to Trea Museum Clinic you can have at it here's another example right here so spreading out arterials and these little dilated blood vessels they're just toing Pages all right next what we talk about a pyogenic granulomas these are B acquired vascular lesions they tend to happen on mucus membrane as well as the skin uh they're common in children and young adults you want to check them out for um in pregnant females because they can have these lesions inside their mouth as well on their on their gingera may occur in cyac patients on isoto so keep that in mind in the back of your head if you're seeing it in real world Clinic these tend to be easily Frable what I mean by that is the surf the skin covering these lesions it can be torn very very easily and they have a lot of bleeding because they have l blood vessels running through them and the bleeding can be difficult to control this is what it can look like it tends to be less than 1 cm it can be yellow to bright red I've seen them very very bright red dark red almost uh Dome shaped and they tend to look like they're almost wet like if they have some Vaseline or something on them they tend to glisten you can get these on the head neck fingers and gingiva especially in pregnant females treatment G purage the base in the Border you have to get the entire Legion out or it can regrow a lot of times I'll use Electric to eradicate and then um cauterizes it cuts it out and if any of the lesion is left and not removed they can grow back there's some examples right here one's on the scal and it can be easily Miss if you don't do a throw exam uh throughout the hair one's on the bottom lip as you can see right there and these are easily Frable they're easily ruptured and they tend to bleed a lot they can be tender as well right lipoma benign tumor of Vose tissue most common benign soft tissue tumor so lipomas are the most common morphology soft pill mobile subcutaneous lesions now these can be as deep as the subcutaneous tissue so if you're removing these they may have to to inze a little deep in their tissue when it says soft and pillowy and mobile those are three characteristics that you can use to describe liom in your documentation but in addition if they don't meet that criteria for example if they're very very hard more than likely it's not a lipoma if it's not pillowy and it's not mobile what I mean by that is you should be able to grab the tissue and move it around uh underneath if it's fixed to the underlying tissue such as underneath the subcutaneous tissue and you can't move it it's more concerning you want to get someone's attention you definitely don't want to excise them out if they're fixed to the underlying tissue because it could mean that it's um not a lipoma and something more concerning in addition we don't discuss it but for real world Clinic there's a subset of lipomas it's called an angio lipoma Ang lipomas are lipomas with a rich blood supply so when you're trying to remove these just like any other lipoma and you cut it out from the base it tends to bleed a lot now since these can be near the subcutaneous tisue or connected to the subcutaneous tisue it's going to be a little bit deeper right so when you lift these up and you clip it at the base with some scissors whatever it tends to cool underneath this the skin and it's hard to control the bleeding so anytime you're removing these you want to assess how deep they are and evaluate the structures to make sure that you don't believe it's an angio licom and make sure you can control the bleeding a lot of times these can be found on the trunk and also the extremities so these can be in any age a lot of times you'll seem in their 20s they can be uh they mostly asymptomatic but if certain lipomas are on certain locations for example if I have a lipoma at the ball of my elbow and I'm always leaning on my elbow the lipomas can get inflamed which can contribute to your desire to remove them especially if patient is complaining that they're symptomatic exision or no treatment just because they're benign if they if they're small enough and they don't bother the patient and they don't want it moved you don't have to these aren't concerning once moved um they normally do not rec recur and there it can be benign if it's anything other other than the characteristics that we described if they're very very hard or if they're fixed to the underlying tissue and they're not mobile you want to bring up um another specialist to take a look because more than likely it's probably not a and this is what it can look like they can get very very big and trunk and EXT extremities are the areas that have them the most you can't have them on the scalp as well here's an example of an individual with multile on his forearm now if you can imagine if you had one underneath his elbow and he always leaned on it how it can become tender you want to be careful with that all right this is stuff we talked about where these stuck on appearance recosis skin tags with friction tag take cordons squeeze in the center squeeze on sides and it dimples in mify these house multiple regions such asuris type one neurom and if it's ad post tissue underneath get anywhere on trunk or extremity lipomas and then this one get yeah okay good job guys see you w