43 Pediatric Skin Lesions
Cutaneous lesions are common in children. Although almost always benign, they may cause psychosocial morbidity and anxiety concerning malignant degeneration. This chapter reviews the diagnosis and management of the most frequently treated pediatric skin lesions: acrochordon, dermoid cyst, epidermal cyst, epidermal nevus, granuloma annulare, hypertrophic scar/keloid, lipoma, juvenile xanthogranuloma, mucocele, nevus sebaceous, neurofibroma, pilar cyst, pilomatrixoma, Spitz nevus, and verruca vulgaris.
Cutaneous lesions are common in children and frequently are managed by pediatric plastic surgeons. They are almost always benign, although some can be premalignant. Skin lesions may cause a deformity and psychosocial morbidity. Patients and families often are anxious about malignant degeneration. Most conditions are diagnosed by history and physical examination; imaging or biopsy rarely is indicated. Lesions necessitating removal usually require a general anesthetic in young children; adolescents may tolerate excision using local anesthesia. This chapter reviews the most common pediatric skin conditions that are encountered by plastic surgeons: acrochordon, dermoid cyst, epidermal cyst, epidermal nevus, granularum annulare hypertrophic scar/keloid, juvenile xanthogranuloma, lipoma, nevus sebaceous, neurofibroma, mucocele, pilar cyst, pilomatrixoma, Spitz nevus, and verruca vulgaris (Table 43‑1).
Most cutaneous lesions can by diagnosed by history and physical examination. Age of onset (congenital or acquired), changes in appearance, and symptoms (e.g., bleeding, infection, pain, ulceration) are elicited. Examination should assess color, location, mobility, size, symmetry, and tenderness. Pinching the lesion in relation to the surrounding soft tissue can determine the depth of involvement. If the skin can be approximated over the lesion, then the abnormality is located beneath the integument (e.g., dermoid cyst, lipoma, etc.).
Imaging rarely is indicated if (1) the diagnosis is uncertain despite clinical evaluation and (2) the results of the study will influence management. Generally, ultrasonography is the first-line imaging modality. It can distinguish solid from cystic lesions and assess vascularity. Magnetic resonance imaging (MRI) or computed tomography (CT) is considered if ultrasonography is unclear. Biopsy to elucidate a histopathological diagnosis prior to extirpation usually is unnecessary. If removal is required, definitive diagnosis will be confirmed with an excisional biopsy.
43.3 Nonoperative Management
Asymptomatic lesions with a low malignant potential can be observed and followed serially. Nonexcisional treatments (e.g., dermabrasion, laser) may be used to improve the appearance of some cutaneous conditions, but the cancer risk is not eliminated and fibrosis may complicate later histopathology.
43.4 Operative Management
Skin lesions are excised because of (1) symptoms, (2) malignant risk, or (3) aesthetic concerns. Removal of a lesion that is likely to cause psychosocial morbidity can be considered between 3 and 4 years of age when self-esteem and long-term memory develop. Most cutaneous disorders that necessitate extirpation are lenticularly excised and closed linearly. Round facial lesions may benefit from circular excision and purse-string closure to give the shortest possible scar. A second stage can be performed to convert the circular scar into a line. Subcutaneous lesions are removed using an incision (or small skin excision) over the abnormality. Disorders beneath the skin usually can be resected with a scar that is shorter than the diameter of the lesion.
Acrochordon (i.e., skin tag) is a common pedunculated fibroepithelial polyp. It exhibits epidermal hyperplasia; large lesions may have an adipose component. Acrochordons are soft, flesh-colored, and can be sessile or pedunculated. They have a predisposition to develop in skin folds (e.g., neck, axilla, groin) and occur more frequently in diabetic or pregnant patients. Large lesions can cause discomfort and deformity. Symptomatic acrochordons are usually treated by excision; cryotherapy is a less common option.
43.4.2 Dermoid Cyst
Dermoid cysts are congenital and usually located on the face or cranium. Lesions contain ectodermal and endodermal tissue; lining consists of keratinizing squamous epithelium and pilosebaceous structures. Orbitofacial dermoids are caused by dermal and epidermal cell displacement along embryonic lines of fusion. They are asymptomatic, slow growing, and most frequently located in the frontotemporal, nasoglabellar, or orbital area (the most common site is the lateral brow; Fig. 43‑1). If a dermoid is suspected, imaging is unnecessary unless the lesion is along the nasal midline. MRI is obtained to determine whether a midline nasal dermoid extends intracranially along a tract. Dermoids located over the nasal bones have a low risk of intracranial extension, while lesions involving the nasal tip have an approximately 50% risk of intracranial communication. Brow and orbital dermoids usually can be removed through an eyelid incision. Nasoglabellar dermoids without intracranial involvement can be excised directly or using an open-rhinoplasty approach. Dermoids with intracranial extension may require a nasal and coronal incision with a craniotomy to remove the entire tract.