1 Onset and duration

It is important always to ask the patient’s opinion of the cause of the lesion or of any incident associated with its onset. The patient may relate the lesion to an occupation, a drug or an injury. The length of history gives some idea of prognostic significance. The onset of skin lesions may be related by the patient to a triggering factor such as an insect bite. A previous history of repeated trauma may be important in pyogenic granuloma and in implantation dermoid cyst. A sudden change in the characteristics of a pre-existing mole suggests melanoma. Other skin lesions may be induced by local or systemic drug treatment.

2 Change and progression

The rate of progression helps to distinguish between benign and malignant conditions (Table 1.1). A skin lesion that progresses to a significant lump within a few days suggests infection (e.g. pyogenic granuloma); in a few weeks, hyperplasia (e.g. keratoacanthoma); or over several months, malignancy (e.g. basal and squamous cell carcinoma, melanoma). A pigmented skin lump that has not changed over several years suggests a benign mole. Most subcutaneous lumps are benign and very slowly progressive. ‘Sebaceous’ or epidermoid cysts are prone to infection, partial resolution and recurrence. Sometimes a ganglion may rupture after trauma and disappear, to return later. Abdominal wall hernias may appear suddenly after a strain and slowly progress; they are usually reducible and reappear on standing. Basal cell carcinomas may appear to heal in part of their circumference but are usually inexorably progressive.

Table 1.1 Growth pattern of some common skin nodules

3 Other symptoms

Pain is not a common symptom of subcutaneous lumps. When present it suggests inflammation or lesions such as neurofibromas and implantation dermoid cysts. Glomus tumours contain numerous nerve endings; they are classically associated with severe pain. Severe pain in an ulcer suggests an ischaemic cause.

Ulceration and bleeding suggest malignant change. Catching of the lesion on clothing suggests the possibility of malignant change in a pigmented naevus but is also a feature of any verrucous lesion.

Itch is common in basal cell carcinoma, melanoma and leukaemic skin nodules.

4 Multiplicity

The presence of other lumps or ulcers is often a guide to pathology. Lipomas and neurofibromas are sometimes multiple and symmetrical. ‘Sebaceous’ cysts are often multiple, particularly when on the scalp or scrotum. Many benign skin lesions tend to be multiple, particularly in older patients (cherry angiomas, seborrhoeic keratoses, senile purpura, liver spots). The appearance of satellite nodules suggests that a mole is malignant.

The history should be completed by a general systems review and the family, social, occupational and allergic history. This is particularly important for skin ulcers where systemic diseases such as alcoholism, rheumatoid arthritis and diabetes are important factors to consider, both in aetiology and in treatment. Diabetes mellitus is frequently a factor in delayed healing of ulcers. Some conditions have a particular geographical predisposition such as the ‘Bairnsdale ulcer’ for which the aetiology is an atypical mycobacterium of limited geographical range.

1 Situation and depth

If you can accurately describe the anatomical position of a lump and know the range of pathology possible at that site you will more easily make a clinical diagnosis.

Situation is described regionally in relation to the body surface. Depth is assessed in relation to the skin and deeper layers. The region occupied by the lesion is defined. The relationship of the lesion to surface landmarks, including distance of the lump from prominent bony points, is recorded. Many lumps are characteristic of specific regions: ‘sebaceous’ cysts occur in the scalp and scrotum, implantation dermoid cysts occur mainly in the hand. Lipomas are most often found in the subcutaneous tissues of the trunk or limbs. Ganglia, tendon sheath swellings and bursae occur at defined points near joints, bony prominences and tendons. Lymph node swellings occur in defined anatomical areas.

The site of ulcers is often also suggestive of their diagnosis. Ischaemic ulcers are at the tips of digits or over points of pressure necrosis — the latter often suggesting neuropathy. The ulcers of venous insufficiency are usually situated around the ankle and lower leg.

