Pediatric Benign Skin Growths and Pigmentation Disorders

Birthmarks are areas of discolored or raised skin that are seen at birth or within a few weeks of birth. Birthmarks may be made up of malformed pigment cells or blood vessels.

Medical experts don’t know what causes birthmarks. But most of them are not cancer (benign) and don't require treatment. Babies with birthmarks should be checked and diagnosed by a healthcare provider.

These are the most common types of vascular birthmarks:

• Macular stains or salmon patches. These are characterized by pink to red marks that may appear anywhere on the body. Angel kisses and stork bites are the most common type of vascular birthmark:
  
  • Angel's kisses. Marks located on the forehead, nose, upper lip and eyelids that usually disappear with age.
  • Stork bites. Marks on the back of the neck that may disappear with age.
• Hemangioma. These are a common vascular birthmark. Hemangiomas become visible within the first few weeks or months of life and continue to grow rapidly for about 6 to 9 months. Then they slowly lose this red color and shrink. They are called strawberry patch hemangiomas. By age 5, 50% of these go away and 90% go away by age 9 without any treatment. Hemangiomas that grow into other organs or structures or become ulcerated should be checked by your healthcare provider.
• Port-wine stain. A port-wine stain is a flat, pink, red or purple mark that appears at birth, often on the face, arms and legs. It continues to grow as the child grows. Port-wine stains don't go away, and may become more purple or thicker with age. These birthmarks often need treatment if located on the eyelid or forehead. Port-wine stains involving the face may cause eye problems and be linked with other developmental disorders.

These are the most common types of pigmented birthmarks:

• Moles. These can be skin-colored, brown or black, flat or raised, and small or large. They can happen anywhere on the body. Moles can also happen in adulthood. But only moles that are present at birth are considered birthmarks. Other moles can appear within the first 2 years of life. Moles can develop into cancer later in life. Larger moles have a higher risk of becoming cancerous.
• Cafe-au-lait spots. This is French for coffee with milk. These are usually oval-shaped and light brown. Typically these fade with age and are not a problem. But many of them grouped together can be a sign of other health issues and should be checked by a healthcare provider. 
• Mongolian spots. These are blue or blue-gray spots on the lower back or buttocks. They are most common in babies with darker skin, such as African-American or Asian babies. They can be mistaken for bruises. They usually fade with age.

As a child grows older and is exposed to sunlight, the skin changes. Benign skin growths mean they aren’t cancer. Children may have freckles and moles. These may multiply or darken over time in response to sun exposure. Check with a healthcare provider if your child develops any skin changes.

Dermatofibromas

• Small, firm, red or brown scar-like bumps caused by a buildup of fibroblasts (soft tissue cells under the skin). They often happen on the legs and may itch. They often result from trauma, like a bug bite.
• Treatment: Dermatofibromas can be surgically removed if they become painful or itchy.

Dermoid cysts

• A noncancerous (benign) tumor that is made up of hairs, sweat glands, and oil (sebaceous) glands. Some internal dermoid tumors may even contain cartilage, bone fragments, and teeth. These are rare and are usually present at birth.
• Treatment: Dermoid cysts may be surgically removed for cosmetic reasons or if they are causing a problem, such as on an eyelid.

Freckles

• Darkened, flat spots that typically appear only on sun-exposed areas of the skin. Freckles are common in people with blond or red hair.
• Treatment: No treatment is needed for freckles.

Keloids

• Smooth, firm, raised, fibrous growths on the skin that form in wound sites. Keloids are more common in African-Americans.
• Treatment: Keloids respond poorly to most treatment approaches. Injections of corticosteroid drugs may help to flatten the keloids. Other treatment approaches may include surgery, laser or silicone patches to further flatten the keloids.

Lipomas

• Round or oval lumps under the skin caused by fatty deposits. They tend to appear on the forearms, torso and back of the neck.
• Treatment: Lipomas are generally harmless. But if the lipoma changes shape, a biopsy may be advised. Treatment may include surgical removal if the lipoma bothers the child.

Moles (nevi)

• Small skin marks caused by pigment-producing cells in the skin. Moles can be flat or raised, smooth or rough, and some contain hair. Most moles are dark brown or black. Some are skin-colored or yellowish. Moles can change over time and often respond to hormonal changes.
• Treatment: Most moles are benign and no treatment is needed. Some benign moles may develop into skin cancer (melanoma). See "atypical moles (dysplastic nevi)" for signs.

