Papules/Nodules
Papules/Nodules: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
Pigmented
❑ Nevus
❑ Seborrheic keratosis
❑ Atypical nevus
❑ Melanoma
Colored
❑ Cherry angioma
❑ Basal cell carcinoma
❑ Erythema nodosum
❑ Lichen planus
❑ Xanthoma
❑ Kaposi sarcoma
❑ Sarcoidosis
❑ Blue nevus
❑ Amyloidosis
❑ Lymphoma cutis
❑ Polyarteritis nodosa
❑ Bacillary angiomatosis
❑ Sweet syndrome
❑ Bowen disease
❑ Cutaneous tuberculosis
Non-pigmented
❑ Epidermoid inclusion cyst
❑ Lipoma
❑ Acrochordon
❑ Dermatofibroma
❑ Ganglion cyst
❑ Wart
❑ Molluscum contagiosum
❑ Milia
❑ Rheumatoid nodule
❑ Tophus
❑ Squamous cell carcinoma
❑ Keratoacanthoma
❑ Neurofibroma
❑ Neuroma
❑ Cutaneous metastasis
❑ Calcinosis cutis
❑ Adenoma sebaceum
Diagnostic Approach
Violaceous papules and plaques occur in cutaneous sarcoidosis, lymphocytoma cutis, and cutaneous lupus.
Findings useful in differentiating atypical from benign nevi are as follows:
Clinical Findings
Nevus Uniformly round brown lesions, they are either flat or raised, with smooth borders.
Seborrheic keratosis Typically, they are brown plaques with a “stuck-on” appearance and a rough, greasy surface. A sudden increase in number with inflammation, the Leser-Trelat sign, may herald an internal malignancy, particularly of lung or gastrointestinal origin.
Atypical nevus Larger than common moles, these nevi have borders that are irregular and ill-defined. The color is variegated, tan to dark brown, often on a pink background. Atypical nevi are at increased risk for subsequently developing into melanoma. A congenital nevus is present at birth and usually larger. When greater than 20 cm in size, it has a 3% to 6% risk of developing into melanoma.
Melanoma Hallmarks are an irregular border that sometimes has a notch and variegation in color and pigmentation pattern. The background color is usually jet black instead of brown. Admixed red, blue, gray, pink, and purple colors help to differentiate them from benign nevi. A previous blistering sunburn (episodic intense sun exposure), red hair with fair skin, and a family history of melanoma are important risk factors.
Cherry angioma They are small, red-purple, and dome-shaped.
Basal cell carcinoma It appears as a translucent papule with fine superficial telangiectasias. As it enlarges, it may ulcerate in the center. It occurs in sun-exposed areas in individuals who spend time outdoors, such as farmers and sailors.
Erythema nodosum Lesions are initially red, but they may become blue as they resolve. They occur primarily over the shins and are tender to touch. There may be systemic symptoms, such as fever and arthralgias, even without underlying disease. Associated conditions include sarcoidosis, streptococcal and upper respiratory infections, inflammatory bowel disease, tuberculosis, drugs (oral contraceptives, sulfonamides, aspartame, and iodides), cat scratch fever, and infectious diarrhea.
Lichen planus They are lilac pink, flat-topped, shiny polygonal papules on the flexor surfaces. Fine white lines traverse them (Wickham striae).
Xanthoma Eruptive xanthomas are crops of yellow papules with an
erythematous halo over the buttock or extensor surfaces, occurring in hypertriglyceridemia, as in uncontrolled diabetes. Tendon xanthomas occur on the Achilles and finger extensor tendon surfaces, in conjunction with hypercholesterolemia.
Kaposi sarcoma These purple, nodular lesions occur in patients with HIV infection.
Sarcoidosis Lesions are red-brown, waxy papules, or deeply indurated (lupus pernio). Typical locations are periorbital, nose, mouth, and scalp. Additional findings include prominent lymphadenopathy, scarring alopecia, and parotid or lacrimal gland enlargement.
Blue nevus These dome-shaped lesions commonly occur on the backs of the hands.
Amyloidosis Pink translucent lesions, especially in the periorbital and perioral regions, occur in primary amyloidosis. “Pinch purpura” and macroglossia may also be found.
Lymphoma cutis Lesions are infiltrated pink to red-purple papules and plaques and are sometimes arcuate. They occur most often in non-Hodgkin lymphoma and may precede the diagnosis.
Polyarteritis nodosa Painful subcutaneous nodules and ulcers arise within an area of red-purple reticular pattern.
Bacillary angiomatosis Multiple red, hemangioma-like lesions uncommonly occur in an HIV-positive patient.
Sweet syndrome Painful red to red-brown plaques and nodules appear on the head, neck, and upper extremities. Of these, 10% are associated with cancer, most commonly acute myelogenous leukemia.
Bowen disease Lesions develop as a chronic, nonhealing, slowly enlarging erythematous patch with a sharp but irregular outline, representing squamous cell carcinoma in situ.
Cutaneous tuberculosis It develops as a red-brown plaque on the face, with a yellow-brown color on diascopy. There is active tuberculosis elsewhere, usually pulmonary.
Epidermoid inclusion cyst Mobile, rubbery, and compressible, it has a central pore. Multiple cysts on the face occurring at an early age suggest Gardner syndrome, associated with colon cancer.
Lipoma It feels soft, mobile, and lobulated, and has indistinct borders. The lobulation can be felt when the lesion is compressed between the thumb and forefinger of one hand while the surface is stroked with the other.
Acrochordon A skin tag is a soft, pedunculated lesion at the flexor surface, especially in the neck, axilla, and groin.
Dermatofibroma It is a firm, skin-colored to brownish (due to hemosiderin) nodule less than 1 cm in diameter. The lesion retracts below the surface with lateral pressure (dimple sign).
Ganglion cyst Adjacent to a synovial joint, especially on the volar wrist, the lump is fixed, firmly compressible and feels cystic.
Wart Most commonly found on the hands and the sole of the feet. The top is rough and irregular. Skin lines are disrupted as they pass through the lesion. There may be small black dots, representing thrombosed capillaries.
Molluscum contagiosum They appear as multiple, 2 to 5 mm, pearly flesh-colored nodules with an umbilicated center.
Milia Tiny, firm, whitish papules appear primarily on the face.
Rheumatoid nodule Nodules appear over pressure points in 20% of patients with rheumatoid arthritis, 6% with Still disease, and transiently in rheumatic fever.
Tophus This firm nodule around the joints of the hand, on the helix of the ear, or in the olecranon and prepatellar bursa, has a characteristic waxy, yellow appearance when the overlying skin is stretched.
Squamous cell carcinoma Arising from an actinic keratosis, it appears as a flesh-colored nodule, which slowly enlarges, ulcerates, and crusts.
Keratoacanthoma This dome-shaped, rapidly enlarging nodule with a central keratin plug is often confused with squamous cell cancer.
Neurofibroma These soft papules or nodules exhibit the “button-hole” sign; that is, they invaginate into the skin with pressure, like a hernia. They may be found singly in otherwise healthy patients, but in persons with von Recklinghausen disease, they appear in association with multiple cafe-au-lait spots and 1 mm yellow-brown Lisch nodules in the iris.
Neuroma Multiple papules occur on the eyelids, lips, distal tongue, or oral mucosa in patients with MEN (multiple endocrine neoplasia, type 2b) syndrome.
Cutaneous metastasis Hard nodules usually occur late in the course of malignancy.
Calcinosis cutis This lesion is calcium-hard and may drain chalky contents through ulceration.
Adenoma sebaceum Skin-colored papules around the nose are classic for tuberous sclerosis.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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