The depth of the lesion in relation to the skin must always be noted. A lump is ‘layered’ in the correct anatomical plane; an ulcer’s floor, base and edge are assessed. A lump in a limb will be arising primarily from or involving skin, subcutaneous tissue, muscle layers or the underlying bone. On the trunk it will be important to determine if a lump is within the body cavity or the parieties. Assessment of depth should be ordered and precise and demands accurate sectional anatomical knowledge of the region. Lumps in the subcutaneous fat plane that are attached to the fascia investing deeper muscles will have their mobility impaired when the muscles are tensed. A lump below the fascial plane will be obscured, as well as becoming less mobile, when the muscles are tense. Bony lumps are fixed and immobile.

The edge of an ulcer may be protuberant and elevated above the skin surface, suggesting malignancy. A healing ulcer has pink healthy granulation tissue in the floor and the edge is made less distinct by a thin overlying layer of regenerating epithelium that may appear bluish. A sloughing floor, with induration extending around the base and sharply outlined edges, suggests chronicity. Deep chronic indolent ulcers with little granulation tissue are often ischaemic.

2 Size

The lesion should be measured in centimetres. Estimation of size is unreliable and it is useful to be aware of the span of one’s own digits and hand as a graduated ruler is not always available. The size of a lump or ulcer is usually measurable with precision in two dimensions; diameter in depth should be estimated as accurately as possible.

3 Shape and surroundings

The lump’s shape and physical characteristics are defined in the subsequent steps of examination. Following a practised sequence ensures that no important details, such as the presence of pulsation within the lump, are omitted.

The shape of a lump or ulcer can be regular or irregular. Regular shapes are spheres, circles and ovals.

A smoothly regular spherical lump strongly suggests a cyst. Most solid lumps have slight or prominent irregularities of shape, even when generally spherical or oval. To describe a lump’s shape as spherical implies that it has been assessed totally in three dimensions. This is only possible with very mobile lumps or when an adjunct to examination such as an ultrasound is available. More often only a portion of the circumference of the lump can be felt and its roundness implied from this assessment. Cystic liquid collections are common in skin and subcutaneous tissues and include ‘sebaceous’ cysts and bursae.

Solid lumps such as lipomas, neurofibromas and lymph nodes are usually irregularly round or oval in shape. Lipomas have another very characteristic feature: they are lobular, mirroring their origin from lobulated fat. They thus form mobile soft lobulated subcutaneous lesions with an indistinct ‘slipping’ edge, unlike ‘sebaceous’ cysts that are spherical and firmer, are attached to the skin and have distinct margins. Lymph nodes also have discrete margins and, when multiple, present as lobulated or bosselated swellings with a defined edge.

Lumps arising from the skin may be nodular, flattened, dome-like or polypoidal in shape; polyps may be sessile or pedunculated. Neurofibromas of the skin form soft, domed lumps (molluscum fibrosum). Subcutaneous neurofibromas form firm, fusiform subcutaneous swellings at the site of nerves.

Many anatomical structures have such a characteristic shape and such constancy of position that a swelling of the whole organ can often be identified virtually on sight: thyroid and parotid glands, kidney, liver and spleen. Tubular or dumb-bell-shaped subcutaneous lesions suggest enlargements of tendon sheaths.

Ulcers can be regular or irregular in shape and their edges can also be described as serpiginous, sloping, everted, rolled, overhanging or punched-out (Fig 1.2). Brown pigmentation, a desquamative rash and induration of skin and subcutaneous tissues around an ulcer suggest venous insufficiency. Redness, heat, oedema and cellulitis indicate active spreading infection.

The lump’s relationship to its surroundings is assessed. Impaired mobility, with attachment to surrounding structures, is an important diagnostic sign. Relationships must be assessed in all dimensions. Attachments to overlying skin and deeper layers are noted, as well as any effects on key local structures such as nerves, tendons or tubes such as blood and lymph vessels and viscera. Nerve function proximal and distal to the lesion is noted, as are the effects of tendon and joint movements. Evidence of arterial or venous insufficiency, of lymphatic enlargement or obstruction, or of visceral obstruction or fistulation, is sought.

