General Surgery
Skin, Soft Tissue and Swellings
MBBS surgery notes on skin and soft tissue swellings: examination of a lump, benign cysts and skin cancers including melanoma, mapped to NMC codes SU18.1 to SU18.3.
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Skin, Soft Tissue and Swellings
MBBS surgery notes on skin and soft tissue swellings: examination of a lump, benign cysts and skin cancers including melanoma, mapped to NMC codes SU18.1 to SU18.3.
This chapter covers the clinical assessment of skin and soft tissue swellings and the common benign and malignant lesions. It stresses the systematic description of a lump or ulcer and the warning features of skin cancer.
High-yield: Skin, Soft Tissue and Swellings
- Every swelling is described by site, size, shape, surface, edge, consistency, fluctuation, transillumination, temperature, tenderness and relation to surrounding structures.
- A lipoma is a soft, lobulated, mobile subcutaneous swelling with a characteristic slip sign at its edge.
- A sebaceous cyst has a central punctum, is attached to the skin and contains keratin, and may become infected.
- A dermoid cyst arises along lines of embryonic fusion and is common at the outer angle of the eyebrow.
- Ganglion is a cystic swelling near a joint or tendon sheath, commonly on the dorsum of the wrist, and transilluminates.
- A neurofibroma is a firm swelling arising from a nerve, mobile side to side but not along the nerve, and may be multiple in neurofibromatosis.
- Basal cell carcinoma is the commonest skin cancer, presents as a pearly nodule with rolled edges and telangiectasia, and rarely metastasises.
- Squamous cell carcinoma presents as an ulcerated or nodular lesion, may arise in a chronic wound or scar, and can metastasise to lymph nodes.
- A Marjolin ulcer is a squamous cell carcinoma arising in a long-standing scar, ulcer or burn, and is relatively slow to metastasise.
- Malignant melanoma is suspected from asymmetry, irregular border, colour variation, diameter over 6 mm and evolution.
- The Breslow thickness of a melanoma is the strongest predictor of prognosis and guides the width of surgical excision margins.
- Sentinel lymph node biopsy stages the regional nodes in intermediate thickness melanoma.
- An ulcer is described by its edge; a rolled edge suggests basal cell, an everted edge malignancy, and an undermined edge tuberculosis.
- A benign lump is typically well defined, mobile and slow growing, whereas malignant features include a hard fixed lump with irregular edges.
- Any non-healing ulcer or changing pigmented lesion should be biopsied to exclude malignancy.
Common subcutaneous swellings
- **Lipoma:** Soft, lobulated, mobile, positive slip sign; benign fatty tumour.
- **Sebaceous cyst:** Central punctum, skin-tethered, keratin filled; may get infected.
- **Ganglion:** Cystic swelling near a joint or tendon sheath, often dorsal wrist; transilluminates.
- **Dermoid cyst:** Along embryonic fusion lines, classically the outer eyebrow angle.
NMC competencies in this chapter
- **SU18.1:** Clinical assessment of swellings and ulcers
- **SU18.2:** Benign skin and soft tissue swellings
- **SU18.3:** Skin cancers: basal cell, squamous cell and melanoma
- **SU6.2:** Principles of wound and ulcer care
Frequently Asked Questions
How is a swelling described clinically?
By site, size, shape, surface, edge, consistency, fluctuation, transillumination, temperature, tenderness and its relation to skin and deeper structures, which help distinguish benign from malignant lumps.
What are the warning signs of melanoma?
The ABCDE features: asymmetry, irregular border, colour variation, diameter over 6 mm and evolution or change over time in a pigmented lesion.
What is a Marjolin ulcer?
A squamous cell carcinoma that develops in a long-standing scar, chronic ulcer or old burn. It is relatively slow to metastasise but needs excision.
How does basal cell carcinoma present?
As a slow-growing pearly nodule with a rolled edge, surface telangiectasia and central ulceration. It is locally invasive but rarely metastasises.
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