Nodular lesions

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Luke Rusowicz-Orazem, B.S.

Overview

A nodular lesion that is > or equal to 1 cm is referred to as a nodule. There are many differential diagnoses for nodules as they can be subcutaneous, intraepidermal, dermal or exophytic. To obtain the correct diagnosis it is importnat to observe the growth rate, color, symptoms and any underlying conditions that may have caused the nodules.

Causes

Life Threatening Causes

• Apocrine hidrocystoma
• Basal cell papilloma
• Granular cell tumor
• Melanoma
• Squamous cell carcinoma of skin
• Stomach cancer

Common Causes

• Actinic keratosis
• Angiocentric immunoproliferative lesion
• Blue nevus
• Calcinosis cutis
• Cold panniculitis of haxthausen
• Cutaneous abscess
• Cutaneous metastasis
• Cutaneous nodules
• Dermatofibroma
• Dermatofibrosarcoma protuberans
• Desmoid
• Enchondromatosis
• Eosinophilic cellulitis
• Epidermal inclusion cyst
• Erythema elevatum diutinum
• Erythema induratum
• Erythema nodosum
• Familial cutaneous collagenoma
• Focal dermal hypoplasia
• Follicular infundibulum tumor
• Garrod pads
• Granular cell tumor
• Granuloma annulare
• Granuloma faciale
• Juvenile xanthogranuloma
• Kaposiform hemangioendothelioma
• Keloid
• Keratoacanthoma
• Lipoid dermatoarthritis
• Lobomycosis
• Lymphocytoma cutis
• Malakoplakia
• Merkel cell carcinoma
• Microcystic adnexal carcinoma
• Necrobiosis lipoidica
• Panniculitis
• Pigmented naevus
• Spitz nevus
• Squamous cell carcinoma of skin
• Subcutaneous nodules
• Tendon nodules
• Tophus
• Trichofolliculoma
• Xanthomata

