++
As with any examination, the routine of look, feel, move, measure, auscultate and transilluminate should be followed.
++
The lump or lumps can be described thus:
++
number
site
shape—regular or irregular
size (in metric units)
position
consistency (very soft, soft, firm, hard or stony hard)
solid or cystic
mobility
surface or contour
special features:
– attachments (superficial/deep)
– exact anatomical site
– relation to anatomical structures
– relation to overlying skin
– colour
– temperature (of skin over lump)
– tenderness
– pulsation (transmitted or direct)
– impulse
– reducibility
– percussion
– fluctuation (? contains fluid)
– bruit
– transilluminability
– special signs: slipping sign, emptying sign of cavernous haemangioma
– spread: local, lymphatic, haematogenous
– regional lymph nodes
– ? malignancy (is it primary or secondary?)
+++
Relation of the lump to anatomical structures3
++
The question ‘In what tissue layer is the lump situated?’ needs to be addressed.
++
Is it in the skin? The lump moves when the skin is moved (e.g. epidermoid cyst).
Is it in subcutaneous tissue? The skin can be moved over the lump. The slipping sign: if the edge of the lump is pushed, the swelling slips from beneath the finger (e.g. lipoma).
Is it in muscle? The lump is movable when the muscle is relaxed but on contraction of the muscle this movement becomes limited.
Is it arising from a tendon or joint? Movement of these structures may cause a change in the mobility or shape of the tumour.
Is it in bone? The lump is immobile and best outlined with the muscles relaxed.
+++
LUMPS OF THE SKIN AND MUCOUS MEMBRANES
++
+++
Fibroepithelial polyps
++
Synonyms: skin tags, acrochordon, benign squamous papilloma, soft fibroma.
++
Benign skin overgrowth
Pedunculated soft fibroma
Increased incidence with age
Commonest on neck, axillae, trunk, groins
No malignant potential
Can be irritating or unsightly to patient
++
Can leave or remove
To remove:
snip off with scissors or bone forceps (see FIG. 124.1)
or
tie base with fine cotton or suture material
or
diathermy or electrocautery of base
or
apply liquid nitrogen (see FIG. 124.2)
++
++
++
These methods do not require local anaesthetic.
+++
Epidermoid (sebaceous) cyst
++
Synonyms: ‘pilar’ cyst, keratinous cyst, wen, epidermoid cyst, sebaceous cyst (similar in appearance).
++
Firm to soft regular lump (usually round)
Fixed to skin but not to other structures (see FIG. 124.3a)
Move with the skin
Found in hair-bearing skin mainly on scalp—then face, neck, trunk, scrotum
Contains sebaceous material
Usually fluctuant
May be a central punctum containing keratin
Tendency to inflammation
++
++
If before puberty—think of polyposis coli. Can leave if small and not bothersome.
+++
Surgical removal methods
++
There are several methods of removing epidermoid cysts after infiltrating local anaesthetic over and around the cyst. These include:
++
Method 1: Incision into cyst Make an incision into the cyst to bisect it, squeeze the contents out with a gauze swab and then avulse the lining of the cyst with a pair of artery forceps or remove with a small curette.
Method 2: Incision over cyst and blunt dissection Make a careful skin incision over the cyst, taking care not to puncture its wall. Free the skin carefully from the cyst by blunt dissection. When it is free from adherent subcutaneous tissue, digital pressure will cause the cyst to ‘pop out’.
Method 3: Standard dissection Incise a small ellipse of skin to include the central punctum over the cyst (see FIG. 124.3b). The objective is to avoid rupture of the cyst. Inserting curved scissors (e.g. McIndoe’s scissors), free the cyst by gently opening and closing the blades (see FIG. 124.3c). Bleeding is not usually a problem. Send the cyst for histopathology.
+++
Treatment of infected cysts
++
Incise the cyst to drain purulent material. When the inflammation has resolved completely the cyst should be removed by method 1 or method 3 (see above).
++
Synonym: implantation dermoid.
++
++
++
++
++
+++
Hyperplastic scarring
++
++
A hypertrophic scar is simply a lumpy scar caused by a nodular accumulation of thickened collagen fibres. It does not extend beyond the margins of the wound and regresses within a year but sometimes can be permanent.
++
A keloid is a special type of hyperplastic scar that extends beyond the margins of the wound.
