Benign Tumors of the Skin and Subcutaneous Tissue

have a tendency to occur at different areas of the body. The common wart (verruca vulgaris) is found on the fingers Cysts (Epidermal, Dermoid, Trichilemmal) and toes and is rough and bulbous (Fig. 16-3). Plantar warts (verruca plantaris) Cutaneous cysts are categorized as either occur on the soles and palms, and may resemble a common callus. Flat warts epidermal, dermoid, or trichilemmal.48,49 (verruca plana) are slightly raised and flat. Although surgeons often refer to This particular subtype tends to appear on cutaneous cysts as sebaceous cysts the face, legs, and hands.3739 Venereal because they appear to contain sebum, warts (condylomata acuminata) grow in this is a misnomer and the substance is the moist areas around the vulva, anus, actually keratin.48,49 Epidermal cysts are the most common type of cutaneous cyst, and scrotum. Histologic examination demonstrates hyperkeratosis (hypertrophy and may present as a single, firm nodule anywhere on the body. Dermoid cysts are of the horny layer), acanthosis (hypertrophy of the spinous layer), and congenital lesions that result when papillomatosis.3739 A multitude of various epithelium is trapped during fetal midline therapies have been created to eradicate closure.48,49 Although the eyebrow is the the papillomatous growth. Warts may be most frequent site of presentation, removed via application of chemicals, dermoid cysts are common anywhere such as formalin, podophyllum, and 48,49 from the nasal tip to the forehead. phenol-nitric acid.3739 Curettage with Trichilemmal (pilar) cysts, the second most common cutaneous cyst, occur more electrodesiccation also can be used for scattered lesions. Treatment of extensive often on the scalp of females.48,49 When areas of skin requires surgical excision ruptured, these cysts have an intense, under general anesthesia.3739 Because of characteristic odor. the infectious etiology, recurrences are common, and repeated excisions are On clinical examination, it is difficult to often necessary. Some warts (especially distinguish one type of cyst from another: HPV types 5, 8, and 10) are associated Each cyst presents as a subcutaneous, with squamous cell cancers, therefore thin-walled nodule containing a white, lesions that grow rapidly, atypically, or creamy material.48,49 Histologic ulcerate should be biopsied.38,39 examination reveals several key features. Cyst walls consist of an epidermal layer oriented with the basal layer superficial, and the more mature layers deep (i.e., with the epidermis growing into the center Condylomata acuminata is one of the most common sexually transmitted of the cyst).48,49 The desquamated cells diseases, and largely results from HPV (keratin) collect in the center to form the types 6 and 11 (Fig. 16-4).3739 Extensive cyst. Epidermal cysts have a mature growths, facilitated by concomitant HIV epidermis complete with granular infection, are often multiple and can grow layer.48,49 Dermoid cysts demonstrate squamous epithelium, eccrine glands, and large in size (Buschke-Lwenstein tumor). In addition to local destruction or excision, pilosebaceous units. In addition, these adjuvant therapy with interferon, particular cysts may develop bone, tooth, 48,49 isotretinoin, or autologous tumor vaccine or nerve tissue on occasion. decreases recurrence rates.38,39 Immune Trichilemmal cyst walls do not contain a response modifiers, such as imiquimod, granular layer; however, these cysts may also optimize long-term eradication of contain a distinctive outer layer 3739 resembling the root sheath of a hair follicle HPV-induced anogenital lesions. 4850 Because larger lesions have a significant (trichilemmoma). Each of these cysts risk of malignant transformation, close typically remain unnoticed and observation of lesion return or atypical asymptomatic until they rupture, cause presentation should be advised. local inflammation, or become infected. Once infected, these cysts behave similar to abscesses, and incision and drainage is recommended. After resolution of What is a papilloma? inflammation, the cyst wall must be Papilloma is a general medical term for a removed in its entirety or the cyst will tumor of the skin or mucous membrane recur. with finger-like projections. Papillomas are Human Papillomavirus also known as neoplasms. While the vast majority of papillomas are benign Warts are epidermal growths resulting (noncancerous), they can occasionally be from human papillomavirus (HPV) infection. Different morphologic types

