Pictorial Case Study - A nodular scalp lesion

This slow-growing skin lesion can appear in women aged 50 or over.

The presentation

This elderly woman had been aware of a nodular lesion on her scalp for about five years. Initially it was small, hidden by her hair and caused her no problem; but over the years, it had increased in size to become a larger, 'rubbery' nodule, measuring 3cm across.

The management

Her GP suspected a cylindroma and referred her for confirmation of the diagnosis and surgical removal. A cylindroma is a benign tumour that most commonly occurs in the region of the head and neck; its cause is unknown. Single lesions usually occur in women after the age of 50.

Occasionally, multiple tumours occur, which tend to appear in early adult life. Multiple tumours appear to have a genetic link with changes in the CYLD gene.

The firm, rubbery, well-circumscribed nodules range in colour from pink to red or bluish, and gradually increase in diameter from a few millimetres to as much as 6cm. Occasionally, the lesions undergo malignant change; a careful watch should therefore be kept for the development of suspicious signs.

The diagnosis may be confirmed by biopsy and the treatment of choice for single lesions is surgical excision. However, small lesions may be dealt with by cryotherapy, curettage and cautery, or CO2 laser. The help of a plastic surgeon should be enlisted for multiple lesions that may require staged operations.

POSSIBLE DIFFERENTIAL DIAGNOSES
  • Pilar cyst
  • Epidermoid (sebaceous) cyst
  • Pyogenic granuloma
  • Dr Watkins is a retired GP in Hampshire.

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