Chapter 124: Common lumps and bumps

Lumps and bumps are very common presentations and the skin a very common site for neoplastic lesions. Most of these lesions only invade locally, with the notable exception of malignant melanoma. Pigmented skin tumours thus demand very careful consideration, although only a very few are neoplastic. The optimum time to deal with the problem and cure any skin cancer is at its first presentation. The family doctor thus has an important responsibility to screen these tumours and is faced with two basic decisions: the diagnosis and whether to treat or refer.

Most skin lumps are benign and can be left in situ, but the family doctor should be able to remove most of these lumps if appropriate and submit them for histological verification. The main treatment options available in family practice are: biopsy, cryotherapy, curette and cautery, excision or intralesional injections of corticosteroid.¹ A list of common and important lumps is presented in TABLE 124.1.

The three main skin cancers are the non-melanocytic skin cancers—basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)—and melanoma. The approximate relative incidence is BCC 80%, SCC 15–20%, and melanoma less than 5%.² The incidence of non-melanocytic skin cancer, which is increasing 2.5 times as fast as other cancers, is approximately 800 new cases per 100 000 population per year, and 25 per 100 000 for melanoma. About 80% of skin cancer deaths are due to melanoma and the rest mainly due to SCC.²

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.

Fibroepithelial polyps

Synonyms: skin tags, acrochordon, benign squamous papilloma, soft fibroma.

Clinical features

• 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

Management

• 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).

Clinical features

• 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

Management

If before puberty—think of polyposis coli. Can leave if small and not bothersome.

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.

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).

Implantation cyst

Synonym: implantation dermoid.

Clinical features

• Small cystic swelling

• May be tender

• Usually follows puncture wounds

• Especially on finger pulp (e.g. hairdressers, sewers)

• Contains mucus

Management

• Incision removal (similar to epidermoid cyst)

Mucocele

A mucous retention cyst.

Clinical features

• A benign tumour

• Cyst containing mucus

• Appears spontaneously

• Common on lips and buccal mucosa

• Smooth and round

• Yellow or blue colour

Management

• Incision removal

Hyperplastic scarring

Hypertrophic scar

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.

Keloid

A keloid is a special type of hyperplastic scar that extends beyond the margins of the wound.

Clinical features

• 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 and papillomas

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

Clinical features

• 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

Types of warts

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.

Treatment options

Topical applications:⁵

• 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.

Note:

• excessive keratin must be pared before freezing

• the results are often disappointing

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.

• 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)

• Consider cimetidine

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:

  1. Soak the wart/s in warm soapy water.

  2. Rub back the wart surface with a pumice stone.

  3. 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

Pox virus lumps

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.

Clinical features

• 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

Management

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.

Treatment options

• 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

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.

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.

Seborrhoeic keratoses

Synonyms: seborrhoeic warts, senile warts, senile keratoses (avoid these terms).

Clinical features

• 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)

Management

• 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

Stucco keratoses

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

Granuloma annularae are a common benign group of papules arranged in an annular fashion.

Clinical features

• 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

Management⁷

• Check urine/blood for sugar

• Give reassurance (they usually subside in a year or so)

• Cosmetic reasons:

  • – first-line: potent topical corticosteroids ± occlusion, apply bd for minimum of 4–6 weeks

  • – if ineffective: intradermal injection into the extending outer margin of triamcinolone 10% or similar corticosteroid (dilute equal volume with N saline); can repeat at 6-weekly intervals if effective

Dermatofibroma

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.

Clinical features

• 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

Treatment

• Reassurance

• Simple excision if requested

Solar keratoses⁷

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.

Clinical features

• 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

Management⁷

• 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.

Keratoacanthoma

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.

Clinical features

• 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

Management

• 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

Clinical features

• 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

Clinical types

1. Cystic nodular—translucent or pale grey

2. Ulcerated—nodular BCC that has necrosed centrally

3. Pigmented—usually spotted, may be all black

4. Superficial—erythematous scaly patch, may be misdiagnosed as eczema or psoriasis Red flag pointer for BCC

5. Morphoeic (fibrotic)—scar-like, poorly defined margin

6. Common: pearly edge, telangiectasia, ulcerated (see FIG. 124.16)

7. Basi-squamous—mixed BCC & SCC

Management⁸

• 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.

Clinical features

• 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

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.

Bowen disease⁷

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.

Management

• 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:

• solar keratosis

• BCC

• SCC

• keratoacanthoma

• gouty tophi

• chondrodermatitis nodularis helicis

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.

Malignant melanoma

These are usually enlarging pigmented lesions with an irregular, notched border. Refer to CHAPTER 125 on pigmented skin lesions.

Secondary tumour

These complex tumours may metastasise from the lung, melanoma or bowel and may arise in surgical scars (e.g. for breast cancer).

Kaposi sarcoma¹⁰

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.

Lipoma

Lipomas are common benign tumours of mature fat cells situated in subcutaneous tissue.

Clinical features

• 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

Management

• Reassurance about benign nature

• Removal for cosmetic reasons or to relieve discomfort from pressure. Use surgical excision or punch biopsy

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.

Neurofibroma

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

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.

Pseudoaneurysm¹¹

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.

Ganglion

Ganglia are firm cystic lumps associated with joints or tendon sheaths.

Clinical features

• 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

Management

• 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.