dysplastic (precancerous) or malignant (cancerous). Papilloma Spotlight Papillomas can occur in areas throughout the body. Papillomas on the skin (cutaneous papillomas) are commonly referred to as warts. They occur on areas such as the hands, feet and knees. Papillomas can also occur in the nose, brain, genitals, conjunctiva of the eye, and female breast ducts. Papilloma in the throat, windpipe and lungs is a rare disease called recurrent respiratory papillomatosis (RRP). Most papillomas are caused by a virus. The human papillomaviruses (HPVs) are a group of more than 150 viruses that can cause papillomas. HPVs can cause papillomas of the skin, genitals, mouth, eyes and throat. Certain HPVs can cause cervical cancer in women. Some types of papilloma have other, nonviral, causes. For example, nasal papilloma may be caused by a tissue injury. In addition, there are types of papillomas that do not have known causes. These include intraductal (breast duct) papilloma and choroid plexus papilloma (a rare benign brain tumor most often seen in young children). Genital warts, a type of papilloma caused by HPV infection, are very contagious through sexual contact. They can also lead to a potentially serious disease, called recurrent respiratory papillomatosis, in an infant or child born to a mother with active genital warts during pregnancy. Seek early and regular prenatal care to reduce the risk of transmission of HPV infection during pregnancy or delivery. Seek prompt medical care if you, your partner, or your child, have a new skin or genital growth, whether or not it is painful, so it can be properly diagnosed and treated to prevent complications. In rare cases, recurrent respiratory papillomatosis can produce rapidly growing tumors in the respiratory tract. This can lead to complete respiratory

obstruction or blockage. Another type of papilloma, choroid plexus papilloma, can lead to increased intracranial pressure and hydrocephalus (fluid on the brain).Seek immediate medical care (call 911) if you, your child, or someone you are with, have serious symptoms of these conditions including difficulty breathing; bulging soft spot on top of an infants head (fontanel); change in level of consciousness, such as passing out; sudden change in vision; sudden paralysis; seizure; or sudden feeling of severe pressure in the head. What are the symptoms of a papilloma? Papillomas can occur on the skin and inside the mouth, throat (recurrent respiratory papillomatosis) and nose. They can also occur in and around the genitals and anus (genital warts) and in the female breast ducts. Symptoms of papillomas vary depending on where they occur in the body. Symptoms of cutaneous (skin) papilloma Papillomas that occur on the skin (cutaneous papilloma) are commonly known as warts. They can occur on areas such as the hands and knees. Symptoms can include: Black dots in the wart, often called seed warts Clusters of bumps on the skin Painful or painless bumps Raised or flat warts Rough or smooth bumps or warts Symptoms of genital papilloma Genital HPV infection is extremely common and most often occurs without any symptoms. Because of this, many people may be infected with HPV and not realize it. When genital HPV infection is symptomatic, warts appear on the genitals or anus. In fact, approximately 20 million Americans are infected with HPV, but only about 1% of sexually active adults will have genital warts at any given time. (Source: CDC).

Symptoms of intraductal (breast duct) papilloma Intraductal papillomas can cause the following symptoms: Breast lumps Breast pain Breast swelling Nipple discharge Because these symptoms may also occur with other diseases, disorders or conditions, it is important to contact your healthcare provider for a proper diagnosis. Symptoms of nasal papilloma Nasal papillomas occur in the nose and can cause the following symptoms: Headache Nasal congestion Postnasal drip Symptoms of recurrent respiratory papilloma (RRP) RRP is a rare disease caused by HPV. It results in tumors in the respiratory tract, including the throat, voice box (larynx), and, more rarely, the lungs. Symptoms may include: Chronic cough Difficulty swallowing or speaking Hoarseness Loss of voice Noisy breathing and snoring Shortness of breath Weak cry in infants and young children Symptoms that might indicate a serious or life-threatening condition Some forms of papilloma can produce serious and life-threatening complications. Recurrent respiratory papillomatosis (RRP) can, in rare cases, produce rapidly growing tumors in the respiratory tract leading to complete respiratory obstruction. Choroid plexus papillomas occur in the brain and can lead to increased intracranial pressure and hydrocephalus (fluid on the brain). Seek immediate medical care (call 911) if you,

