A study of epidermal and dermal tumors over face in ageing skin

Introduction: Ageing is a complex process that has been defined as the accumulation of molecular damage over time. signs of ageing skin are atrophy, laxity, wrinkling, sagging, dryness, yellowness, a multiplicity of pigmented and other blemishes and sparse grey hair. More than 90% of age-associated cosmetic problems are caused by ultraviolet (UV) radiation on exposed skin, which damages telomeres, generates free-radicals and whose effects are largely proportionate to skin type. Skin tumours develop as a result of proliferation of a single or multile components of the skin. Skin tumours are a challenging group of conditions that can be categorized into epidermal and dermal tumors depends on their origin. skin tumours in ageing skin are challenging because of wide variatios in cliical presentations, the occurence, behaviour and variety of the epidermal and dermal tumours makes it worthwhile to study this topic. Aim: The aim of this study was to study the clinical features and epidemiology of epidermal and dermal tumours of skin over face in ageing. Materials and Methods: fifty patients with Epidermal and Dermal skin tumors over face in ageing skin attending the opd of department of dermatology. Results: The highet age prevalances was in 5th decade (50%), The female: male ratio was 1.2: 1. The commonest skin tumours recorded were epidermal tumours (74%), followed by dermal tumors (26%). Commonest among Epidermal tumours were seborrheic keratosis – 28 cases (75.07%), were firm in consistency in 30 cases (81.08%), cystic in 04 cases (10.81), soft in 03 cases (8.1 %). Among Commonest among dermal tumors were compound nevus – 5 cases (38.46%), Among dermal tumors, 06 cases were biopsied.clinical diagnosis concordance with histopatholgical diagnosis was seen in 04 cases (66.66%). Discordance seen in 02 cases (33.33%), clinically suspected as sebaceoma and dermal nevus turned out to be dermal nevus and dermatofibroma histopathologically. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by/4.0/)


Source of Data
50 patients of Epidermal and Dermal skin tumors of both sexes over face with age more than 50 years. Attending the department of Dermatology All patients in our study undergone a detailed history taking, general physical, systemic and dermatological examination and a set of routine investigations. Skin biopsy routinely not done for all patients as the lesions were present over the face and patients were not willing due to cosmetic concerns.
However 15 cases were subjected to skin biopsy when there was a diagnostic dilemmas and patients who were willing. For smaller lesions, excisional biopsy and for larger lesions incisional biopsy was done Special stains like mason fontana for melanin were used whenever diagnostic dilemma in histopathology.
Clinical photographs were taken in all cases of facial tumors.Patient was referred to oncosurgeon in case of suspested malignant epidermal, dermal tumors for biopsy and further necessary management.

Evaluation
For the study, a proforma was prepared to record the relevant details of the patient like age, sex, occupation, socioeconomic status, number of lesions,site, symptoms, and clinical examinations which include presnting lesion, consistency etc. In clinically doubtful cases and those willing for biopsy skin biopsy was done. Results were correlated for concordance and discordance.
Records were maintained and data analyzed, variables was tested using apropriate statistical tool .(SPSS Software version 16).
Among males, maximum numbers of cases were in the age group of 51-60 years,9 cases (18%) and least was in the age group of 81-90 years 02 cases(4%), whereas in females, commonest was in the age group of 51-60 years, 16cases (32 %) and least was in the age group of 71-80 years, 04cases (8 %). Out of 50 cases, 28 were females and 22 were males.

Associated Diseases
Most patients did not have any associated conditions 34 cases (68%), associated conditions seen were diabetes mellitus in 07 cases (14%) and hypertension 9 cases (18 %).           The epidermis overlying the dermal tumor is acanthotic and papillomatous with a central 'dell'.

