Management Approach for Special Lesion Types
The management of special lesion types requires a targeted approach based on the specific lesion type, location, and characteristics, with treatment decisions guided by evidence-based protocols to optimize outcomes and minimize complications.
Cutaneous Leishmaniasis (CL) Lesions
Simple vs. Complex Lesions
Simple CL lesions (clinically simple, healing spontaneously, caused by non-ML risk species):
- May be observed without treatment in immunocompetent patients who agree with this approach 1
- Requires wound care, documentation of lesion evolution, and patient education
Complex CL lesions require systemic treatment 1, including:
- Lesions at risk for mucosal leishmaniasis (ML)
- Lesions with unknown species from ML-risk regions
- Special syndromes (leishmaniasis recidivans, diffuse cutaneous leishmaniasis, disseminated cutaneous leishmaniasis)
Monitoring and Follow-up
- Active monitoring with nasal/oropharyngeal examination periodically for up to 1 year (or 2 years if at increased ML risk) 1
- Educate patients about signs of relapse or ML development
- Symptoms like nasal stuffiness, epistaxis, hoarseness, or septal perforation should prompt evaluation for ML 1
Hidradenitis Suppurativa (HS) Acute Lesions
Management Options for Acute Lesions (All Stages)
- Antiseptic washes
- Warm compresses
- Short-term oral steroids
- Intralesional steroids
- Incision and drainage
- Topical resorcinol
- Deroofing procedures 1
Treatment Recommendations
- Topical clindamycin for pustules (note: risk of bacterial resistance)
- Resorcinol 15% cream (may cause contact dermatitis)
- Antibacterial washes (chlorhexidine, zinc pyrithione)
- Intralesional corticosteroids for inflamed lesions 1
Vascular Lesions: Intracranial Arteriovenous Malformations (AVMs)
Grading and Treatment Selection
Treatment based on Spetzler-Martin grading system:
- Grade I and II lesions: Surgical excision recommended 1
- Grade III lesions: Case-by-case basis; generally surgery recommended for both symptomatic and asymptomatic patients 1
- Grade IV and V lesions: Multidisciplinary approach with individual analysis 1
Treatment Options
- Microsurgery: Complete obliteration with intraoperative/postoperative angiography
- Endovascular techniques
- Radiosurgery (focused radiation)
- Combined approaches 1
Gastrointestinal Subepithelial Lesions (SELs)
Diagnostic Approach
- Endoscopic ultrasound (EUS) with tissue acquisition for solid non-lipomatous SELs 1, 2
- EUS-guided FNB or FNA with rapid on-site evaluation for solid SELs 1
Management Based on Lesion Type
- Lipomas: No tissue sampling or surveillance required; removal only if symptomatic 1
- Pancreatic rests: No surveillance required; removal only if symptomatic 1
- Duplication cysts: Avoid EUS-FNA for mediastinal lesions; surgical removal only if symptomatic 1
- Gastrointestinal stromal tumors (GISTs):
Endoscopic Resection Techniques
- Endoscopic submucosal resection: Non-exposed technique for submucosal lesions
- Endoscopic submucosal dissection: Exposed technique, ideal for lesions not involving muscularis propria
- Submucosal tunnel endoscopic resection: Non-exposed technique for submucosal lesions
- Endoscopic full-thickness resection: For lesions involving muscularis propria, limited to lesions up to 20 mm 1
Basal Cell Carcinoma (BCC)
Treatment Based on Risk Classification
- Low-risk lesions: Curettage and cautery, suitable for small nodular or superficial lesions 1
- High-risk facial lesions: Mohs micrographic surgery recommended (5-year cure rates of 99% for primary BCC and 94.4% for recurrent disease) 1
- Recurrent lesions: Wider peripheral surgical margins (5-10 mm) than primary lesions 1
Indications for Mohs Micrographic Surgery
- Recurrent BCC
- High-risk facial lesions
- Lesions with aggressive histological subtypes
- Lesions in anatomically sensitive areas 1
Bowen's Disease (Squamous Cell Carcinoma In Situ)
Treatment Selection Based on Lesion Characteristics
- Small, single/few lesions, good healing site: Curettage (first choice), cryotherapy, topical 5-FU, PDT 1
- Large, single lesion, good healing site: PDT (first or second choice), topical 5-FU/imiquimod, excision 1
- Multiple lesions, good healing site: Topical imiquimod (first choice), PDT, topical 5-FU 1
- Lesions on poor healing sites: PDT (first choice), topical imiquimod/5-FU 1
- Facial lesions: Cryotherapy, curettage (first choices), excision with appropriate margins 1
- Digital lesions: Excision (first choice), PDT, topical 5-FU 1
- Perianal lesions: Excision (first choice), radiotherapy 1
- Penile lesions: Excision, cryotherapy, topical 5-FU/imiquimod, PDT 1
Soft Tissue and Visceral Sarcomas
Special Types Management
- Desmoid-type fibromatosis: Initial watchful waiting policy for stable disease; for progressing cases, individualized strategy including surgery, radiation therapy, or systemic therapy 1
- Breast sarcomas: Referral to sarcoma units; breast-conserving surgery may be considered depending on margins and tumor size; angiosarcomas often require mastectomy 1
Peripheral Arterial Disease Lesions
Iliac and Femoropopliteal Lesions
Treatment based on TransAtlantic Inter-Society Consensus (TASC) classification:
- TASC type A lesions: Endovascular procedure is treatment of choice 1
- TASC type D lesions: Surgery is procedure of choice 1
- TASC type B and C lesions: More evidence needed; consider individual factors 1
Specific Recommendations
- Endovascular intervention recommended for TASC type A iliac and femoropopliteal arterial lesions 1
- Stenting effective as primary therapy for common iliac artery stenosis/occlusions 1
- Stenting effective as primary therapy for external iliac artery stenosis/occlusions 1
By following these evidence-based management approaches for special lesion types, clinicians can optimize treatment outcomes while minimizing complications and preserving quality of life.