Chapter 116 - Common lumps and bumps
It will never get well if you pick it.
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 116.1.
|Table 116.1 Important lumps and their tissue of origin3|
|Skin and mucous membranes
|• fibroepithelial polyp (skin tag)
|• epidermoid (sebaceous) cyst
|• implantation cyst
|• sebaceous hyperplasia
|• hypertrophic scar and keloid
|• warts and papillomas
|• pox virus lumps
| — molluscum contagiosum
| — orf
| — milker's nodules
|• seborrhoeic keratoses
|• granuloma annularae
|• solar keratosis/actinic keratosis
|• basal cell carcinoma
|• squamous cell carcinoma
|• Bowen's disorder
|• malignant melanoma
|• Kaposi's sarcoma
|• secondary tumour
|Subcutaneous and deeper structures
|• soft fibroma
|• lymph node
The three main skin cancers are the non-melanocyctic skin cancers—basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)—and melanoma. The approximate relative incidence is BCCs 80%, SCCs 15–20%, and melanomas less than 5%.2 The incidence of non-melanotic skin cancer 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
A diagnostic approach to the lump
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:
- shape—regular or irregular
- size (in metric units)
- consistency (very soft, soft, firm, hard or stony hard)
- solid or cystic
- surface or contour
- special features
- attachments (superficial/deep)
- exact anatomical site
- relation to anatomical structures
- relation to overlying skin
- temperature (of skin over lump)
- pulsation (transmitted or direct)
- fluctuation (? contains fluid)
- special signs
- slipping sign
- emptying sign of cavernous
- 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.
Synonyms: skin tags, acrochordon, benign squamous papilloma.
- benign skin overgrowth
- increased incidence with age
- commonest on neck, axillae, trunk, groins
- no malignant potential
- can be irritating or unsightly to patient
- Can leave or remove
- Snip off with scissors or bone forceps (Figure 116.1) or
Figure 116.1 Removal of skin tag using bone forceps
- tie base with fine cotton or suture material or
- diathermy base or
- apply liquid nitrogen (Figure 116.2)
Figure 116.2 Removal of skin tag by liquid nitrogen: a cotton bud soaked in liquid nitrogen is applied to the forceps, which grasp the tag firmly
These methods do not require local anaesthetic.
Epidermoid (sebaceous) cyst
Synonyms: ‘pilar’ cysts, keratinous cyst, wens, epidermoid cysts, sebaceous cysts (similar in appearance).
- firm to soft regular lump (usually round)
- fixed to skin but not to other structures (Figure 116.3a)
Figure 116.3 (a) Configuration of a sebaceous cyst (b), (c) Standard dissection of a large sebaceous cyst
- 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 (Figure 116.3b). Apply forceps to this skin to provide traction for dissection of the cyst from the adherent dermis and subcutaneous tissue. Ideally, forceps should be applied at either end. 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 (Figure 116.3c). Bleeding is not usually a problem. When the cyst is removed, obliterate the space with subcutaneous Vicryl, Dacron, PDS or Monocryl (all preferable) or catgut. The skin is sutured with a vertical mattress suture to avoid a tendency to inversion of the skin edges into the slack wound. 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 (above).
Synonym: implantation dermoid.
- small cystic swelling
- may be tender
- usually follows puncture wounds
- especially on finger pulp (e.g. hairdressers, sewers)
- contains mucus
- Incision removal (similar to epidermoid cyst)
A mucous retention cyst.
- a benign tumour
- cyst containing mucus
- appears spontaneously
- common on lips and buccal mucosa
- smooth and round
- yellow or blue colour
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.
A keloid is a special type of hypertrophic 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
- follows trauma, even minor (e.g. ear piercing)
- may be burning or itchy and tender
- Prevention (avoid procedures in keloid-prone individuals).
- Intradermal injection of corticosteroids in early stages (2–3 months) or X-ray treatment of surgical wounds within 2 weeks of operation.4
Warts and papillomas
Warts are skin tumours caused by the human papilloma virus (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 races 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 (Figure 116.5).
Figure 116.5 Configuration of various types of warts
Skin-coloured tumours with a rough surface, found mainly on the fingers, elbows and knees.