4 Colour

Variations in skin reaction and colour occur over lumps and skin lesions and at the edge and floor of ulcers. A skin nodule featuring a waxy or pearly nodular edge with fine cutaneous telangiectasis is likely to be a basal cell carcinoma. Pigmented skin lesions are common. Deep black suggests melanoma or skin necrosis with gangrene. Variegated colour intensity and halo depigmentation can also be features of melanoma. Brown lesions include benign and malignant moles, seborrhoeic keratoses, dermato-fibromas and some basal cell carcinomas. Vascular lesions can be red or brownish. Senile angiomas and pyogenic granulomas are usually bright red, as are strawberry naevi and spider naevi. Port wine stains are a deeper red colour. Seborrhoeic keratoses are characteristically brown, greasy and rough to the touch — like a blob of sealing wax on the skin. Yellow discolouration seen through the skin may indicate pus, xanthoma or gouty tophus. A grey or tan verrucous appearance is common with a number of benign nodules. Cutaneous lymphoedema varies in appearance but may be tan or pinkish with a characteristic orange peel appearance where the skin pouts between the pores. Erythema and heat suggest superadded infection.

5 Contour

The surface contour of a lesion is allied to its shape and can also be described as regular (smooth, round) or irregular. An irregular contour can be:

6 Consistency

The consistency of the lesion is often very helpful in diagnosis. The simplest classification of consistency of lumps is:

Apart from these four grades, familiar analogies can help to describe size and consistency (e.g. golf ball or tennis ball size and feel). A diagnostic description (solid or cystic lump) combines the clinical features of shape, contour, consistency and other aspects.

A cyst is a localised collection of fluid: cysts in body tissues mostly contain liquid, a few contain gas (lung cyst, pneumatosis coli). Cysts usually have an epithelial lining. The term pseudo-cyst is often applied to pancreatic and peripancreatic liquid collections without an epithelial lining.

Associated physical features that should be considered along with consistency are compressibility, cough impulse, reducibility and pulsation.

Compressibility is the sign of emptying on pressure. This sign is found with venous lakes and cavernous haemangiomas (compressible, but not pulsatile, vascular lesions); with hernias (compressible and reducible lesions); and with some bursae and ganglia that communicate freely with adjacent joints. After emptying on pressure, lesions may refill when the pressure is released. Hernias may not recur and refill unless the patient stands or is made to cough.

Vascular blushing on compression is an allied important sign, which occurs when some pigmented vascular lesions are compressed with a transparent slide. Cavernous haemangiomas, telangiectasis and spider naevi show this sign; in the case of spider naevi it occurs when the central arteriole is compressed. Port wine stains (capillary haemangiomas) and senile angiomas, where the colour is not due only to easily displaced intraluminal blood, do not show the sign, nor do purpuric or petechial spots.

Cough impulse: on coughing an expansile impulse is felt over a hernia. Hernias share this sign with venous swellings associated with valvular incompetence and with meningoceles.

Reducibility is a term usually applied to hernias. Venous swellings, pharyngeal diverticula and some ganglia communicating with joints can also be reduced by recumbency and pressure.

Pulsation may be apparent on inspection. It should be confirmed by palpation and checked to be synchronous with the pulse. Venous pulsation is usually visible but impalpable; arterial pulsation is visible and palpable. Pulsation may be truly expansile due to an aneurysm or a very vascular solid lump such as a toxic goitre or vascular neoplasm. Pulsation may, however, be transmitted to the lump by a nearby blood vessel. Differentiation between the two forms of pulsation can be very difficult, particularly with deeply situated lumps such as para-aortic lymphadenopathy versus an abdominal aortic aneurysm. Help can sometimes be given by the two finger test: a finger is placed on either side of the swelling — movement of the fingers in the same direction occurs with transmitted pulsation and centrifugally divergent movement occurs with expansile pulsation. The test is often difficult to interpret.

If pulsation is detected it is essential to also test for a thrill on palpation and a bruit on auscultation. These findings suggest arterial stenosis, aneurysm or arteriovenous shunting.

7 Temperature

Increased warmth on palpation indicates inflammation or increased vascularity from some other cause. Vascular tumours are often warm to palpation. The temperature is best assessed by applying the drier, thinner and cooler dorsal surface of the fingers to the skin over the swelling and comparing it to a similarly exposed area. Increased warmth may accompany a focal infected lesion such as a furuncle or a diffuse inflammation such as cellulitis. Heat, a localised cord-like swelling and tenderness suggest thrombophlebitis when found along the anatomical position of a superficial vein, or acute lymphangitis when along the course of lymphatic drainage to tender lymph nodes. Warmth in focal lesions such as bursae, cysts or tendon sheaths suggests inflammation or infection. Unilateral coldness of a limb indicates the presence of ischaemic vascular disease.

