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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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408
NODULES
The GP overview
Skin nodules are larger than papules – more than 5 mm diameter. However, their depth is more
signicant clinically than their width. Some are free within the dermis; others are xed to skin
above or subcutaneous tissue below. e causes are various; the patient is usually concerned about
the cosmetic appearance or malignant potential.
Differential diagnosis
COMMON
sebaceous cyst
lipoma
basal cell carcinoma (BCC)
warts
xanthoma
OCCASIONAL
dermatobroma (histiocytoma)
squamous cell carcinoma
nodulocystic acne
kerato-acanthoma
gouty tophi
chondrodermatitis nodularis chronica helicis
rheumatoid nodules and Heberden’s nodes
pyogenic granuloma
RARE
malignant melanoma (becoming more common in the UK)
vasculitic: erythema nodosum, nodular vasculitis, polyarteritis nodosa
atypical infections (e.g. leprosy, treponema, lupus vulgaris, sh tank and swimming pool
granuloma, actinomycosis)
lymphoma and metastatic secondary carcinoma
sarcoidosis
pretibial myxoedema
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NODULES 409
Ready reckoner
Xanthoma Sebaceous cyst BCC Wa r t Lipoma
Reddish-brown Ye s No Ye s No No
Central punctum No Ye s No No No
Characteristic distribution Ye s No Ye s No No
Normal skin surface No Ye s No No Yes
Multiple Ye s Possible Possible Possible Possible
Possible investigations
LI KE LY: None (skin biopsy or cytology if doubt about the lesion or clinical diagnosis of possible
carcinoma).
POSSIBLE: Lipid prole, FBC, ESR/CRP, urate, rheumatoid factor/anti-CCP, urinalysis.
SMALL PRINT: TFT, skin biopsy, further investigations guided by clinical picture (see below).
Excision biopsy is the denitive investigation for achieving a diagnosis; cytology from skin
scrapings can be used to diagnose BCC.
Lipid prole: Xanthomata require a fu ll lipid prole to dene any underlying hyperlipidaemia .
Urinalysis: If suspect inammatory or vasculitic skin lumps, as may reveal proteinuria if
associated with systemic and renal disorders.
FBC and ESR/CRP: ESR/CRP raised in inammatory disorders and malignancy; may also
reveal anaemia of chronic disease or malignancy (including lymphoma).
Check urate if gouty tophi are clinically likely.
Rheumatoid factor/anti-CCP: Nodules are usually associated with positive rheumatoid
factor.
TFT: To diagnose Graves’s disease with pretibial myxoedema.
Skin biopsy: May contribute to a diagnosis of sarcoidosis.
Further investigations according to clinica l picture: Some lesions, such as er ythema nodosum,
may require further investigation to establish the underlying cause; histological conrmation
of skin secondaries may similarly require further assessment, although the overall condition
of the patient may mean this is a futile exercise.
TOP TIPS
Look at the lesion under the magnifying glass – this may reveal suspicious signs such as
ulceration or a rolled, pearly edge.
In uncertain cases which do not require urgent attention, record your ndings carefully
(including precise dimensions) and review in a month or two.
Stoical patients may underestimate the signicance of a suspicious lesion, particularly if you
discover it during a routine examination – if you are referring them for biopsy, impress upon
them the need to attend their appointment.
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410 SYMPTOM SORTER
Establish the patient’s concern, which will usually centre on worries about cosmetic
appearance or cancer. is will result in a more functional consultation and a more satised
patient.
Night sweats and itching with skin nodules raises the suspicion of lymphoma. Examine
lymph nodes, liver and spleen carefully.
e elderly patient complaining of a lesion in a sun-exposed area which ‘just won’t heal’ may
well have a squamous or basal cell carcinoma.
e appearance of a nodule in a mole is highly signicant and requires referral.
A patient with nodulocystic acne requires referral to a dermatologist for possible treatment
with 13-cis-retinoic acid.
e unwell middle-aged or elderly patient who develops bizarre and widespread skin nodules
over a period of a few weeks probably has an underlying carcinoma.
NOTES:
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411
PAPULES
The GP overview
Papules are solid, circumscribed skin elevations up to 5 mm in diameter. If they are larger, they
are called nodules – these are dealt with elsewhere (see ‘Nodules’). (Clearly, many nodules start
life as a papule; to avoid confusion, if they are generally ‘nodular’ by the time they present to the
GP, then they are dealt with in that section, and not repeated here.) ey are usually round but
the shape, and the colour, may vary. ey may be transitional lesions, e.g. becoming vesicular,
or about to ulcerate.