Causes by Organ System

Cardiovascular	Amyloidosis, Angiocentric immunoproliferative lesion, Angiolymphoid hyperplasia with eosinophilia, Familial hypertriglyceridaemia, Ldl receptor deficiency, Lipoprotein lipase deficiency, Osler nodes
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	Actinic keratosis, Angiocentric immunoproliferative lesion, Blue nevus, Calcinosis cutis, Cold panniculitis of haxthausen, Cutaneous abscess, Cutaneous metastasis, Cutaneous nodules, Dermatofibroma, Dermatofibrosarcoma protuberans, Desmoid, Enchondromatosis, Eosinophilic cellulitis, Epidermal inclusion cyst, Erythema elevatum diutinum, Erythema induratum, Erythema nodosum, Familial cutaneous collagenoma, Focal dermal hypoplasia, Follicular infundibulum tumor, Garrod pads, Granular cell tumor, Granuloma annulare, Granuloma faciale, Juvenile xanthogranuloma, Kaposiform hemangioendothelioma, Keloid, Keratoacanthoma, Lipoid dermatoarthritis, Lobomycosis, Lymphocytoma cutis, Malakoplakia, Merkel cell carcinoma, Microcystic adnexal carcinoma, Necrobiosis lipoidica, Panniculitis, Pigmented naevus, Spitz nevus, Squamous cell carcinoma of skin, Subcutaneous nodules, Tendon nodules, Tophus, Trichofolliculoma, Xanthomata
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	Apocrine hidrocystoma, Eccrine porocarcinoma, Eccrine poroma, Eccrine spiradenoma, Hidradenoma, Lipoma
Environmental	No underlying causes
Gastroenterologic	Benign cystic mucinous tumor, Colorectal cancer, Glycogenosis type 1b, Stomach cancer, XanthomataBenign cystic mucinous tumor, Colorectal cancer, Glycogenosis type 1b, Stomach cancer, Xanthomata
Genetic	Blau syndrome, Calcinosis-raynaud-sclerodactyly-telangiectasia syndrome, Cholestanol storage disease, Cole disease, Farber lipogranulomatosis, Lipoid proteinosis, Nakajo-nishimura syndrome, Osteopoikilosis, Systemic hyalinosis, Systemic sclerosis, Torg-winchester syndrome
Hematologic	Apolipoprotein c-ii deficiency, Apoprotein e deficiency, Basal cell papilloma, Familial hypertriglyceridaemia, Glycogenosis type 1b, Ldl receptor deficiency, Leukemia cutis, Lipoid proteinosis, Spindle cell hemangioendothelioma, Vitamin e deficiency
Iatrogenic	No underlying causes
Infectious Disease	Balamuthia mandrillaris, Botryomycosis, Cutaneous abscess, Cysticercosis, Enchondromatosis, Lobomycosis, Mycobacterium abscessus, Mycobacterium marinum, Mycobacterium ulcerans, Myiasis, Onchocerciasis, Protothecosis, Pyogenic granuloma, Sporotrichosis, Tinea profunda, Zygomycosis
Musculoskeletal/Orthopedic	Osteopoikilosis, Pretibial myxoedema, Tendon nodules
Neurologic	Neurofibromatosis type 1
Nutritional/Metabolic	Sitosterolemia, Vitamin e deficiency
Obstetric/Gynecologic	Breast cancer, Ovarian cancer
Oncologic	Apocrine hidrocystoma, Basal cell papilloma, Breast cancer, Bronchogenic carcinoma, Colorectal cancer, Cutaneous metastasis, Dermatofibrosarcoma protuberans, Desmoid, Eccrine porocarcinoma, Eccrine poroma, Eccrine spiradenoma, Endovascular papillary angioendothelioma, Follicular infundibulum tumor, Granular cell tumor, Granuloma annulare, Granuloma faciale, Hereditary leiomyomatosis, Hidradenoma, Keratoacanthoma, Leukemia cutis, Lipoma, Lymphocytoma cutis, Melanoma, Merkel cell carcinoma, Microcystic adnexal carcinoma, Ovarian cancer, Pilomatrixoma, Pyogenic granuloma, Renal adenocarcinoma, Sister mary joseph nodule, Spindle cell hemangioendothelioma, Spitz nevus, Squamous cell carcinoma of skin, Stomach cancer, Subcutaneous nodules, Trichofolliculoma
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	Bronchogenic carcinoma
Renal/Electrolyte	Hereditary leiomyomatosis, Polyarteritis nodosa, Renal adenocarcinoma, Renal failure
Rheumatology/Immunology/Allergy	Amyloidosis, Angiolymphoid hyperplasia with eosinophilia, Calcinosis-raynaud-sclerodactyly-telangiectasia syndrome, Dermatofibroma, Farber lipogranulomatosis, Garrod pads, Graves' disease, Heberden nodes, Infantile digital fibromatosis, Juvenile xanthogranuloma, Kaposiform hemangioendothelioma, Lipoid dermatoarthritis, Malakoplakia, Neurofibromatosis type 1, Osler nodes, Otulin related autoinflammatory syndrome, Panniculitis, Pigmented naevus, Polyarteritis nodosa, Polymyositis, Pretibial myxoedema, Rheumatic fever, Rheumatoid disease, Sister mary joseph nodule, Tophus, Weber-christian disease
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Miscellaneous	No underlying causes

Causes in Alphabetical Order

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3

Differential Diagnosis

In alphabetical order.

• Dermatofibroma
• Dermal/subcutaneous neoplasms
• Epidermoid
• Epidermal inclusion cyst
• Ganglion cyst
• Hypertrophic scars
• Kaposi's sarcoma
• Lipoma
• Nodular melanomas
• Pilar cyst
• Pyogenic granuloma
• Xanthoma

Diagnosis

History and Symptoms

• Note the morphology of the nodule

• size changes
• tenderness

• History

• malignancies/ rheumatoid arthritis
• immunosupression
• family history of melanoma

Laboratory Findings

• Appropriate cultures should taken of suppurative lesions

Other Diagnostic Studies

• Biopsy to determine characteristics of nodule

• Shave
• Punch
• Excisional

Treatment

• Treatment includes excision whether for cosmetic or symptomatic reasons
• Epidermoid cysts:

• Lesions must calm down before excision
• Intralesional steroids
• It must be completely removed to avoid a recurrent lesion