++
Firm, raised, red–purple, skin overgrowth
Common on ear lobes, chin, neck, shoulder, upper trunk
Hereditary predisposition (e.g. dark-skinned person)
Follows trauma, even minor (e.g. ear piercing)
May be burning or itchy and tender
+++
Management of scarring
++
Prevention (avoid procedures in keloid-prone individuals).
Compression and silicone dressings
Intradermal injection of corticosteroids in early stages (2–3 months) or intralesional cytotoxics (e.g. fluorouracil) or X-ray treatment of surgical wounds within 2 weeks of operation.4
Consider re-excision of hypertrophic scarring
++
Warts are skin tumours caused by the human papillomavirus (HPV). The virus invades the skin, usually through a small abrasion, causing abnormal skin growth. Warts are transmitted by direct or fomite contact and may be autoinoculated from one area to another.5
++
Average incubation period—4 months
Increased incidence in children and adolescents
Peak incidence around adolescence
Occurs in all ethnicities at all ages
About 25% resolve spontaneously in 6 months5 and 70% in 2 years
Present as various types
++
These include common warts, plane warts, filiform warts (fine elongated growths, usually on the face and neck), digitate warts (finger-like projections, usually on scalp), genital and plantar warts (see FIG. 124.4).
++
++
These are skin-coloured tumours with a rough surface, found mainly on the fingers, elbows and knees.
++
These are skin-coloured, small and flat, occurring in linear clusters along scratch lines (see FIG. 124.5). They mainly occur on the face and limbs. They are difficult to treat because they contain very few virus particles. They are prone to Koebner phenomenon, which is seeding when a scratch passes through a plane wart.
++
++
++
salicylic acid—for example: 5–20% in flexible collodion (apply daily or bd) or 16–17% salicylic acid + 16–17% lactic acid
formaldehyde 2–4% alone or in combination
podophyllotoxin 0.5% for anogenital warts—it is good on mucosal surfaces but does not penetrate normal keratin
cytotoxic agents (e.g. 5-fluorouracil: very good for resistant warts such as plane warts and periungual warts)
the immunomodulator, imiquimod
++
Carbon dioxide (−56.5˚C) or liquid nitrogen (−195.8˚C) destroys the host cell and stimulates an immune reaction.
++
++
++
A most common treatment; some plantar warts can be removed under LA with a sharp spoon curette. The problem is a tendency to scar, so avoid over a pressure area such as the sole of the foot.
++
A high-frequency spark under LA is useful for small, filiform or digitate warts. A combination of curettage and electrodesiccation is suitable for large and persistent warts.
+++
Vitamin A and the retinoids
++
Topical retinoic acid (e.g. tretinoin 0.1% cream—Retin-A) is effective on plane warts
Systemic oral retinoid, acitretin (Neotigason) for recalcitrant warts (with care)
++
+++
Specific wart treatment
++
The method chosen depends on the type of wart, its site and the patient’s age.
++
Plantar warts: refer to CHAPTER 68
Genital warts: podophyllotoxin 0.5% paint or imiquimod (best for penile warts, see CHAPTER 117)
Filiform and digitate warts: liquid nitrogen or electrodissection
Plane warts: liquid nitrogen; salicylic acid 20% co (e.g. Wartkil); consider 5-fluorouracil cream or tretinoin 0.05% cream (Retin-A)
Common warts: a recommended method:
Soak the wart/s in warm soapy water.
Rub back the wart surface with a pumice stone.
Apply keratolytic paint (only to the wart; protect the surrounding skin with Vaseline). The paints: formalin 5%, salicylic acid 12%, acetone 25%, collodion to 100%.4
Do this daily or every second day.
Carefully remove dead skin between applications
or (preferable applications)
(adult) 16% salicylic acid, 16% lactic acid in collodion paint (Dermatec, Duofilm), apply once daily until wart cleared
(children) 8% salicylic acid, 8% lactic acid in collodion
Combined method: salicylic acid 70% paste in linseed oil. Leave 1 week then pare and freeze (cryotherapy).
Periungual warts (fingernails): consider
5-fluorouracil or liquid nitrogen with care.
Always use a paint rather than ointment or paste on fingers.
Specialised treatment includes bleomycin, immunotherapy (e.g. topical diphencyprone—DPCP) and cantharidin
++
Skin tumours can be caused by pox viruses, some of which result from handling infected sheep, cows and monkeys and other animals such as deer. Hence they are usually found in sheep shearers, farmers and zookeepers.