NOTE: ere are more causes of papules than can be listed here. is is a sensible selection.
Differential diagnosis
COMMON
acne
scabies
viral wart and molluscum contagiosum
Campbell de Morgan spot
skin tag
OCCASIONAL
viral illness
milia
insect bites
early seborrhoeic wart
xanthomata
guttate psoriasis
pityriasis lichenoides chronica, lichen planus
prickly heat
keratosis pilaris
RARE
malignant melanoma, early basal cell carcinoma, Kaposi’s sarcoma
Darier’s disease
acanthosis nigricans
pseudoxanthoma elasticum
tuberous sclerosis
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412 SYMPTOM SORTER
Ready reckoner
Acne Scabies Viral wart C. de M. spot Skin tag
Itchy No Ye s No No No
Characteristic distribution Ye s Ye s No Ye s No
Red Yes Ye s No Ye s No
Associated lesions Ye s Ye s No No No
History of contact No Ye s Possible No No
Possible investigations
In practice, very few investigations are needed with this presentation: A lipid screen is required in
the presence of xanthomata; genita l warts require referral for screening for other STDs; thorough
investigation may be needed in the very rare case where underlying malignancy is possible (e.g.
acanthosis nigricans); and obscure rashes or solitary papules may occasionally require excision
biopsy for a denitive diagnosis.
TOP TIPS
Bear in mind that skin cancer is usually uppermost in the patient’s mind, especially in
subacute or chronic cases – so provide appropriate reassurance.
In obscure solitary lesions, record clinical ndings carefully and arrange to review in due
course.
Itchy, asymmetrical grouped papules are likely to be insect bites, although the patient may
take some convincing!
An enlarging dark blue or blue-black papule may be a malignant melanoma, blue naevus or
Kaposi’s sarcoma. Refer for urgent opinion.
Brown, skin-coloured papules crowded around the nose of a child may be tuberous sclerosis.
is can be associated with serious systemic pathology so refer for expert opinion.
An intensely itchy papular rash which is worse at night and has no other obvious cause is
likely to be scabies, even if scabetic burrows are not evident – treat on suspicion.
NOTES:
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413
PURPURA AND
PETECHIAE
The GP overview
Purpura are reddish-purple lesions which do not blanch with pressure. When less than 1 cm in
diameter, they are called petechiae; if larger, they are known as ecchymoses. e problem oen
presents as ‘bruising easily’ – a common ‘while I’m here’ complaint in primary care. Most cases
are normal, with causative minor trauma simply being forgotten or unnoticed.
Differential diagnosis
COMMON
trauma
senile purpura
liver disease (especially alcoholic cirrhosis)
increased intravascular pressure, e.g. coughing, vomiting, gravitational
drugs, e.g. steroids, warfarin, aspirin
OCCASIONAL
vasculitis (e.g. Henoch–Schönlein purpura, connective tissue disorders)
thrombocytopenia (e.g. idiopathic thrombocytopenia purpura [ITP]), bone marrow damage
(e.g. lymphoma, leukaemia, cytotoxics), aplastic anaemia
renal failure
infective endocarditis
RARE
paraproteinaemias (e.g. cryoglobulinaemia)
inherited clotting disorders (e.g. haemophilia, Christmas disease, von Willebrand’s disease)
infections (e.g. meningococcal septicaemia, Rocky Mountain spotted fever)
vitamin C and K deciency
disseminated intravascular coagulation (DIC)
congenital vessel wall abnormalities (e.g. Ehlers–Danlos syndrome)
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414 SYMPTOM SORTER
Ready reckoner
Trauma Senile purpura Liver disease Increased IV pressure Drugs
Tender bruising Yes No No No No
Spontaneous No Possible Yes No Yes
Widespread No Ye s Ye s No Ye s
Recurrent No Ye s Yes No Possible
Petechial Possible No No Yes Possible
Possible investigations
LI KE LY: FBC, ESR/CRP, INR (if on warfarin).
POSSIBLE: LFT, U&E, coagulation screen, plasma electrophoresis.
SMALL PRINT: Autoimmune testing, further hospital investigations (see below).
FBC, ESR/CRP: FBC may reveal thrombocytopenia or evidence of blood dyscrasia. ESR/
CRP and WCC may be raised in blood dyscrasia, connective tissue disorder and infection.
LFT, U&E: For underlying liver or renal disease.
INR: If on warfarin.
Autoimmune testing: If possible connective tissue disease causing vasculitis.
Coagulation screen: To test haemostatic function (e.g. bleeding time, prothrombin time,
activated partial thromboplastin time).