Atypical moles (dysplastic nevi)

• Atypical moles are larger than normal moles), and are not always round. Atypical moles can be tan to dark brown, on a pink background. These types of moles may happen anywhere on the body.
• Treatment: Treatment may include removal of any atypical mole that changes in color, shape, or diameter. People with atypical moles should avoid sun exposure, since sunlight may accelerate changes in atypical moles. People with atypical moles should talk with a healthcare provider for any changes that may indicate skin cancer.

Pyogenic granulomas

• Red, brown or bluish-black, raised marks caused by excessive growth of capillaries (small blood vessels) and swelling. Pyogenic granulomas usually form after an injury to the skin. They tend to bleed easily.
• Treatment: Some pyogenic granulomas disappear without treatment. Sometimes, a biopsy is needed to rule out cancer. Treatment may include surgical removal.

Epidermoid cysts

• Also called epidermal inclusion cysts, these are common benign lumps that most often don't cause discomfort unless they become inflamed or infected. They range from a half to two inches in size and are common on the back, head and neck. They are firm and contain a white substance.
• Treatment: Treatment to remove the cyst is not needed unless the cyst becomes inflamed, or if its location is a problem. Epidermoid cysts generally go away without treatment but may return.

Skin color is determined by a pigment (melanin) made by specialized cells in the skin (melanocytes). The amount and type of melanin determines a person's skin color.

Melanin's role is to protect DNA in body cells from sun damage. It gives color to the skin, hair and irises of the eyes. Levels of melanin depend on race and amount of sunlight exposure. Sun exposure increases melanin production to protect the skin against harmful UV (ultraviolet) rays. In addition, hormone changes can affect melanin production.

Albinism

• This is a rare, inherited disorder. It reduces the amount of melanin pigment in the skin, hair, and eyes. People with albinism (albinos) have white hair, pale skin, and pink or blue eyes. Their eyes may seem red in different lighting conditions. Many also have vision problems.
• Treatment: There is no cure for albinism. People with this condition should avoid sun damage to the skin and eyes by wearing sunscreen, hats and sunglasses.

Melasma

• This causes dark brown to gray-brown, symmetric patches of pigment on the face. During pregnancy, this is called the mask of pregnancy. Sun exposure, hormones and birth control pills are thought to cause melasma.
• Treatment: Sunscreens and avoiding sun exposure can prevent melasma from getting worse. Other treatment may include prescription creams containing hydroquinone and tretinoin to lighten the patches. Chemical peels and laser treatment can also be used.

Pigment loss after skin damage

• Sometimes after an ulcer, blister, burn or infection, the skin does not replace some of the pigment in that area.
• Treatment: No treatment is needed. Makeup can usually cover the blemish.

Vitiligo

• This causes smooth, white patches on the skin. It is caused by the loss of pigment-producing cells in the skin (melanocytes). It's thought to be an autoimmune disease. The white patches are very sensitive to the sun.
• Treatment: Treatment may include covering smaller patches with makeup or long-lasting dyes, light-sensitive medicines, UV light therapy, corticosteroid creams, surgery and removing the remaining pigment from the skin (depigmentation) so that white areas are less obvious.

Skin cancer is a type of cancer that grows in the cells of the skin. It can spread to and damage nearby tissue and spread to other parts of the body. Skin cancer is very rare in children.

Exposure to sunlight is the main factor for skin cancer. Skin cancer is more common in people with light skin, light-colored eyes, and blond or red hair. Other risk factors include:

• Age. Your risk goes up as you get older.
• Family history of skin cancer
• Having skin cancer in the past
• Time spent in the sun
• Using tanning beds or lamps
• History of sunburns
• Having many freckles
• Having many moles
• Having atypical moles (dysplastic nevi). These large, oddly shaped moles run in families.
• Radiation therapy in the past
• Taking a medicine that suppresses the immune system
• Certain rare, inherited conditions such as basal cell nevus syndrome (Gorlin syndrome) or xeroderma pigmentosum (XP)
• HPV infection
• Actinic keratoses or Bowen disease. These are rough or scaly red or brown patches on the skin.