Sex
Among males, maximum numbers of cases were in the age group of 51-60 years, 9cases (18%) and least was in the age group of 81-90 years 02 cases(4%), whereas in females, commonest were in the age group of 51-60 years, 16cases (32 %) and least was in the age group of 71-80 years, 04cases (8 %). Out of 50 cases, 28 were females and 22 were males.
The female: male ratio being 1.27: 1.In the present study 38 patients (76 %) belonged to urban area and only 12 patients (24%) belonges to rural area. Though lot of people attend our hospital from rural areas the lower prevalance among them reflects their ignorance regarding the cosmetic orientation and also due to the asymptomatic nature of the lesions In the present study among the occupational group, housewives constituted the majority (54%), followed by clerks (16 %), Business and agriculture (12% each ), not applica le in (2%),labourer (2%), supervisor and nurse (2% each).This reflects the degree of cosmetic orientation in these various occupational groups. In the present study 42 patients (84%) belonged to the middle socio-economic status whereas 04pateints each (08%) belonged to the upper and lower socioeconomic status. This is in concurrence with the observation that the majority of the patients attending our hospital belonged to middle socio-economic status. The lower prevalance among higher and lower socioeconomic status can be attributed to the fact that these patients as they are capable of attending private consultants remain out of record and thus add to a probable low prevalance.

Duration
Most of the patients with epidermal tumors suffered for years (86.48%), compared to those with months (13.5%) . In epidermal tumors SK most commonly presented for years (p value = 0.02 , < 0.05) Among dermal tumors most patients suffered for years (46.15%), compared to those with months (30.76%) at birth (23.07%) . In dermal tumors,compound nevus most commonly presented for years (p value = 0.01 , < 0.05)

Clinico pathological correlation
Among epidermal tumors, 09 cases were biopsied.clinical diagnosis concordance with histopatholgical diagnosis was seen in 09 cases(100%). No discordance seen.
Among dermal tumors, 06 cases were biopsied.clinical diagnosis concordance with histopatholgical diagnosis was seen in 04 cases(66.66%).Discordance seen in 02 cases (33.33%), clinically suspected as sebaceoma and dermal nevus turned out to be dermal nevus and dermatofibroma histopathologically. Table 6 A ,B.

Associated diseases
Most patients did not have any associated conditions 34 cases (68%), associated conditions seen were diabetes mellitus in 07 cases (14%) and hypertension 9 cases (18 %).

Seborrhoiec keratosis
In the present study, most common among epidermal tumors were seborrhoiec keratosis seen in 28 pateints (56%) (pvalue 0.014 < 0.05) out of which there were 15 females and 13 males. The female male ratio was 1.15:1. According to Quinn et al, 1 the males and females are equally affected. The highest age of onset was 87 years and least being 51 years. With mean age of onset was 67.42 years. This correlates well with statement by Jain et al8 that, seborrhoeic keratosis is common in the middle aged and elderly person.
Most commonly seborrhoeic keratosis presented for years. (pvalue 0.02 <0.05). In our study, 25 patients were asymptomatic (pvalue 0.01 <0.05), while 3 patients had itching, lesions were located over cheek in each of the patients, they were diagnosed as inflamed seborrhoiec keratosis.
Most commonly it presented as papules in 17 patients The commonest site found was on the cheek (pvalue 0.02 <0.05) and forehead. Other sites were chin. observations in the pre ent study are almost identical to the observations mentioned in the literature. [1][2][3] In our study, only 6 patients were biopsied, and the remaining 22 patients did not agree for biopsy as the lesions were located over co metically concerned areas. Out of 6 patients, three showed features of irritated type ,two showed features of hyperkeratotic type, and other one showed features of pigmented type. Observatios in the present study are almost identical to the observatios mentioned in the literature. 1,4

Epidermal cyst (Epidermoid cyst)
In the present study, there were 4 cases of epidermal cysts (8 %), 2 male and 2 females. According to Quinn et al, 5 it is commonly seen in young and middle aged adults. In this study the mean age of onset was 55.33 years.According to kirkham, 2 the commonest site of involvement is face, scalp, neck and trunk but in our study all lesions were seen over the face.
In our study, only 1 patient were biopsied and the remaining 3 patients did not agree for biopsy. one patient showed features of typical histopathological features which were consistent with the findings of Quinn et al 1 Kirkham. 2