Plasma electrophoresis: For hypergammaglobulinaemia, paraproteinaemia and
cryoglobulinaemia.
Further investigations (usually secondary care): To investigate underlying cause, e.g. skin
biopsy to conrm vasculitis, bone marrow biopsy if possible marrow inltrate.
TOP TIPS
Multiple bruises of varying ages on the legs of young children who are otherwise well and
have no other stigmata of clotting disorder or abuse are likely to be non-pathological.
Senile purpura should be easy to diagnose from the history and examination. Reassurance,
rather than investigation, is required.
A few petechiae on or around the eyelids of a well child can be caused by vigorous coughing
or vomiting. If the history is clear, explain the cause to the parents – but emphasise that the
appearance of an identical rash elsewhere requires urgent attention.
e distribution of purpura can give useful clues to the diagnosis. On the legs, platelet
disorders, paraproteinaemias, Henoch–Schönlein purpura or meningococcal septicaemia
are likely; lesions on the ngers and toes indicate vasculitis; and senile and steroid purpura
tend to aect the back of the hands and arms.
Purpura caused by vasculitis tend to be raised palpably above the skin.
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PURPURA AND PETECHIAE 415
Remember that the rash of meningococcal septicaemia can appear before a child is obviously
systemically unwell. If there is any suspicion that this might be the diagnosis, give parenteral
penicillin and admit immediately.
e absence of a family history does not exclude a signicant inherited bleeding disorder –
these disorders can arise spontaneously.
Take very seriously the pale patient with purpura – a bone marrow problem is likely. Arrange
an urgent FBC or admit.
Always do a full surface examination of a child with bruising, not forgetting the anogenital
area. Keep non-accidental injury in mind.
Never give an IM injection if a serious bleeding disorder is suspected.
NOTES:
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416
PUSTULES
The GP overview
Pustules are raised lesions less than 0.5 cm in diameter containing a yellow uid. ey signify
infection to most people, and will oen present in an urgent appointment, as they are likely to
have appeared suddenly. Patients will oen expect antibiotic treatment. is will not always be
necessary, so be prepared to oer a clear explanation and an appropriate alternative.
Differential diagnosis
COMMON
impetigo
other staphylococcal infections (e.g. early boils, folliculitis, sycosis barbae)
herpes simplex and zoster
acne vulgaris
rosacea
OCCASIONAL
perioral dermatitis
hidradenitis suppurativa (axillae and groins)
candidiasis (satellite vesicopustules around moist eroded patch)
pustular psoriasis (palmar and plantar commoner than generalised pustular psoriasis of von
Zumbusch)
RARE
dermatitis herpetiformis
Behçet’s syndrome
viral: cowpox and orf (Note: chickenpox is vesicular, not pustular)
hot tub folliculitis (supercial Pseudomonas infection)
drug induced
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PUSTULES 417
Ready reckoner
Impetigo Other staphylococcal
infections
Herpes simplex or
zoster
Acne
vulgaris
Rosacea
Grouped or single Possible Possible Ye s No No
Staphylococcal Ye s Ye s No No No
Recurrent No Possible Possible Ye s Ye s
Affects eye No No Possible No Possible
Tingling before lesion No No Ye s No No
Possible investigations
ere are very few investigations likely to prove useful or necessary in primary care. e presence
of widespread or recurrent candidal or staphylococcal lesions might necessitate a urinalysis or
blood sugar/HbA1c to exclude diabetes; a swab of pus may help conrm a clinically suspected
infective agent; and in very obscure cases, a skin biopsy might prove helpful.
TOP TIPS
Take time to explain to the patient the nature of the problem in recurrent staphylococcal
infections. Exclude diabetes, check carrier sites and reassure that the patient’s ‘hygiene’ is not
in question. A prolonged course of antibiotics may be helpful.
Check self-treatment in rosacea and perioral dermatitis. Treatment with OTC topical
steroids will exacerbate the problem. Warn the patient that the condition may worsen before
it improves on withdrawal of this inappropriate treatment.
Papules and pustules around the mouth and eyes, oen with a halo of pallor around the lip
margin, are caused by perioral dermatitis. Treat with antibiotics, not topical steroids.
Widespread, severe and recurrent staphylococcal lesions suggest diabetes or possible
immunosuppression.
Localised pustular psoriasis can be very resistant to standard treatments, so have a low
threshold for referral. e very rare generalised form can make the patient dangerously ill –
admit urgently.
Remember that herpes simplex or zoster infections in the immunocompromised can become
disseminated and severe.
Ocular problems in rosacea can be complicated and troublesome – refer to an ophthalmologist.
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