+++
Molluscum contagiosum
++
This common pox virus infection can be spread readily by direct contact, including sexual contact (see CHAPTER 117). The incubation period is 2–26 weeks.
++
Common in school-aged children
Single or multiple (more common)
Shiny, round, pink-white papule (see FIG. 124.6)
Hemispherical up to 5 mm
Central punctum gives umbilical look
Can be spread by scratching
++
++
They are difficult to treat. Avoid using the bath—they spread to other body parts and those sharing the bath. Showering is preferable. There is a case for simply reassuring the family and waiting for spontaneous resolution.
++
Liquid nitrogen with care (a few seconds following topical anaesthetic) then dry dressings for 2 weeks
Pricking the lesion with a pointed stick soaked in 1% or 2.5% phenol
Application of 15% podophyllin in Friar’s Balsam (compound benzoin tincture)
Application of 30% trichloracetic acid
Application of imiquimod 0.1% cream tds for 6 weeks
Destruction by electrocautery or diathermy
Ether soap and friction method
Lifting open the tip with a sterile needle inserted from the side (parallel to the skin) and applying 10% povidone–iodine (Betadine) solution (parents can be shown this method and continue to use it at home for multiple tumours)
If more localised, covering with a piece of Micropore or Leucosilk tape—change every day after showering (may take a few months). This method also prevents spread
For large areas, aluminium acetate (Burow’s solution 1:30) applied bd can be effective
++
Note: The extract of the Cantharis beetle (cantharidin) (prepared as Cantharone) if available is reportedly very effective.
++
Orf is due to a pox virus and presents as a single papule or group of papules on the hands of sheep-handlers after handling lambs with contagious pustular dermatitis. The papules change into pustular-like nodules or bullae with a violaceous erythematous margin. It clears up spontaneously in about 3–4 weeks without scarring and usually no treatment is necessary.
++
Practice tip for orf
Rapid resolution (days) can be obtained by an intralesional injection of triamcinolone diluted 50:50 in normal saline.6
+++
Milker’s nodules (pseudo cowpox)
++
In humans 2–5 papules appear on the hands about 1 week after handling cows’ udders or calves’ mouths. It is caused by a parapoxvirus. The papules enlarge to become tender, grey nodules with a necrotic centre and surrounding inflammation (see FIG. 124.7). The patient can be reassured that the nodules are a self-limiting infection and spontaneous remission will occur in 5–6 weeks without residual scarring. One infection gives lifelong immunity.
++
++
Practice tip for milker’s nodule
Rapid resolution (days) can be obtained by an intralesional injection of triamcinolone diluted 50:50 in normal saline.6
+++
Seborrhoeic keratoses
++
Synonyms: seborrhoeic warts, senile warts, senile keratoses (avoid these terms).
++
Very common
There is a variety of subtypes
Increasing number and pigmentation with age >40 years
Sits on skin, appears in some like a ‘sultana’ pressed into the skin (i.e. well-defined border)
Has a ‘pitted’ surface (see FIG. 124.8)
May be solitary but usually multiple
Common on face and trunk, but occurs anywhere
Usually asymptomatic
Usually causes patients some alarm (confused with melanoma)
++
++
Usually nil apart from reassurance
Does not undergo malignant change
Can be removed for cosmetic reasons
Light cautery to small facial lesions or ablative laser therapy
Freezing with liquid nitrogen (especially if thin) decolours the tumour
10% (or stronger) phenol solution applied carefully—repeat in 3 weeks
Apply trichloroacetic acid to surface: instil gently by multiple pricks with a fine-gauge needle, twice weekly for 2 weeks
May drop off spontaneously
If diagnosis uncertain, remove for histopathology
++
This subtype of seborrhoeic keratoses comprises multiple, non-pigmented (often white), small, friable keratoses over the lower legs. They can be treated with a topical keratolytic such as 3–5% salicylic acid in sorbolene.
++
Granuloma annularae are a common benign group of papules arranged in an annular fashion.
++
Most common among children and young adults
Firm papules grouped in a ‘string of pearls’ pattern (see FIG. 124.9)
Dermal nodules
May be associated with minor trauma
Associated with diabetes
Usually on dorsum or sides of fingers (knuckle area), backs of hands, the tops of feet, elbows and knees
++
++
++
Synonyms: sclerosing haemangioma; histiocytoma.