There are three main types of skin cancer:

• Basal cell carcinoma. The majority of skin cancers are basal cell carcinoma. It’s a very treatable cancer. It starts in the basal cell layer of the skin (epidermis) and grows very slowly. The cancer usually appears as a small, shiny bump or nodule on the skin. It occurs mainly on areas exposed to the sun, such as the head, neck, arms, hands and face. It more often occurs among people with light-colored eyes, hair and skin.
• Squamous cell carcinoma. This cancer is less common. It grows faster than basal cell carcinoma, but it’s also very treatable. Squamous cell carcinoma may appear as nodules or red, scaly patches of skin, and may be found on the face, ears, lips and mouth. It can spread to other parts of the body, but this is rare. This type of skin cancer is most often found in people with light skin.
• Melanoma. This type of skin cancer is a small portion of all skin cancers, but it causes the most deaths. It starts in the melanocyte cells that make pigment in the skin. It may begin as a mole that turns into cancer. This cancer may spread quickly. Melanoma most often appears on fair-skinned people, but is found in people of all skin types.

Symptoms of basal cell carcinoma appear on areas exposed to the sun, such as the head, face, neck, arms, and hands. The symptoms can include:

• A small, raised bump that is shiny or pearly, and may have small blood vessels
• A small, flat spot that is scaly, irregularly shaped, and pale, pink, or red
• A spot that bleeds easily, then heals and appears to go away, then bleeds again in a few weeks
• A growth with raised edges, a lower area in the center, and brown, blue, or black areas

Symptoms of squamous cell carcinoma appear on areas exposed to the sun, such as the head, face, neck, arms and hands. They can also appear on other parts of the body, such as skin in the genital area. The symptoms can include:

• A rough or scaly bump that grows quickly
• A wart-like growth that may bleed or crust over.
• Flat, red patches on the skin that are irregularly shaped, and may or may not bleed

Symptoms of melanoma include a change in a mole, or a new mole that has ABCDE traits such as:

• Asymmetry. One half of the mole does not match the other half.
• Border irregularity. The edges of the mole are ragged or irregular.
• Color. The mole has different colors in it. It may be tan, brown, black, red, or other colors. Or it may have areas that appear to have lost color.
• Diameter. The mole is bigger than six millimeters across, about the size of a pencil eraser. But some melanomas can be smaller.
• Evolving. A mole changes in size, shape, or color.

Other symptoms of melanoma can include a mole that:

• Itches or hurts
• Oozes, bleeds or becomes crusty
• Turns red or swells
• Looks different from your child's other moles

The healthcare provider will examine your child's skin. Tell the healthcare provider:

• When you first noticed the skin problem
• If it oozes fluid or bleeds, or gets crusty
• If it’s changed in size, color or shape
• If your child has pain or itching

Tell the healthcare provider if your child has had skin cancer in the past, and if other your family members have had skin cancer.

Your child's healthcare provider will likely take a small piece of tissue (biopsy) from a mole or other skin mark that may look like cancer. The tissue is sent to a lab. A doctor called a pathologist looks at the tissue under a microscope. He or she may do other tests to see if cancer cells are in the sample. The biopsy results will likely be ready in a few days or a week. Your child's healthcare provider will tell you the results. He or she will talk with you about other tests that may be needed if cancer is found.

Types of treatment for basal cell and squamous cell cancers include the below.

Chemotherapy

This is medicine applied as a cream or ointment onto the skin. It’s also called topical chemotherapy. This kind of medicine is only used if the cancer is just in the top layers of the skin. The medicine is applied several times a week for a few weeks.

Radiation Therapy

This is treatment with high-energy X-rays. Electron beam radiation is often used for skin cancer. This type of radiation doesn’t go deeper than the skin. This helps limit side effects. The radiation damages the cancer cells and stops them from growing. Radiation therapy is a local therapy. This means that it affects the cancer cells only in the treated area.

Mohs Surgery

This procedure removes the cancer and a small amount of normal tissue. It’s done on sensitive areas, such as the face. During Mohs surgery, your child is given a local anesthetic to numb the area being treated. The cancer is removed from the skin one layer at a time. Each layer is checked under a microscope for cancer. If cancer cells are seen, another layer of skin is removed. Layers are removed until the doctor doesn’t see any more cancer. The procedure may take several hours, depending on how many layers need to be removed. After this surgery, the cancer is fully removed and the wound can be repaired.

