Skin and Subcutaneous Nodules

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

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.

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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, but 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
Wart Lipoma BCC Xanthoma Acrochordons
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.[2]

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 a squamous or basal cell carcinoma.
  • 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.
  • Excision biopsy is the definitive investigation:
    • Cytology from skin scrapings can be used to diagnose BCCs.
    • If malignant melanoma is suspected, try to take a normal margin too.[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, then investigations, including biopsy are required.

Further reading & references

  • Luba M et al; Common Benign Skin Tumors. Am Fam Physician 2003;67(4):729-38; An excellent primary care overview with good images and diagnostic algorithms
  • Diseases database; Cutaneous nodules.
  • DermAtlas, Dermatlas.org
  1. Fromm LJ et al, Epidermal Inclusion Cyst, Medscape, Jun 2012
  2. Skin cancer - suspected, NICE CKS, 2005
  3. Improving Outcomes for People with Skin Tumours including Melanoma (update): The Management of Low-risk Basal Cell Carcinomas in the Community; NICE (2010)

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Hayley Willacy
Current Version:
Document ID:
1115 (v23)
Last Checked:
18/03/2011
Next Review:
16/03/2016