Skin-coloured, small and flat, occurring in linear clusters along scratch lines (Figure 116.4). Mainly occur on the face and limbs. Difficult to treat because they contain very few virus particles. Prone to Koebner phenomenon, which is seeding when a scratch passes through a plane wart.
Figure 116.4 Plane warts on the dorsum of the hand
Treatment options for warts
- salicylic acid—e.g. 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.
- Excessive keratin must be pared before freezing.
- Results 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 electrodissection 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 (see Chapter 110).
- Filiform and digitate warts: liquid nitrogen or electrodissection.
- Plane warts: liquid nitrogen; salicylic acid 20% co (e.g. Wartkil); consider 5-fluorouracil cream or 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 the paint (only to the wart; protect the surrounding skin with Vaseline). The paint: 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 (children) 8% salicylic acid, 8% lactic acid in collodion
- Periungual warts (fingernails): consider 5-fluorouracil or liquid nitrogen with care. Always use a paint rather than ointment or paste on fingers.
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.
This common pox virus infection can be spread readily by direct contact, including sexual contact (p. 1133). The incubation period is 2–26 weeks.
- common in school-age children
- single or multiple (more common)
- shiny, round, pink-white papule (Figure 116.6)
Figure 116.6 Molluscum contagiosum with the round pink pearly appearance and central punctum
- 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) 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
- 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 (prepared as Canthrone) 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.
Rapid resolution (days) can be obtained by an intralesional injection of triamcinolone diluted 50:50 in normal saline.6
In humans 2–5 papules appear on the hands about 1 week after handling cows' udders or calves' mouths. The papules enlarge to become tender grey nodules with a necrotic centre and surrounding inflammation (Figure 116.7). 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.
Figure 116.7 Milker's nodule in a person who milks cows showing the grey nodule with the necrotic centre
Intralesional corticosteroid injection (as for Orf).
Synonyms: seborrhoeic wart, senile wart, 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 (Figure 116.8)
Figure 116.8 Seborrhoeic keratosis in a 70-year-old man. The large pigmented warty mass appears to sit on top of the skin. Photo courtesy Robin Marks
- 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
- 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% salicyclic 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 (Figure 116.9)
Figure 116.9 Granuloma annularae: this pearly papular tumour was long standing on this finger. After taking a small biopsy 20 mg of methylpredisolone acetate was injected into the tumour
- dermal nodules
- may be associated with minor trauma
- associated with diabetes
- usually on dorsum or sides of fingers (knuckle area), backs of hands, the elbows and knees
- 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
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
- Simple excision if requested
Solar keratoses (actinic keratoses) are reddened, adherent, scaly thickenings occurring on light-exposed areas, 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) (Figure 116.10)
Figure 116.10 Solar keratoses showing the reddened scaly thickenings on sun-exposed areas. Biopsy of one of the lesions proved squamous cell carcinoma
- dry, rough, adherent scale
- discomfort on rubbing with towel
- scale can separate to leave oozing surface
- a small proportion undergo malignant change
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. 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 116.11.
Figure 116.11 Relative growth rates of three types of skin tumours: keratoacanthoma, squamous cell carcinoma and basal cell carcinoma
- rapidly growing lesion on sun-exposed skin
- raised crater with central keratin plug (Figure 116.13 and Figure 116.12)
Figure 116.13 A typical keratoacanthoma
Figure 116.12 Keratoacanthoma : this tumour, with its central plug appeared suddenly on the face of a 63-year-old man. It may be confused with squamous cell carcinoma. Surgical excision is appropriate treatment
- 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 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 basal cell carcinomas for which they may be mistaken. There is no need for surgical excision.
Basal cell carcinoma
- 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%) (Figure 116.15)
Figure 116.15 Typical areas in which basal cell carcinomas occur
- 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
- 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
- Morphoeic (fibrotic)—scar-like, poorly defined margin
- Common: pearly edge, telangiectasia, ulcerated (Figure 116.14)
Figure 116.14 Basal cell carcinoma showing a pearly nodular appearance with telangiectatic vessels. Photo courtesy Robin Marks
- Excision (3-mm margin) is best.
- If not excision, do biopsy before other treatment.
- Radiotherapy is an option, especially in frail people.
- Moh's 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.
