Diagnosing Common Benign Skin Tumors

 


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Patients will experience a wide range of skin growths and changes over their lifetime. Family physicians should be able to distinguish potentially malignant from benign skin tumors. Most lesions can be diagnosed on the basis of history and clinical examination. Lesions that are suspicious for malignancy, those with changing characteristics, symptomatic lesions, and those that cause cosmetic problems may warrant medical therapy, a simple office procedure (e.g., excision, cryosurgery, laser ablation), or referral. Acrochordons are extremely common, small, and typically pedunculated benign neoplasms. Simple scissor or shave excision, electrodesiccation, or cryosurgery can be used for treatment. Sebaceous hyperplasia presents as asymptomatic, discrete, soft, pale yellow, shiny bumps on the forehead or cheeks, or near hair follicles. Except for cosmesis, they have no clinical significance. Lipomas are soft, flesh-colored nodules that are easily moveable under the overlying skin. Keratoacanthomas are rapidly growing, squamoproliferative benign tumors that resemble squamous cell carcinomas. Early simple excision is recommended. Pyogenic granuloma is a rapidly growing nodule that bleeds easily. Treatment includes laser ablation or shave excision with electrodesiccation of the base. Dermatofibromas are an idiopathic benign proliferation of fibroblasts. No treatment is required unless there is a change in size or color, bleeding, or irritation from trauma. Epidermal inclusion cysts can be treated by simple excision with removal of the cyst and cyst wall. Seborrheic keratoses and cherry angiomas generally do not require treatment.

Skin problems are commonly encountered in primary care. One retrospective chart review of dermatology referrals at a university general medicine clinic found that approximately one-third of patients were referred during their initial visit to their primary care physician.1 However, family physicians can effectively treat most skin disorders.2 A review of diagnoses made by primary care physicians found they were correct 70% of the time (compared with 93% for dermatologists).3 Another multisite prospective cohort study found overall agreement in diagnoses and treatment between family physicians and dermatologists, with a concordance of 72% and 80%, respectively.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography can aid in the diagnosis of lipomas. High-frequency ultrasonography (i.e., with probes greater than 20 MHz) provides high-resolution images of subcutaneous tumors and surrounding structures.

C

10

Diagnosis of dermatofibromas is based on the characteristic appearance and dimpling or retraction of the lesion beneath the skin with lateral compression.

C

20

Intralesional steroid injection with interval excision can hasten resolution of inflamed epidermal inclusion cysts.

C

23

The Leser-Trélat sign is the sudden onset or increase in the number of seborrheic keratosis lesions and may be the result of an underlying malignancy.

C

26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography can aid in the diagnosis of lipomas. High-frequency ultrasonography (i.e., with probes greater than 20 MHz) provides high-resolution images of subcutaneous tumors and surrounding structures.

C

10

Diagnosis of dermatofibromas is based on the characteristic appearance and dimpling or retraction of the lesion beneath the skin with lateral compression.

C

20

Intralesional steroid injection with interval excision can hasten resolution of inflamed epidermal inclusion cysts.

C

23

The Leser-Trélat sign is the sudden onset or increase in the number of seborrheic keratosis lesions and may be the result of an underlying malignancy.

C

26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Clinicians must take special precautions in evaluating skin tumors and screening for skin cancer. The use of dermoscopy to improve diagnosis has been addressed in a previous article in American Family Physician.4  However, the preferred method of diagnosing skin cancer is physical examination. This article will review some common benign skin tumors that are amenable to office procedures, as well as those that may require referral (Table 1).

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Table 1.

Comparison of Common Benign Skin Tumors

ConditionCharacteristicsDifferential diagnosisTreatmentCommentsPrecautions and referral criteria

Acrochordon

Skin-colored to brown

The Authors

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JAMES C. HIGGINS, CAPT, MC, USN, RET, is a staff physician in the Family Medicine Residency Program at the Naval Hospital Jacksonville, Fla., and assistant clinical professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

MICHAEL H. MAHER, CAPT, MC, USN, RET, is a staff physician at the Family Medicine Residency Program at the Naval Hospital Jacksonville, and an assistant clinical professor of family medicine at the Uniformed Services University of the Health Sciences.

MARK S. DOUGLAS, LCDR, MC, USN, is head of the Department of Dermatology at Naval Hospital Jacksonville.

Address correspondence to James C. Higgins, CAPT, MC, USN, RET, Naval Hospital Jacksonville, 2080 Child St., Jacksonville, FL 32214 (e-mail: james.c.higgins2.civ@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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