Chapter 116 - Common lumps and bumps

It will never get well if you pick it.

American Proverb

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
• mucocele
• hypertrophic scar and keloid
• warts and papillomas
• pox virus lumps
  — molluscum contagiosum
  — orf
  — milker's nodules
• seborrhoeic keratoses
• granuloma annularae
• dermatofibroma
• solar keratosis/actinic keratosis
• keratoacanthoma
Malignant tumours
• basal cell carcinoma
• squamous cell carcinoma
• Bowen's disorder
• malignant melanoma
• Kaposi's sarcoma
• secondary tumour

Subcutaneous and deeper structures
• lipoma
• neurofibroma
• soft fibroma
• lymph node
Musculoskeletal
• ganglion

Skin cancer

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:

Relation of the lump to anatomical structures3

The question ‘In what tissue layer is the lump situated?’ needs to be addressed.

Fibroepithelial polyps

Synonyms: skin tags, acrochordon, benign squamous papilloma.

Clinical features:

Management

These methods do not require local anaesthetic.

Epidermoid (sebaceous) cyst

Synonyms: ‘pilar’ cysts, keratinous cyst, wens, epidermoid cysts, sebaceous cysts (similar in appearance).

Clinical features:

Management

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:

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).

Implantation cyst

Synonym: implantation dermoid.

Clinical features:

Management

Mucocele

A mucous retention cyst.

Clinical features:

Management

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.

Keloid

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

Clinical features:

Management

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

Clinical features:

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

Common warts

Skin-coloured tumours with a rough surface, found mainly on the fingers, elbows and knees.

Plane warts

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

Topical applications:5

Cryotherapy

Carbon dioxide (−56.5°C) or liquid nitrogen (−195.8°C) destroys the host cell and stimulates an immune reaction.

Note:

Curettage

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.

Electrodissection

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

Medication

Specific wart treatment

The method chosen depends on the type of wart, its site and the patient's age.

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 (p. 1133). The incubation period is 2–26 weeks.

Clinical features:

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

Note: The extract of the Cantharis beetle (prepared as Canthrone) 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.

Practice tip

Rapid resolution (days) can be obtained by an intralesional injection of triamcinolone diluted 50:50 in normal saline.6

Milker's nodules

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
Practice tip

Intralesional corticosteroid injection (as for Orf).

Seborrhoeic keratoses

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

Clinical features:

Management

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% salicyclic acid in sorbolene.

Granuloma annularae

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

Clinical features:

Management7

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:

Treatment

Solar keratosis

Solar keratoses (actinic keratoses) are reddened, adherent, scaly thickenings occurring on light-exposed areas, with a potential for malignant change, especially on the ears.

Clinical features:

Terminology

Solar keratoses = ‘sun spots’

Solar lentigines = ‘age spots’ or ‘liver spots’

Management

Keratoacanthoma

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

Clinical features:

Management

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 basal cell carcinomas for which they may be mistaken. There is no need for surgical excision.

Basal cell carcinoma

Clinical features:

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
  5. Morphoeic (fibrotic)—scar-like, poorly defined margin
  6. 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

Management

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.

Clinical features:

Management

NB: Surgery is the treatment of choice for most tumours, cryotherapy and curettage is not.

Bowen's disorder

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.

Management

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:

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

Malignant melanoma

These are usually enlarging pigmented lesions with an irregular notched border. Refer to Chapter 117 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 carcinoma of the breast).

Kaposi's sarcoma

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.

Lipoma

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

Clinical features:

Management

Surgical excision

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.

Method

Principle: cut, squeeze, ‘pop’

  1. Outline the extent of the lipoma and note its anatomical relationships.
  2. Infiltrate the area with 1% lignocaine with adrenaline (include the deepest part of the lipoma).
  3. 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
  4. 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).
  5. If necessary, insert curved scissors and use a blunt opening action to free any fibrous bands tethering the lipoma (Figure 116.21d).
  6. Ensure that all the fatty tissue is removed. Send it for histological examination.
  7. Use a gauze swab to control bleeding and remove debris from the dead space.
  8. Close the dead space with interrupted catgut sutures.
  9. Close the skin with interrupted or subcuticular sutures.

Neurofibroma

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

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.

Ganglion

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

Clinical features:

Management

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

Method

  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 (Figure 116.23).

    Figure 116.23 Injection treatment of ganglion
  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.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)
Skin tags
Seborrhoeic keratoses
Molluscum contagiosum
Sebaceous hyperplasia
Solar keratoses

Method (basic steps)

  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 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
  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 (Figure 116.24b) 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.

Method

  1. Infiltrate with LA.
  2. 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
  3. Diathermy may be required for haemostasis.

The biopsy site usually heals with minimal scarring.

Punch biopsy

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.)

Method

  1. Clean the skin.
  2. Infiltrate with LA.
  3. Gently stretch the skin between the finger and thumb to limit rotational movement.
  4. Select the punch (4 mm is the most useful size) and hold it vertically to the skin.
  5. 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
  6. Use fine-toothed forceps or a tissue hook to grip the outer rim of the plug.
  7. Exert gentle traction and undercut the base of the plug parallel to the skin surface, using fine-pointed scissors or a scalpel.
  8. Place the specimen in fixative.
  9. Secure haemostasis by firm pressure or by diathermy.
  10. Apply a dry dressing or a single suture to the defect.

Steroid injections into skin lesions

Suitable lesions for steroid injections are:

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

Method

  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 (Figure 116.27).

    Figure 116.27 Injection of corticosteroid into mid-dermis
  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 (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

General points

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:

Key point


REFERENCES
  1. Paver R. The surgical management of cutaneous tumours in general practice. Mod Med Aust, 1991; March: 43–51.
  2. Marks R. Skin cancer. In: MIMS Disease Index (2nd edn). Sydney: IMS Publishing, 1996: 469–72.
  3. Davis A, Bolin T, Ham J. Symptom Analysis and Physical Diagnosis (2nd edn). Sydney: Pergamon Press, 1990: 302–6.
  4. de Launey WE, Land WA. Principles and Practice of Dermatology (2nd edn). Sydney: Butterworths, 1984: 280–1.
  5. Berger P. Warts: how to treat them successfully. Mod Med Aust, 1990; August: 28–32.
  6. Reddy J. Intralesional injection for orf: a practice tip. Aust Fam Physician, 1993; 22: 65.
  7. Marley J (Chair). Therapeutic Guidelines: Dermatology (Version 2). Melbourne: Therapeutic Guidelines Ltd, 2004; 253–4.
  8. La Villa G. Methylprednisolone acetate in local therapy of ganglion. Clin Therapeutics, 1986; 47: 455–7.