Note: Avoid cryotherapy; imiquimod may be an option. To biopsy a BCC, do a shave biopsy, not a punch biopsy.
Squamous cell carcinoma
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's disorder, or it can arise de novo.
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 (Figure 116.16)
Figure 116.16 Squamous cell carcinoma. This recurrent non-healing lesion on the index finger of a 58-year-old man had raised hard edges and was fixed to tendon and bone. Treatment was by surgical amputation of the finger
- occurs on the hands and forearms and the head and neck (see Figure 116.17)
Figure 116.17 Common sites of squamous cell carcinoma
- ulcers have a characteristic everted edge
- capable of metastases 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 4-mm margin (in most cases), 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.
NB: Surgery is the treatment of choice for most tumours, cryotherapy and curettage is not.
Bowen's disorder begins as a slowly enlarging, sharply demarcated, thickened red plaque, especially on the lower legs of females. It may resemble solar keratosis 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
- Imiquimod is considered promising (awaiting trials)
Note: Biopsy a single patch of suspected psoriasis or dermatitis not responding to topical steroids.
Lumps on ears
Lumps on ears, especially on the helix, demand close attention. SCCs which arise here have up to 17 times the ability to metastasise and demand early wedge resection.
Causes of ear lumps include:
- solar keratosis
- basal cell carcinoma
- squamous cell carcinoma
- gouty tophi
- chondrodermatitis nodularis helicus
Chondrodermatitis nodularis helicus
This lump, which is not a neoplasm, presents as a painful nodule on the most prominent part of the helix or antehelix of the ear (Figure 116.18). It is seen more often in men while it is found more often on the antehelix in women. It is caused by sun dam-age. Histologically a thickened epidermis overlies inflammed cartilage. It looks like a small corn, is tender, and affects sleep if that side of the head lies on the pillow. If cryotherapy fails, wedge resection under local anaesthetic is an effective treatment.
Figure 116.18 Typical sites of chondrodermatitis nodularis helicus
These are usually enlarging pigmented lesions with an irregular notched border. Refer to Chapter 117 on pigmented skin lesions.
These complex tumours may metastasise from the lung, melanoma or bowel and may arise in surgical scars (e.g. for carcinoma of the breast).
Kaposi's sarcoma presents as brownish-purple papules on the skin and mucosa. Apart from the well-known presentation in immunocompromised individuals, it is seen as a primary tumour mostly in elderly men of central or eastern European origin.
Lipomas are common benign tumours of mature fat cells situated in subcutaneous tissue.
- soft and may be fluctuant
- well defined; lobulated (Figure 116.19)
Figure 116.19 Lipoma: the 66-year-old woman had a longstanding soft, fluctuant rubbery lump of 18 years. It was surgically removed for cosmetic reasons
- rubbery consistency
- may be one or many
- most common on limbs (especially arms) and trunk
- can occur at any site
- Reassurance about benign nature
- Removal for cosmetic reasons or to relieve discomfort from pressure
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.
Principle: cut, squeeze, ‘pop’
- Outline the extent of the lipoma and note its anatomical relationships.
- Infiltrate the area with 1% lignocaine with adrenaline (include the deepest part of the lipoma).
- Make a linear incision (Figure 116.21a) in the overlying skin, preferably in a natural crease line for about two-thirds of its length. The lipoma should bulge through the wound. For large lipomas, incise an ellipse of skin (Figure 116.21b).
Figure 116.21 (a) Linear incision for small lipomas; (b) elliptical incision for large lipomas; (c) gloved-finger dissection to bring the lipoma to the surface; (d) blunt scissors dissection to free the lipoma from tethering fibrous bands
- Insert a gloved finger between the skin and fatty tumour to determine whether it will shell out. It is important to seek the outer edge of each lobule, dissect it and bring it to the surface (Figure 116.21c).
- If necessary, insert curved scissors and use a blunt opening action to free any fibrous bands tethering the lipoma (Figure 116.21d).
- Ensure that all the fatty tissue is removed. Send it for histological examination.
- Use a gauze swab to control bleeding and remove debris from the dead space.
- Close the dead space with interrupted catgut sutures.
- Close the skin with interrupted or subcuticular sutures.