Acrochordons
In the present study, acrochordons were seen in 03 pateints (6%). of which 2 were males and 1 were females. According to Quinn et al, 5 females were more commonly affected than males. The mean age of onset was 63.63 years, which is similar to the study by Zaher et al. 6 Majority of lesions were multiple, small pedunculated papules (9%) located over periorbital,cheek .
According to Kumar et al,7 acrochordons are associated with diabetes mellitus, obesity, hyperlipidemia, acromegaly and intestinal polyps, however in our study diabetes mellitus and hypertension was not associated with acrochordon. The observations made in the present study with regard to the clinical features of lesions are not in concurrence with the observations made in other studies. 1,7

Compound nevus
In the present study, most common among dermal tumors were compound nevi seen in 5 patients (10 %) (pvalue 0.009 <0.05) ,3 females and 02 males they belonged to 50-70 years of age group. Most commonly presented as single lesions observed in 3 patients (p value 0.05 = 0.05 ) and asymptomatic in all 05 patients ( pvalue 0.009 < 0.05). All the lesions were located over the face Observations in the present study are almost identical to the observatio s mentioned in the literature. 8,9 In our study, two patients were biopsied and the others did not agree for biopsy as the lesion was located over cosmetically co cerned area. Histopathological features showed junctional activity of nevus cells and superficial dermis was composed predominantly of type a nevus cells arranged in nests. The observations in the reent study are in concurrence with the observation mentioned in the literature. 8-10

Intradermal nevi
In the present study, intradermal nevi were seen in 1 female patient. . The lesions was single and situated over the cheek. In our study, initially thought of sebaceoma clinically but confirmed as dermal nevus with typical histopathological features of intradermal nevus which were consistent with the findings of Elder 10 , Newton Bishop 8 Katarkar. 11

Appendageal tumours
In the present study, appendageal tumours were seen in 5 pateints (10%). Out of which three patient had syringoma (6%) and two patient had sebaceous hyperplasia (4%). In our study, 2male and 1 female patient (6%) had syringoma of onset 50-60 years of age concordant with study by Ramaswamy et al, 12 which showed that it was common in middle aged males. All cases presented with multiple lesions (p value 0.01 < 0.05) were seen around the eyelids (p value 0.01 <0.05). According to Calonje, 13 commonest site involved is head and neck, rarely over trunk and extremities. Histopathological findings were typical as descriedy Ramaswamy et al 12 Calonje16Ahmed.17In the resent study, 01 male and 02 female patient (4%) had sebaceous hyperplasia. The lesions were multiple, yellow to skin coloured papules and nodules over forehead, nose and cheek. Observations in the present study are almost identical to the observations mentioned in the literature. 12 16, Histopathological findings were typical as descried by Ahmed. 14 Kumar et al. 15

Benign soft tissue tumours
In the present study, benign soft tissue tumours was seen in 1 pateint (2%), had dermatofibroma (2%). In our study, there was 1 Dermatofibroma male patient (2%), Lesions were multiple over face , however according to calonje et al, 16 they are common in young adults, however in our study found in old age. clinically thought of intradermal nevus initially but after histopathology diagnosed as dermatofibroma.Histopathology showed cellular type of dermatofibroma.Observations made in the present study are almost identical to the observations mentioned in the literature. 14

Basal cell carcinoma
In the present study, basal cell carcinoma were seen in 01 pateint (2 %) According to minnesota study, 16 males were more commonly affected than females. In our study, 01 female patient had basal cell carcinoma. with age of onset was 69 years.According to australian case-control study by Kricker et al. 17 presence of large number of naevi, freckles and solar elastosis all add to the BCC risk, however in our study large numberof nevi, freckles was not as ociated. It is more common in sun exposed areas like head and neck. The observations made in the present study with regard to the clinical features of lesions are in concurrence with the observations made in by purnima et al. 18 In our study, 1 case (2%) was biopsied by oncosurgeon,showed typical features of Noduloulcerative type basal cell carcinoma. which were consistent with the features described by purnima et al 18 Immunohistohistochemistry was not done as this patient lost her follow up in our hospital.

Conflict of interest
None.