++
This is a common pigmented nodule arising in the dermis due to a proliferation of fibroblasts, believed to develop as an abnormal response to minor trauma including insect bites. The nodule gives a characteristic button-like feel and dimpling when laterally compressed (pinched) from the side with the fingers.
++
Usually multiple
Firm, well-circumscribed nodules
Oval, 0.5–1 cm in diameter
Freely mobile over deeper structures
Slightly raised in relation to skin
Mainly on limbs, especially legs
May itch
Mainly in women
Variable colour, pink or brown, tan or grey or violaceous
Characteristic ‘dimple’ sign on pinching margins
++
++
Solar keratoses (actinic keratoses or sun spots) are reddened, adherent, scaly hyperkeratotic thickenings occurring on light-exposed areas. They represent intra-epidermal keratinocytic dysplasia with a potential for malignant change, especially on the ears.
++
Sun-exposed fair skin
Mainly on face, ears, scalp (if balding), forearms, dorsum of hands (especially) (see FIG. 124.10)
Vary in size from 2–20 mm in diameter
Dry, rough, adherent scale
Usually asymptomatic
Discomfort on rubbing with towel
Scale can separate to leave oozing surface
A small proportion undergo malignant change
++
++
Can disappear spontaneously
Liquid nitrogen
Topical field treatment for patients with multiple solar keratoses or who cannot tolerate repeated cryotherapy:
5-fluorouracil 5% cream daily for 3–4 weeks on face or 3–6 weeks on arms and legs
or
imiquimod, once daily 3 times a week for 3-4 weeks (for one to three cycles with 4-week spells between cycles)
or
ingenol mebutate 0.015% gel topically on face or scalp, once daily for 3 consecutive days
or
ingenol mebutate 0.05% gel topically on trunk or limbs, once daily for 2 consecutive days
Surgical excision for suspicious and ulcerating lesions
Tenderness on lateral pressure requires a biopsy to exclude SCC
Biopsy if doubtful
++
Topical field treatments cause severe inflammation that can last up to several weeks; warn the patient and show them the expected erythema using patient information handouts. Fluorouracil is most commonly used due to its lower cost but causes inflammation for several weeks. Ingenol produces dramatic erythema and vesiculation within 24–48 hours, but the skin heals in approximately 7 days.
++
Terminology
Solar keratoses ‘sun spots’
Solar lentigines ‘age spots’ or ‘liver spots’
++
Keratoacanthomas (KA), which are rapidly evolving tumours of keratinocytes, occur singly on light-exposed areas. They are now considered a low-risk variant of SCC.7 The major problem is differentiation from SCC, especially if on the lip or ear. The relative growth rates of three types of skin tumours are shown in FIGURE 124.11.
++
++
Rapidly growing lesion on sun-exposed skin
Raised crater with central keratin plug (see FIGS 124.12 and 124.13)
Grows to 2 cm or more
Arises over a few weeks, remains static, then spontaneously disappears after about 4–6 months; can leave a big scar
Can be confused with SCC
++
++
++
Remove by excision—perform biopsy
If clinically certain—curettage/diathermy
Treat as SCC (by excision) if on lip/ear
++
The recommended treatment is surgical excision and histological examination. Ensure a 2–3 mm margin for excision. Most patients will not tolerate a tumour for 4–6 months on an exposed area such as the face while waiting for a spontaneous remission. Also, if it is an SCC, a potentially lethal cancer has remained in situ for an unnecessarily long period.
+++
Sebaceous hyperplasia
++
Sebaceous hyperplasia presents as single or multiple nodules on the face, especially in older people. The nodules are small, yellow–pink, slightly umbilicated and are found in a similar distribution to BCCs, for which they may be mistaken. There is no need for surgical excision. Cryotherapy or fine wire diathermy achieves good results.
+++
Basal cell carcinoma8
++
Most common skin cancer (80%)
Age: usually >35 years
More frequent in males
Mostly on sun-exposed areas: face (mainly), neck, upper trunk, limbs (10%) (see FIG. 124.14)
May ulcerate easily = ‘rodent ulcer’
Slow-growing over years
Has various forms: nodular, pigmented, ulcerated, etc.