your child, or someone you are with, have serious symptoms of these conditions including: Bulging soft spot (fontanel) on top of an infants head Change in level of alertness or consciousness, such as passing out, lethargy, or decreased responsiveness Change in mental status, such as confusion or disorientation Paralysis Respiratory difficulties, such as severe shortness of breath, labored breathing, or high-pitched whistle while inhaling Seizure Severe headache Sudden change in vision Sudden difficulty speaking Uncontrollable coughing What causes a papilloma? Most papillomas are caused by a human papillomavirus (HPV). There are over 150 different types of HPVs. Skin warts and genital warts are also caused by HPVs. HPVs that cause skin warts are not easily spread from person to person. However, HPVs that cause genital warts are passed very easily through sexual contact. HPVs can also cause recurrent respiratory papillomatosis (RRP) in which papillomas grow in the respiratory tract. In rare cases, RRP can be passed from a pregnant mother with active genital warts to her baby during pregnancy or delivery. Papillomas can be caused by other factors, such as ultraviolet (UV) light. Nasal papilloma may be caused by a tissue injury. In some cases, the cause is not known, such as for intraductal (breast duct) papilloma and choroid plexus papilloma. Choroid plexus papilloma is a rare benign (noncancerous) brain tumor most often seen in young children. What are the risk factors for a papilloma? Papillomas are very frequently caused by the human papillomaviruses (HPV). A number of factors increase the risk of developing a HPV infection including:

Direct contact with skin warts of others Direct sexual contact with an infected partner, through vaginal, anal or oral sex, or by genital-togenital contact Exposure of a baby to maternal HPV infection during pregnancy or delivery Multiple sexual partners Unsafe sexual practices such as sex without the proper use of condoms

as cryotherapy (freezing with a chemical) or laser surgery. Skin warts may also be removed by excision (cutting away the wart or removing it with electricity). Surgical removal is a primary treatment for papillomas of the brain, breast ducts, and respiratory tract.

What are the potential complications of a papilloma? Complications of papilloma vary depending on their location, size, and underlying cause. Controlling your risk factors for papilloma and regularly visiting your physician are the best prevention for potential complications. Complications of papillomas include: Embarrassment Hydrocephalus (high levels of fluid in the brain or water on the brain) Increased risk of catching other sexually transmitted diseases, including HIV, herpes, chlamydia,gonorrhea, and other infections with HPV Permanent brain damage from a papilloma in the brain Permanent scarring or skin discoloration Severe respiratory obstruction and respiratory distress

Reducing your risk of human papillomavirus infection You may be able to lower your risk of contracting or spreading an HPV infection by: Avoiding contact with warts on other people Practicing safe sex. The use of condoms limits the transmission of HPV Seeking early and regular prenatal care to reduce the risk of transmission of HPV infection during pregnancy or delivery Quitting smoking, as smoking is associated with an increased risk of HPV infection Cervarix and Gardasil are two vaccines available for the prevention of the HPV types most commonly associated with genital warts and cervical cancer. They can be given to girls as young as nine years and women 26 years and younger who have not had the vaccination previously. Gardasil can also be given to boys and men between the ages of nine and 26 for the prevention of genital warts. How is a papilloma treated? Some types of papilloma do not require treatment and may disappear on their own. When treatment is needed, it varies depending on the specific type, size and location of the papilloma. For example: Skin warts and genital warts may be treated with topical medications or procedures, such