Skin and Subcutaneous Nodules

Authored by Dr Laurence Knott, 08 May 2015

Reviewed by:
Dr Helen Huins, 08 May 2015

Patient professional reference

Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Epidermoid and Pilar Cysts (Sebaceous Cysts) article more useful, or one of our other health articles.

Skin nodules are slightly elevated lesions on or in the skin. They are larger than papules - over 5 mm in diameter. The depth of the lesion is more significant than the width. Some are free within the dermis. Some are fixed to skin above or subcutaneous tissue below.

The patient will usually consult because of concern about cosmetic appearance or the possibility of malignancy.

Such lesions are very common but there are numerous causes. It is important to try to define the aetiology.

Common causes

Less common causes

Rarer causes

The diagnosis may be clear from the presentation:

  • Note the age of the patient.
  • Note the position of the lesion or lesions and any changes.
  • To a considerable extent it is like the surgical task of examination of a lump.
  • Do not forget to enquire after systemic symptoms and general state of health.

Malignancies of the skin tend to occur in elderly people who have much solar damage to the skin; however, melanoma in particular can occur in rather younger people but usually 'sun worshippers'. On the basis that common things commonly occur, the following table will help to differentiate the common lesions:

 Epidermoid
(sebaceous) cyst
WartLipomaBCCXanthomaAcrochordons
Normal
skin surface
yes
no
yes
no
no
yes
Multiple
no
possible
possible
possible
yes
often
Characteristic
distribution
no
no
no
yes
yes
yes
Reddish
brown colour
no
no
no
yes
yes
no
Central
punctum
yes
no
no
no
no
no

The less common lesions may also occur but what is most important is not to be blandly reassuring about something that requires attention whilst at the same time not taking biopsies or referring every case that is seen.

Hence, ask questions about red flag features and, if there is any doubt, investigate.[3] 

Causes for concern

  • A nodule in a mole is highly significant and requires excision biopsy in case of malignancy.
  • An elderly patient with a lesion in a sun-exposed area may well have SCC or BCC.
  • A middle-aged or elderly patient who develops widespread skin nodules over a period of a few weeks probably has an underlying carcinoma, especially if unwell and losing weight.
  • Night sweats and itching with skin nodules suggests lymphoma. These are B features. Examine lymph nodes, liver and spleen carefully.
  • Nodulocystic acne is very difficult and probably needs a dermatologist.
  • FBC and erythrocyte sedimentation rate (ESR) are basic investigations.
  • Uric acid should be measured if nodules may be gout - eg, on ear lobes or elbows.
  • The appearance of xanthomata is fairly typical. Fasting lipid profile is required.
  • Urinalysis is required if inflammatory or vasculitic skin lumps are suspected:
    • There may be proteinuria if the lumps are associated with systemic and renal disorders.
  • Ultrasound can improve diagnosis for larger lesions.[4]
  • Excision biopsy is the definitive investigation:
    • Cytology from skin scrapings can be used to diagnose BCCs.
    • Subcutaneous lesions can, depending on site, be removed by endoscopy. This gives a very good cosmetic result and is particularly useful in children.[5]
  • If malignant melanoma is suspected, urgent referral to a dermatologist should be arranged. Excision in primary care is not recommended.[3]

The management depends upon the diagnosis, working diagnosis or differential diagnosis. It may be possible just to be reassuring but if there is any doubt, investigations, including biopsy, are required. GPs should refer to a specialist in a timely fashion according to prevailing guidelines.

Further reading and references

  1. Burns T et al; Diagnosis of Skin Disease, Rook's Textbook of Dermatology, 2010

  2. Luba M et al; Common Benign Skin Tumors. Am Fam Physician 200367(4):729-38.

  3. Skin cancer - suspected; NICE CKS, June 2009 (UK access only)

  4. Kuwano Y, Ishizaki K, Watanabe R, et al; Efficacy of diagnostic ultrasonography of lipomas, epidermal cysts, and ganglions. Arch Dermatol. 2009 Jul145(7):761-4. doi: 10.1001/archdermatol.2009.61.

  5. Pricola KL, Dutta S; Stealth surgery: subcutaneous endoscopic excision of benign lesions of the trunk and lower extremity. J Pediatr Surg. 2010 Apr45(4):840-4. doi: 10.1016/j.jpedsurg.2009.12.016.

I have 2 sebaceous cysts on my bikini line area near my rear end. They have both gotten infected and I put ice on them to bring down the inflammation. When the infection was gone, I put hot...

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