Incidence

1. Benign lesions are common to all races, and they are seen primarily in the adult and elderly populations.

Pathogenesis

1. The course varies, depending on the specific type of lesion.

Predisposing Factors

1. Sun exposure in the adult and elderly populations.
2. Dermatosis papulosa nigra: Common in African Americans and Asians.

Common Complaints

1. New lesion of the skin.

Other Signs and Symptoms

1. Seborrheic keratosis: Waxy papule with a stuck-on appearance is seen in adults on sun-exposed areas; they appear symmetric, 0.2 to 3.0 cm in size, with a well-demarcated border and a variety of colors (tan, black, and brown).
2. Dermatosis papulosa nigra: Hyperpigmented mole is located on face or neck; a pedunculated papule is symmetric, 1 to 3 mm in diameter.
3. Cherry angioma: Vascular papule, red to purple, is located on trunk in adults; begins in early adulthood; 1- to 3-mm diameter papules that do not blanch.
4. Solar lentigines (liver spots): Tan maculae appear on sun-exposed areas in elders, especially on face and hands; border is irregular, and the size varies.
5. Senile sebaceous hyperplasia: Enlarged sebaceous glands appear as yellow papules on sun-exposed areas, especially on face in elders; papules have central umbilication, and their size varies.
6. Keratoacanthoma: Sun-exposed area lesion is smooth, skin-colored or reddish in appearance, dome-shaped papule at first, then may turn and grows to 1 to 2 cm in a few weeks, with crusted interior.

Subjective Data

1. Identify when the patient first discovered the lesion.
2. Determine whether the lesion has changed in size, shape, or color.
3. Ask if the patient has discovered more lesions.
4. Elicit information regarding a family history of skin lesions or cancer.

Physical Examination

1. Inspect:
   1. Observe skin; note all lesions and evaluate each for asymmetry, border, color, diameter, evolving changes, and/or elevation change.
   2. Note the patient’s skin type.

Diagnostic Tests

1. Benign lesions do not require any tests.
2. If unsure regarding possible malignancy, a biopsy is recommended.

Differential Diagnoses

1. Benign skin lesion:
   1. Seborrheic keratosis.
   2. Dermatosis papulosa nigra.
   3. Cherry angioma.
   4. Solar lentigines.
   5. Senile sebaceous hyperplasia.
   6. Keratoacanthoma.
2. Malignant skin lesion.

Plan

1. General interventions:
   1. Reassure the patient that lesions are benign. No treatment is required unless the patient chooses to have the lesion removed for cosmetic purposes.
   2. Lesions may be removed using cryotherapy if they are bothersome for the patient.
2. See Section III: Patient Teaching Guide “Skin Care Assessment.”
3. Pharmaceutical therapy:
   1. Topical 5-fluorouracil, 5% imiquimod cream (Aldara), or topical diclofenac gel may be used for benign lesions.

Follow-Up

1. Routine skin exams should be performed yearly.

Consultation/Referral

1. Immediately refer patient to a dermatologist if malignancy is suspected or confirmed by biopsy.

Individual Considerations

1. Adults: Skin lesions begin to appear in early adulthood. Encourage patients to monitor lesions over time.
2. Geriatrics: Benign lesions are commonly seen in the elderly population:
   1. Encourage annual/biannual skin screenings in the elderly population and the continual use of sunscreen with ultraviolet A (UVA) and ultraviolet B (UVB) coverage. Protective clothing and avoidance of sun exposure is highly recommended for geriatrics with a history of basal cell/benign lesions.
   2. Treatment of benign lesions for geriatrics must be balanced with patient’s preferences, quality of life, and life expectancy. Mohs micrographic surgery, cryosurgery, excision, photodynamic, and topical creams/solutions are acceptable treatments for geriatric patients if they choose. Monitor closely for allergic reactions or toxicity with topical medications: imiquimod (Aldara), 5-fluorouracil, and vismodegib (Erivedge).