These benign tumours are firm (sometimes soft) painless subcutaneous lumps aligned length-wise in the long axis of the limb in relation to peripheral nerves (Figure 116.20). 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.
Figure 116.20 Neurofibroma. This mobile firm subcutaneous lump was tender to firm pressure.
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.
Ganglia are firm cystic lumps associated with joints or tendon sheaths.
- deep subcutaneous lumps
- around joints or tendon sheaths (Figure 116.22)
Figure 116.22 Ganglion of wrist—firm, immobile and translucent. It was eventually treated by aspiration of gelatinous fluid followed by infusion of 40-mg methyl prednisolone acetale
- mostly around wrists, fingers, dorsum of feet
- immobile, fixed to deep tissues
- 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.8
- 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 (Figure 116.23).
Figure 116.23 Injection treatment of ganglion
- 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.8
Some preferred therapeutic options
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 (Table 116.2) 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.
|Table 116.2 Superficial skin tumours suitable for cryotherapy|
|Warts (plane, periungual, plantar, anogenital)
Method (basic steps)
- Inform the patient what to expect.
- Pare excess keratin with a scalpel.
- Use a cotton wool applicator slightly smaller (not larger—see Figure 116.24a) than the lesion.
Figure 116.24 Application of liquid nitrogen: (a) applicator too large; (b) correct size and approach of applicator; (c) correct size but wrong position of applicator
- Immerse it in nitrogen until bubbling ceases.
- Gently tap it on the side of the container to remove excess liquid.
- Hold the lesion firmly between thumb and forefinger.
- Place applicator vertically (Figure 116.24b) on tumour surface.
- Apply with firm pressure: do not dab.
- 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).
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.
This simple technique is generally used for the tissue diagnosis of premalignant lesions and some malignant tumours, but not melanoma.
- Infiltrate with LA.
- Holding a number 10 or 15 scalpel blade horizontally, shave off the tumour just into the dermis (Figure 116.25).
Figure 116.25 Shave biopsy
- Diathermy may be required for haemostasis.
The biopsy site usually heals with minimal scarring.
This biopsy has considerable use in general practice where full-thickness skin specimens are required for histological diagnosis. (Good quality disposable biopsy punches are available from Derma Tech Laboratories.)
- Clean the skin.
- Infiltrate with LA.
- Gently stretch the skin between the finger and thumb to limit rotational movement.
- Select the punch (4 mm is the most useful size) and hold it vertically to the skin.
- Rotate (in a clockwise, screwing motion) with firm pressure to cut a plug about 3 mm in depth (Figure 116.26). Remove the punch.
Figure 116.26 Punch biopsy
- Use fine-toothed forceps or a tissue hook to grip the outer rim of the plug.
- Exert gentle traction and undercut the base of the plug parallel to the skin surface, using fine-pointed scissors or a scalpel.
- Place the specimen in fixative.
- Secure haemostasis by firm pressure or by diathermy.
- Apply a dry dressing or a single suture to the defect.
Steroid injections into skin lesions
Suitable lesions for steroid injections are:
- plaque psoriasis
- granuloma annulare
- hypertrophic scars (early development)
- keloid scars (early development)
- alopecia areata
- 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.
- The steroid should be injected into the lesion (not below it).
- 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 (Figure 116.27).
Figure 116.27 Injection of corticosteroid into mid-dermis
- High pressure is required with some lesions (e.g. keloid).
- Inject sufficient steroid to make the lesion blanch.
- 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.
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 (Figure 116.28). The placement will depend on such factors as the size and shape of the lesion, the margin required (usually 2–3 mm) and the skin tension lines.
Figure 116.28 Ellipse excision
- 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 (Figure 116.29). To determine non-obvious wrinkles, gently compress the relaxed skin in different directions to demonstrate the lines.
Figure 116.29 Recommended lines for excisions on face. Adapted From J.S. Brown, Minor Surgery: A Text And Atlas. London: Chapman & Hall, 1986.
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.
When to refer
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
- squamous cell carcinoma 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
- Uncomplicated small tumours are best removed by an elliptical excision with a 3 mm margin for BCC and a 4 mm margin for SCC.
- Caution should be used in the management of tumours on the face, including the ears and lips.
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