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

1. Insert a 21 gauge needle attached to a 2 mL or 5 mL syringe into the cavity of the ganglion.

2. Aspirate some (not all) of its jelly-like contents, mainly to ensure the needle is in situ.

3. Keeping the needle exactly in place, swap the syringe for an insulin syringe containing up to 0.5 mL of steroid.

4. Inject 0.25–0.5 mL (see FIG. 124.24).

5. Rapidly withdraw the needle, pinch the overlying skin for several seconds and then apply a light dressing.

6. 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.

Liquid nitrogen therapy

Ideally, liquid nitrogen is stored in a special large container and decanted when required into a small thermos flask or spray device.

The easiest method of application to superficial skin tumours (see TABLE 124.2) is via a ball of cotton wool rolled rather loosely on the tip of a wooden applicator stick. The ball of cotton wool should be slightly smaller than the lesion, to prevent freezing of the surrounding skin.

1. Inform the patient what to expect.

2. Pare excess keratin with a scalpel.

3. Use a cotton wool applicator slightly smaller (not larger—see FIG. 124.25a) than the lesion.

4. Immerse it in nitrogen until bubbling ceases.

5. Gently tap it on the side of the container to remove excess liquid.

6. Hold the lesion firmly between thumb and forefinger.

7. Place applicator vertically (see FIG. 124.25b and FIG. 124.25c) on tumour surface.

8. Apply with firm pressure: do not dab.

9. Freeze until a 2 mm white halo appears around the lesion.

Explain likely reaction to patient, such as the appearance of blisters (possibly blood blisters). The optimal time for retreatment of warts is in 2–3 weeks (not longer than 3 weeks).

Biopsies

There are various methods for taking biopsies from skin lesions. These include scraping, shaving and punch biopsies, all of which are useful but not as effective or safe as excisional biopsies.

Shave biopsies

This simple technique is generally used for the tissue diagnosis of premalignant lesions and some malignant tumours, but not melanoma.

1. Infiltrate with LA.

2. Holding a number 10 or 15 scalpel blade horizontally, shave off the tumour just into the dermis (see FIG. 124.26).

3. Diathermy may be required for haemostasis.

The biopsy site usually heals with minimal scarring.

Punch biopsy

This biopsy (see FIG 124.27) has considerable use in general practice where full-thickness skin specimens are required for histological diagnosis. (Good quality disposable biopsy punches are available from Dermatech Laboratories.)

Steroid injections into skin lesions

Suitable lesions for steroid injections are:

• plaque psoriasis

• granuloma annularae

• hypertrophic scars (early development)

• keloid scars (early development)

• alopecia areata

• chondrodermatitis nodularis helicis

• lichen simplex chronicus

• necrobiosis lipoidica

• hypertrophic lichen planus

• orf and milker’s nodules

Triamcinolone is the appropriate long-acting corticosteroid (10 mg/mL). It may be diluted in equal quantities with saline.

1. The steroid should be injected into the lesion (not below it).

2. Insert a 25 or (preferably) 27 gauge needle, firmly locked to a small insulin-type 1 mL syringe, into the lesion at the level of the middle of the dermis (see FIG. 124.28).

3. High pressure is required with some lesions (e.g. keloid).

4. Inject sufficient steroid to make the lesion blanch.

5. Several sites will be needed for larger lesions, so preceding LA may be required in some instances. Avoid infiltration of steroid in larger lesions: use multiple injections.

Elliptical excisions

Small lesions are best excised as an ellipse. Generally, the long axis of the ellipse should be along the skin tension lines identified by natural wrinkles.

The intended ellipse should be drawn on the skin (see FIG. 124.29). The placement will depend on such factors as the size and shape of the lesion, the margin required (usually 3 mm) and the skin tension lines.

General points⁹

• The length of the ellipse should be three times the width.

• This length should be increased (say, to four times) in areas with little subcutaneous tissue (dorsum of hand) and high skin tension (upper back).

• A good rule is to obtain an angle at each end of the excision of 30° or less.

• These rules should achieve closure without ‘dog ears’.

Excisions on the face

It is important to select optimal sites for elliptical excisions of tumours of the face. As a rule it is best for incisions to follow wrinkle lines and the direction of hair follicles in the beard area. Therefore, follow the natural wrinkles in the glabella area, the ‘crow’s feet’ around the eye, and the nasolabial folds (see FIG. 124.30). To determine non-obvious wrinkles, gently compress the relaxed skin in different directions to demonstrate the lines.

For tumours of the forehead make horizontal incisions, although vertical incisions may be used for large tumours of the forehead. Ensure that you keep your incisions in the temporal area quite superficial, as the frontal branch of the facial nerve is easily cut.

Referral should be considered for:

• uncertainty of diagnosis

• suspicion of melanoma

• tumours larger than 1 cm

• recurrent tumours, despite treatment

• incomplete excised tumours, especially with poor healing

• doubts about appropriate treatment

• recommended treatment beyond skills of practitioner

• frequent multiple tumours (e.g. organ transplant patients)

• SCC on the lip or ear

• infiltrating or scar-like morphoeic BCC, particularly those on the nose or around the nasal labial fold

• cosmetic concerns, such as lesions in the upper chest and upper arms where keloid scarring is a potential problem

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Fatty tumour (lipoma)

• Molluscum contagiosum

• Seborrhoeic keratoses

• Skin cancer

• Warts