Curettage and Electrodesiccation

This procedure removes tissue and burns (cauterizes) the area. Your child is given a local anesthetic to numb the area. The doctor then uses a sharp spoon-shaped tool called a curette to remove the cancer. This is called curettage. After curettage, the doctor passes an electric needle over the surface of the scraped area to stop bleeding, and destroy any other cancer cells. After it heals, a flat white scar may remain.

Simple Excision

This is done to cut the cancer from the skin, along with some of the healthy tissue around it. Your child is given a local anesthetic. Then, the doctor uses a scalpel to remove the tumor from the skin. The doctor may also remove some of the normal skin around the tumor. This is called a margin. Stitches or a bandage strip may be used to close the wound. The tissue that was removed is sent to a lab for testing. If the report shows that not all the cancer was removed, your child will likely need another procedure to remove the rest of the cancer.

Shave Excision

This method is used for cancer that is only in the top layers of the skin. Your child is given a local anesthetic. Then, the doctor uses a small blade to shave off the tumor. The goal is to remove the tumor at its base.

Cryosurgery

This method uses cold to destroy the cancer cells. This method is best for very small cancers near the skin’s surface. The doctor uses a device that sprays liquid nitrogen onto the tumor. This freezes the cells and destroys them. The dead skin then falls off. Your child may have some swelling and blistering in the area after treatment. A white scar is usually left behind. The procedure may need to be repeated.

Types of treatment for melanoma include the below.

Surgery

The goal of surgery is to remove the melanoma, while leaving as much of the nearby skin as intact as possible.

Chemotherapy

The goal of chemotherapy is to destroy cancer cells directly to shrink tumors that can’t be removed by surgery. Or it may be used to kill cells that have spread to other areas of the body (metastatic melanoma).

Biological Therapy

The goal of biological therapy is to shrink advanced melanoma tumors. This type of therapy is done with medicines that affect the immune system. It is also called immunotherapy, antibody therapy or vaccine therapy. The medicine uses the body’s immune defense to attack the cancer cells. These may also be given along with chemotherapy.

Targeted therapy

The goal of targeted therapy is to shrink advanced melanoma tumors. This type of therapy is done with medicines that target specific parts of melanoma cells. For example, medicines called BRAF inhibitors target cells with a change in the BRAF gene. This gene is found in about half of all melanomas.

Possible complications depend on the type and stage of skin cancer. Melanoma is more likely to cause complications. And the more advanced the cancer, the more likely there will be complications.

Complications may result from treatment, such as:

• Loss of large areas of skin and underlying tissue
• Scarring
• Problems with the area healing
• Infection in the area
• Damage to nerves
• Return of the skin cancer after treatment

Melanoma may spread to organs throughout the body and cause death.

The American Academy of Dermatology (AAD) and the Skin Cancer Foundation advise you to:

• Limit how much sun your child gets between the hours of 10 a.m. and 4 p.m.
• Use broad-spectrum sunscreen with an SPF 30 or higher that protects against both UVA and UVB rays. Put it on the skin of children older than 6 months of age who are exposed to the sun.
• Reapply sunscreen every two hours, even on cloudy days. Reapply after swimming.
• Use extra caution near water, snow, and sand. They reflect the damaging rays of the sun. This can increase the chance of sunburn.
• Make sure your child wears clothing that covers the body and shades the face. Hats should provide shade for both the face, ears and back of the neck. Wearing sunglasses will reduce the amount of rays reaching the eye and protect the lids of the eyes, as well as the lens.
• Don’t let your child use or be around sunlamps or tanning beds.

The American Academy of Pediatrics approves of the use of sunscreen on babies younger than 6 months old if adequate clothing and shade are not available. You should still try to keep your baby out of the sun. Dress the baby in lightweight clothing that covers most surface areas of skin. But you also may use a small amount of sunscreen on the baby’s face and back of the hands.

If your child has skin cancer, you can help him or her during treatment in these ways:

• Your child may have trouble eating. A dietitian or nutritionist may be able to help.
• Your child may be very tired. He or she will need to learn to balance rest and activity.
• Get emotional support for your child. Counselors and support groups can help.
• Keep all follow-up appointments.
• Keep your child out of the sun.

After treatment, check your child's skin every month or as often as advised.

Call your child's healthcare provider if you see any unusual changes in your child's skin.