Clinical images - Nodular skin lesions

Differentiate the diagnosis of haemangioma, nodular prurigo, squamous cell carcinoma and keratoacanthoma. By Dr Nigel Stollery

Haemangioma

Presentation

  • Can occur at any age and be of varied size
  • Benign vascular lesion that may easily bleed
  • No potential for malignant transformation
  • Typical appearance on dermoscopy
  • Multiple small haemangiomas, known as Campbell De Morgan spots, are common with increasing age

Management

  • Treatment not always necessary
  • If symptomatic, can be excised under local anaesthesia
  • Smaller haemangiomas can be treated with cautery or hyfrecation

Nodular prurigo

Presentation

  • Firm nodules, may result from repeated localised trauma, usually scratching, or from previous trauma, such as a bite
  • 80% of those affected are atopic
  • If diagnosis is in doubt, a biopsy can be helpful
  • Hyperpigmentation may occur in and around the nodules

Management

  • Treatment can be difficult
  • Potent topical steroid cream can be helpful
  • Covering the skin to prevent scratching can help, for example, by paste bandaging
  • In severe, very symptomatic cases, ciclosporin or azathioprine can be helpful

Squamous cell carcinoma

Presentation

  • Appearance very variable and incidence increases with age
  • May develop in damaged skin, such as ulcers or burns
  • Often develops as a rapidly growing nodule that may bleed
  • More common on sun-exposed areas and in patients taking immunosuppressive medication
  • Second most common type of skin malignancy in the UK
  • If suspected, histology should be checked

Management

  • Excision is treatment of choice
  • Radiotherapy may be more appropriate for elderly or for very large, inoperable lesions

Keratoacanthoma

Presentation

  • Relatively common, benign lesions in sun-exposed skin
  • Usually form a nodule with a central keratin plug
  • Cause unknown, but incidence increases with age
  • Often clinically difficult to differentiate from squamous cell carcinoma
  • May grow very rapidly
  • If untreated, usually resolve over four to six months

Management

  • Treatment not required, but most are excised because of diagnostic uncertainty
  • Curettage and cautery may be an alternative to formal excision

Dr Stollery is a GP in Kibworth, Leicestershire, and a clinical assistant in dermatology at Leicester Royal Infirmary

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