Stretching the skin demarcates the lesion, highlights pearliness and distinct margin
Does not metastasise via lymph nodes or bloodstream
Local spread is a problem (see FIG. 124.15)
Can spread deeply if around nose, eye or ear
++
++
++
Cystic nodular—translucent or pale grey
Ulcerated—nodular BCC that has necrosed centrally
Pigmented—usually spotted, may be all black
Superficial—erythematous scaly patch, may be misdiagnosed as eczema or psoriasis Red flag pointer for BCC
Morphoeic (fibrotic)—scar-like, poorly defined margin
Common: pearly edge, telangiectasia, ulcerated (see FIG. 124.16)
Basi-squamous—mixed BCC & SCC
++
++
Simple elliptical excision (3–4 mm margin) is best.
If not excision, do biopsy before other treatment.
Radiotherapy is an option, especially in frail people.
Mohs micrographic surgery—a form of surgical treatment suitable for large or recurrent tumours or those in a site when maximal normal tissue needs to be preserved.
Photodynamic therapy—response rate is >90% for nodular and superficial BCCs.
Cryotherapy is suitable for well-defined, histologically confirmed, superficial tumours at sites away from head and neck. Use judiciously and infrequently.
++
Note: For proven BCC but not on nose and around eyes, imiquimod may be an option. To biopsy a BCC, do a shave biopsy, not a punch biopsy.
+++
Squamous cell carcinoma7
++
SCC is an important malignant tumour of the epidermis; it is also found on sun-exposed areas, especially in fair-skinned people. It tends to arise in premalignant areas such as solar keratoses, burns, chronic ulcers, leucoplakia and Bowen disease, or it can arise de novo. Keratoacanthoma is a variant.
++
Note: Although BCC and SCC are related to cumulative sun exposure, they are not always found in sun-exposed areas.
++
Usually >50 years
Initially firm thickening of skin, especially in solar keratosis
Surrounding erythema
The hard nodules soon ulcerate (see FIG. 124.17)
Occurs on the hands and forearms and the head and neck (see FIG. 124.18)
Ulcers have a characteristic everted edge
Capable of metastases (especially those on lips and ears) and may involve regional nodes
SCCs of ear, lip, oral cavity, tongue and genitalia are serious and need special management
++
++
++
Early excision of tumours <1 cm with a 3–5 mm margin, to deep fat level.
Referral for specialised surgery and/or radiotherapy if large, in difficult site or lymphadenopathy.
SCCs of the ear and lip, which have considerably more malignant potential, can be excised by wedge excision.
There is no alternative to surgery if the SCC is over cartilage—central nose or helix.
++
Note: Surgery is the treatment of choice for most tumours; cryotherapy, imiquimod and curettage are not.
++
Radiotherapy is an optional treatment in a biopsy-proven tumour where surgery is not feasible or will cause unacceptable morbidity.
++
Intra-epidermal carcinoma (Bowen disease) is SCC in situ of the skin. It begins as a slowly enlarging, sharply demarcated, thickened, red plaque, especially on the lower legs of females. It may resemble solar keratosis, dermatitis, or a patch of psoriasis. It remains virtually unchanged for months or years. It may become very crusty, ulcerate or bleed. It has a potential for malignant change since it is a full thickness SCC in situ.
++
Biopsy first for diagnosis
Wide surgical excision if small
Skin grafting may be required
Cryotherapy by double freeze thaw technique
Topical therapy with fluorouracil 5% cream or imiquimod 5% cream are options, but referral to a consultant is advisable
++
Note: Biopsy a single patch of suspected psoriasis or dermatitis not responding to topical steroids.
++
Lumps on ears, especially on the helix, demand close attention. SCCs that arise here have up to 17 times the ability to metastasise and demand early wedge resection.
++
Causes of ear lumps include:
++
+++
Chondrodermatitis nodularis helicis9
++
This lump, which is not a neoplasm, presents as a painful nodule on the most prominent part of the helix or antihelix of the ear (see FIGS 124.19 and 124.20). It is seen more often in men while it is found more often on the antihelix in women. It appears to be caused by pressure between the head and the pillow at night. Histologically a thickened epidermis overlies inflamed cartilage. It looks like a small corn, is tender, and affects sleep if that side of the head lies on the pillow. It can be treated initially by cryotherapy or an intralesional injection of triamcinolone. Most resolve if the patient sleeps on the opposite side. If cryotherapy fails, wedge resection under local anaesthetic is an effective treatment.
