Examination of a Cutaneous Nodule: Key Evaluation Components
When examining a cutaneous nodule, perform a complete total body skin examination with specific attention to the nodule's dermoscopic features, regional and distant lymph node basins, and assessment for satellite/in-transit metastases, while obtaining a focused history on constitutional symptoms and lesion changes 1.
Essential Physical Examination Elements
Primary Nodule Assessment
Dermoscopic evaluation is mandatory for any concerning cutaneous nodule 2. Visual examination alone is insufficient for raised, clinically suspicious lesions—these require dermoscopy as standard practice 2.
Document the nodule's:
- Exact location and size
- Color patterns (vascular arrangements, pigmentation)
- Morphological vascular patterns and arrangement
- Follicular abnormalities
- Surface characteristics (ulceration, bleeding tendency) 3
Critical Pitfall
Raised, clinically suspicious nodules should be biopsied and not monitored given the possibility of nodular melanoma 2. Do not delay biopsy for serial monitoring in these cases.
Regional and Systemic Assessment
Lymph Node Examination
- Palpate all regional lymph node basins draining the nodule site 1
- Examine distant lymph node basins systematically 1
- Regional nodal ultrasound may be warranted for equivocal examination findings in high-risk patients 1
Surrounding Skin Evaluation
- Inspect the area around the nodule for satellite lesions (within 2 cm of primary site) 1
- Evaluate for in-transit metastases (between primary site and regional nodes) 1
- These findings dramatically alter staging and management
Total Body Skin Examination
Perform a complete skin examination of all body surfaces 1. This is non-negotiable—as demonstrated by cases where seemingly isolated nodules led to discovery of primary malignancies elsewhere 4.
Focused History Components
Obtain specific information about:
- Constitutional symptoms: unexplained weight loss, new-onset headaches, fatigue 1
- Lesion evolution: duration, rate of growth, color changes, bleeding 2
- Previous skin cancers or atypical lesions
- Trauma history to the site 5
- Epidemiological exposures (particularly relevant for infectious etiologies) 6
Advanced Evaluation Tools
When Dermoscopy Raises Concern
If dermoscopic features suggest malignancy but diagnosis remains uncertain:
- Reflectance confocal microscopy (RCM) can be considered, though 76% of experts agree that clinically suspicious lesions with likely benign RCM findings still warrant biopsy 2
- Lesions with RCM features of cancer (93% consensus) or clinically suspicious on RCM (91% consensus) require biopsy 2
Laboratory Studies
No baseline laboratory or imaging studies are indicated for asymptomatic patients with localized disease 1. Order tests only to evaluate specific signs or symptoms of metastasis 1.
The Bottom Line Algorithm
- History: Constitutional symptoms, lesion changes, exposures
- Dermoscopy: Mandatory for all concerning nodules
- Local assessment: Satellite and in-transit metastases
- Regional nodes: Palpation of draining basins
- Total body skin exam: Complete examination
- Biopsy decision: If raised and suspicious, biopsy immediately—do not monitor 2
The examination must integrate all findings within the clinical context 3. Dermoscopic findings showing concerning features (irregular vascular patterns, atypical pigmentation, ulceration) combined with any palpable lymphadenopathy or satellite lesions mandate tissue diagnosis and potential staging workup.