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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Synonym: fibrous histiocytoma
Dermatofibromas are common and benign skin tumours but frequently cause concern upon discovery.
Traditionally, dermatofibromas were attributed to a reaction to trauma such as insect bites. However, the precise aetiology is unclear. Some believe them to be benign neoplasms rather than reactive in origin.
The most common dermatofibromas contain a mixture of fibroblasts, macrophages and blood vessels. Most involve the dermis and may extend to the subcutis. A number of less common variants where the histology differs ,such as the aneurysmal fibrous histiocytoma, hemosiderotic fibrous histiocytoma, cellular fibrous histiocytoma and epithelioid fibrous histiocytoma, have been described.Different types are associated with different behaviours and outcomes.
- They are more frequent in women than in men.
- They can occur at any age, most commonly in young adulthood.
- They are more common and more numerous in those with immunosuppression.
- Dermatofibromas are usually single nodules that develop on an extremity, most commonly the lower legs. They are freely moving, firm to hard nodules of 0.5-1.0 cm diameter.
- The skin's surface is generally smooth, occasionally scaly. The overlying skin may be tethered, causing it to dimple when pinched. The skin colour varies from skin-coloured to pink/red to cream/white to brown.
- Lesions can occur at any skin site and individuals may have several lesions (up to 15).
- Multiple variants tend to occur where immunity is impaired (eg, autoimmune disease, systemic lupus erythematosus, HIV, leukaemia).
- The nodule is usually asymptomatic but can be itchy or tender.
- After initial growth, they tend to remain static in size.
- Diagnosis is usually straightforward provided you palpate the lesion, as few other skin lesions are as firm.
- The pinch test is helpful (but not definitive): squeezing the lesion from the sides results in dimpling of overlying skin.
- With a dermatoscope, dermatofibromas typically show a pigment network and central white patch but there is considerable variation.One study noted a difference in dermatoscopy appearance depending on location of the lesion.
- Excision biopsy is useful where diagnostic uncertainty remains after examination.
- Atypical mole.
- Basal cell carcinoma.
- Keloid or hypertrophic scar.
- Malignant melanoma.
- Metastatic carcinoma of the skin.
- Spitz' naevus.
- Blue naevus.
- Squamous cell carcinoma.
Deep penetrating dermatofibromas may be difficult to distinguish, even histologically, from rare malignant fibrohistiocytic tumours - eg, dermatofibrosarcoma protuberans.
- Reassure - generally no treatment is required.
- Remove where cosmetically disliked, symptomatic or there is diagnostic uncertainty. Note that there is a significant local recurrence rate.
- Removal by elliptical excision or punch biopsy usually provides the most satisfactory results: shave excision or cryotherapy have higher risks of incomplete excision and recurrence.
- A Dutch study showed about 2% of GP subcutis excisions yield unexpected or rare malignancies, and UK studies have shown a lack of reliability in GP diagnosis of skin malignancy.[7, 8]Therefore, even where excision is for cosmetic or symptomatic reasons, it is nonetheless worth sending specimens to histology.
When to refer
Referral is normally indicated only for diagnostic assistance, to differentiate from other potentially harmful pigmented lesions.
- Lesions are almost invariably benign - there are extremely rare case reports of metastasising cellular dermatofibromas, although histological distinction from other tumours can prove difficult. Follow up lesions that are histologically atypical or undergo recurrence.
- Most are static and persist indefinitely although, uncommonly, they spontaneously regress.
- The cellular type tends to become larger and, as above, has occasionally been reported to metastasise.
- They may become repeatedly irritated by shaving, for example.
Further reading and references
Higgins JC, Maher MH, Douglas MS; Diagnosing Common Benign Skin Tumors. Am Fam Physician. 2015 Oct 192(7):601-7.
Marghoob AA, Usatine RP, Jaimes N; Dermoscopy for the family physician. Am Fam Physician. 2013 Oct 188(7):441-50.
Alves JV, Matos DM, Barreiros HF, et al; Variants of dermatofibroma--a histopathological study. An Bras Dermatol. 2014 May-Jun89(3):472-7.
Dermatofibroma images; Primary Care Dermatology Society
Dermatofibroma; DermNet NZ
Zaballos P, Puig S, Llambrich A, et al; Dermoscopy of dermatofibromas: a prospective morphological study of 412 cases. Arch Dermatol. 2008 Jan144(1):75-83.
Brancaccio G, Nuzzo T, Di Maio R, et al; Dermatofibroma looks dermoscopically different on trunk vs extremities. G Ital Dermatol Venereol. 2015 Dec 23.
Hanly AJ, Jorda M, Elgart GW, et al; High proliferative activity excludes dermatofibroma: report of the utility of MIB-1 in the differential diagnosis of selected fibrohistiocytic tumors. Arch Pathol Lab Med. 2006 Jun130(6):831-4.
Buis PA, Verweij W, van Diest PJ; Value of histopathologic analysis of subcutis excisions by general practitioners. BMC Fam Pract. 2007 Jan 268:5.
George S, Pockney P, Primrose J, et al; A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial. Health Technol Assess. 2008 May12(23):iii-iv, ix-38.
Bandarchi B, Ma L, Marginean C, et al; D2-40, a novel immunohistochemical marker in differentiating dermatofibroma from dermatofibrosarcoma protuberans. Mod Pathol. 2010 Mar23(3):434-8. Epub 2010 Jan 8.