8 Tenderness

Tenderness on palpation usually coexists with erythema and increased warmth in inflammatory lesions. Most noninflamed lumps are not tender; although, neurofibromas, plantar warts, implantation dermoid cysts and areas of fat necrosis are examples of lumps that can be tender. The glomus tumour, a benign vascular hamartoma affecting the limbs and fingers and presenting as a subcutaneous or subungual small brown swelling, is exquisitely tender and sensitive to the lightest pressure.

9 Transillumination

Transillumination is the most important physical sign characterising a thin-walled cyst containing clear fluid. The sign can be difficult to elicit in very small or deeply placed lesions and should always be tested while the lump and its ambience are well shaded, preferably in a dark room.

Bursae, hydroceles and epididymal cysts are common transilluminable lumps. Ganglia involving tendon sheaths usually transilluminate. Firmer, deeper ganglia near joints usually do not. ‘Sebaceous’ cysts do not transilluminate because of their pultaceous contents and thick walls. Lipomas are not usually transilluminable and never brilliantly so. Transillumination of a focal lump must be differentiated from the normal luminescence of subcutaneous tissue around the beam of a torch.

10 Fluctuation and percussion

Fluctuation is tested (preferably in two planes at right angles to each other) with a compressing and a testing finger. The lump must be fixed to ensure that it has not been itself moved by the compressing finger. The transmitted impulse of fluid is appreciated by the second, testing finger (Fig 1.3). A variation of this test is the demonstration of a fluid thrill in ascites. With some lumps, three fingers can be used conveniently. Two fingers of one hand on opposite sides of the lump control it and both test for transmission of an impulse when the index finger of the other hand compresses the lump, or both compress the lump while the index finger of the other hand tests for fluctuation.

Figure 1.3 Testing fluctuation

Two watching fingers detect transmitted impulse (A) while the displacing finger applies compression (B).

Fluctuation is present in liquid or gaseous lumps with deformable walls and also in some soft, solid swellings. Fluctuation is thus found in hydroceles, sebaceous cysts, bursae, ganglia (if soft and superficial) and in lipomas.

Percussion determines whether a swelling is resonant or dull. Percussing a swelling after confirming it is fluctuant can help distinguish between gas-containing and liquid-containing swellings. An inguinoscrotal hernia with contained bowel will be tympanitic, as contrasted with the dullness of a liquid-containing hydrocele.

11 Fixity

Skin attachment to a lump is demonstrated by skin retraction and dimpling on inspection or by decreased skin mobility on palpation, with inability to pinch or push the skin away from the lump. A dimple forms when the skin over the lump remains fixed to it. If the skin over a lump is tightly stretched the sign is more difficult to elicit.

Swellings should also be tested for their attachment to deeper structures. Free mobility in all directions is found with benign skin lumps and lumps in the subcutaneous fat without deep attachment. Limited mobility over the underlying muscle suggests deep fascial or muscle attachment. The sign is positive with neoplastic or inflammatory fibrosis around a lump and with subfascial or intermuscular lumps.

Transverse mobility across the line of an artery or nerve suggests a lesion of one of these structures. No mobility at all is found with lumps arising from or fixed to bone, periosteum or joint capsule.

Mobility on swallowing is an important sign for neck swellings: structures normally related to the trachea or larynx exhibit this sign, which is characteristic of a goitre (Ch 2.15). Movement on inspiration occurs when intraperitoneal lumps are related to the under surface of the diaphragm (liver, spleen).

12 Fields

Examining the draining lymphatic nodes as potential sites of distant spread of a lesion is a routine part of physical examination and is particularly important in inflammatory and neoplastic lesions.

After finishing the regional examination, a general physical examination and systems review may detect associated abnormalities essential for completion of the diagnosis (metastatic malignancy, other lymph nodes involved and lesions at many sites).

Common causes of benign skin lesions

Clinical features, diagnostic and treatment plans

Diagnosis in most instances can be made on clinical assessment including dermoscopy. Most lesions will need no treatment other than reassurance. Many are specifically age-related.