++
++
++
These are usually enlarging pigmented lesions with an irregular, notched border. Refer to CHAPTER 125 on pigmented skin lesions.
++
These complex tumours may metastasise from the lung, melanoma or bowel and may arise in surgical scars (e.g. for breast cancer).
++
Kaposi sarcoma is a tumour of vascular and lymphatic endothelium that is related to human herpes virus type 8. There are three types:
++
‘classic’ or ‘sporadic’ form of primary tumour seen mostly in elderly males of central or eastern European origin
‘endemic’ form seen in males from Central Africa
immunosuppressed-related form commonly associated with AIDS. Widespread lesions affect skin, bowel, oral cavity and lungs
++
Kaposi sarcoma presents as brownish-purple papules on the skin and mucosa (any organ).
++
Treatment is with radiotherapy, immunotherapy or chemotherapy.
+++
LUMPS OF SUBCUTANEOUS AND DEEPER STRUCTURES
++
++
Lipomas are common benign tumours of mature fat cells situated in subcutaneous tissue.
++
Soft and may be fluctuant
Well defined; lobulated (see FIG. 124.21)
Rubbery consistency
May be one or many
Painless
Most common on limbs (especially arms) and trunk
Can occur at any site
++
++
++
Many lipomas can be enucleated using a gloved finger, but there are a few traps: some are deeper than anticipated, and some are adjacent to important structures such as large nerves and blood vessels. Others are tethered by fibrous bands, and can recur. Recurrence is also possible if excision is incomplete.
++
Caution: Lipomas on back (don’t shell out easily). If >5 cm consider referral.
++
Note: Ultrasound is good at assessing depth of lipoma. CT scan or MRI will help diagnose and define.
++
These benign tumours are firm (sometimes soft), painless, subcutaneous lumps often aligned lengthwise in the long axis of a limb in relation to peripheral nerves (see FIG. 124.22). The lumps are more mobile from side to side than along the long axis. Some are tender to pressure with associated pain and paraesthesia on the nerve distribution.
++
++
Bursae are cystic sacs between the skin and an underlying bony prominence or sacs of gelatinous fluid that separate and aid gliding of adjacent tendons and ligaments.
++
A pseudoaneurysm is a sac-like dilatation of the arterial wall (but not all three layers of the wall). It presents as an expanding subcutaneous nodule located close to a superficial artery. It can form after blunt or penetrating trauma that injures the vessel, leading to a haemorrhage into the vessel wall. Investigate with ultrasound and manage with caution. Refer to a vascular surgeon for surgical management.
++
Ganglia are firm cystic lumps associated with joints or tendon sheaths.
++
Deep subcutaneous lumps
Around joints or tendon sheaths (see FIG. 124.23)
Mostly around wrists, fingers, dorsum of feet
Immobile, fixed to deep tissues
Translucent
Contain viscid gelatinous fluid
Associated with arthritis and synovitis
May disappear spontaneously
Recurrences common
++
++
Can be left—wait and see
Do not ‘bang with a Bible’
Needle aspiration and steroid injection
or
surgical excision (can be difficult)
Suture compression technique: a larger gauge catgut suture is inserted through the middle of the ganglion and firmly tied over it. Side pressure may express the contents through the needle holes. Remove the knot 12 days later.
+++
Injection treatment of ganglia
++
Ganglia have a high recurrence rate after treatment, with a relapse rate of 30% after surgery. A simple, relatively painless and more effective method is to use intralesional injections of long-acting corticosteroid, such as methylprednisolone acetate.12
++
Insert a 21 gauge needle attached to a 2 mL or 5 mL syringe into the cavity of the ganglion.
Aspirate some (not all) of its jelly-like contents, mainly to ensure the needle is in situ.
Keeping the needle exactly in place, swap the syringe for an insulin syringe containing up to 0.5 mL of steroid.
Inject 0.25–0.5 mL (see FIG. 124.24).
Rapidly withdraw the needle, pinch the overlying skin for several seconds and then apply a light dressing.
Review in 7 days and, if still present, repeat the injection using 0.25 mL of steroid.
++
++
Up to six injections can be given over a period of time, but 70% of ganglia will disperse with only one or two injections.9 Be aware of possible subsequent hypopigmentation of overlying skin, especially in people with darker skin.