Ulceration

Thomas G. Takoudes

Ulcerated lesions of the skin of the face and neck occurs when there is loss of the epidermis and a portion of the dermis of the affected region. Lesions can be solitary or multiple, longstanding or new onset, painful or painless and may have secondary infection. They can be further described based on their size, location, color, symmetry, and border. Although there are exceptions, it is useful to categorize these ulcerations based on whether there are one or many lesions.

Solitary Lesions

Basal cell carcinoma: The most common skin malignancy. Typically caused by sun exposure, although genetics, trauma, and immunosuppression may play a role. More common in people with fair skin, former sunbathers, and the aging population. They are often painless.

Squamous cell carcinoma: Second to basal cell carcinoma in incidence. Also associated with sun exposure, immunosuppression, and fair skin, although a non–solar de novo form exists. May arise from a long-standing actinic keratosis. Approaches basal cell carcinoma in incidence in people closer to the equator, secondary to long-term sun exposure. Much less common than basal cell carcinoma in less sunny locations.

Malignant melanoma: Third most common skin malignancy, but more lethal than squamous cell and basal cell carcinomas. Often seen as a multicolored tumor with an irregular border. Typically arises in sun-exposed areas. Aggressive cancer that may metastasize to facial or cervical lymph nodes.

Keratoacanthoma: Rapidly growing tumor usually in sun-damaged skin. Must be distinguished from carcinoma. Typically grows rapidly for up to 8 weeks, plateaus, and spontaneously regresses.