Children

Port-wine stain (capillary haemangioma)

This is the most common vascular developmental lesion and is a hamartoma of endothelial origin. It is present at birth, most often on the face or neck as a dark macular stain. These lesions do not regress and can become darker and develop nodular eruptions late in life. Treatment may be required for cosmetic reasons and utilises laser photocoagulation and, less commonly, surgery.

Strawberry naevus (cavernous haemangioma)

This is a bright red, raised tumour of the face or neck that usually appears in the first few weeks of life, partially blanches on pressure, grows rapidly over the next year or so and then gradually regresses with thrombosis. Most regress completely by the age of 10 years; treatment is usually not required.

Benign mole

A few longstanding benign pigmented brown moles will be found on practically every person. In Australia the risk of malignancy with multiple naevi does not increase until an individual has 200 lesions. There is a recognised genetic predisposition to multiple naevi. There are several varieties containing melanocytes (naevus cells).

Intradermal, junctional and compound naevus

Intradermal naevus is the most common benign mole, deriving its name from the fact that the pigment cells lie entirely within the dermis (Fig 1.5). The macroscopic appearance varies considerably: from a soft flattened pale brown or flesh-coloured nodule or macule, to a deep brown warty excrescence. The edge is usually well defined. Many contain hair, which is a helpful diagnostic point — hairy moles are virtually always intradermal and benign. Intradermal naevi occur all over the body skin and are usually present from birth but are rare on the palms or finger-tips. They vary in size from a few millimetres to large lesions several centimetres across. They are biologically conservative, wholly benign lesions, throughout life.

Figure 1.5 The histology of benign pigmented moles

A: junctional naevus showing melanocytes at the epidermal–dermal junction; B: intradermal naevus with pigmented cells in the dermis. The histological combination of A and B is known as a compound naevus.

Junctional naevus. As its name implies, this lesion contains pigment cells at the junction of epidermis and dermis. Macroscopically these are flatter, often macular lesions, of varying depth of pigmentation. They vary in size from a few millimetres to several centimetres. They may be present at birth or appear later. The edge is sometimes less well defined than that of an intradermal naevus.

Compound naevus contains both junctional and intradermal components. In almost all moles the radical youthful potential of the immature junctional melanocyte progresses to a maturely conservative intradermal adulthood. Occasionally a junctional or compound naevus develops malignant change in adulthood.

Few pigmented moles in children will need treatment. Malignant change does not occur until puberty but skin malignancy is seen in teenagers, albeit rarely. Surgical removal may be required for cosmetic reasons or because of an inconvenient site.

Blue naevus (Mongolian spot)

This lesion is uncommon and is an intradermal lesion of a different type from other pigment-cell naevi. It presents as a characteristically bluish-grey, flat or slightly elevated nodule on the face or limbs. It is always benign. Surgical removal may be required for cosmetic reasons or because of an inconvenient site.

Freckles (ephelides)

These light tan, small pigmented macules are influenced by solar exposure in sensitive individuals with fair skin (sun spots) and may disappear with time.

Infective warts

The common infective wart (verruca vulgaris) is a localised hyperkeratotic skin overgrowth due to stimulation by the human papilloma virus. Warts occur commonly in children and young adults and can persist unchanged for years or regress and disappear spontaneously. They are most common on the hands, often affecting adjacent fingers and form greyish nodules with a classic roughened surface showing a mosaic, finely tessellated appearance. Untreated warts of the hand and fingers are often exophytic in their growth and cauliflower-like in appearance. Warts of the soles are also common in children and adolescents; these tend to become trodden into the foot with a flattened horny surface (endophytic) and often become painful. Differentiation of a plantar wart (‘papilloma’) from a simple callosity is aided by paring down the horny epidermal surface of the lesion to expose the characteristic mosaic appearance with punctate spots — as distinct from the horny featureless plug of keratin exposed by paring a callosity. The procedure is painless and gives symptomatic relief for both conditions as well as aiding diagnosis. The pavemented surface of the wart and its clearly defined margin with a potential cleft separating it from normal skin are other diagnostic aids. Both warts and callosities occur over pressure points such as metatarsal heads or the calcaneum.

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