How do I treat a skin nodule?

Treatment of Skin Nodules

The treatment of a skin nodule should begin with a proper diagnosis through a complete excisional biopsy with 2mm margins of normal tissue to determine the exact nature of the lesion. 1 This is essential before initiating any treatment, as management varies significantly depending on the type of skin nodule.

Diagnostic Approach

Before treatment, consider these key steps:

1. Complete excisional biopsy: Use a scalpel (not electrocautery or laser) to preserve histological features 1
2. Proper specimen handling: Ensure full thickness with subdermal fat and proper orientation for pathological examination 1
3. Histopathological confirmation: Essential for all suspicious lesions, as benignity should never be assumed based solely on clinical appearance 1

Treatment Based on Diagnosis

Benign Skin Nodules

• Acrochordons (skin tags):

  • Simple scissor or shave excision
  • Electrodesiccation
  • Cryosurgery 2

• Sebaceous hyperplasia:

  • Generally requires no treatment unless for cosmetic reasons 2

• Lipomas:

  • Surgical excision if symptomatic or cosmetically concerning 2

• Keratoacanthomas:

  • Early simple excision recommended 2

• Pyogenic granuloma:

  • Laser ablation
  • Shave excision with electrodesiccation of the base 2

• Dermatofibromas:

  • No treatment required unless changes in size/color, bleeding, or irritation occur 2

• Epidermal inclusion cysts:

  • Simple excision with removal of cyst and cyst wall 2

Malignant or Potentially Malignant Nodules

Squamous Cell Carcinoma (SCC)

• Surgical excision is the treatment of choice 3
  • For well-defined, low-risk tumors <2cm: minimum 4mm margin
  • For larger tumors, high-risk tumors, or those in high-risk locations (ear, lip, scalp, eyelids, nose): wider margin (6mm or more) 3
  • Mohs micrographic surgery for high-risk tumors or cosmetically sensitive areas 3

Basal Cell Carcinoma (BCC)

• Superficial BCC: Imiquimod cream 5 times per week for 6 weeks 4
  • Apply to biopsy-confirmed superficial BCC with maximum diameter of 2cm
  • Include 1cm margin of skin around the tumor
  • Leave on for approximately 8 hours, then wash off 4
• Other BCC: Surgical excision with appropriate margins based on size and location

Melanoma

• Wide excision with margins based on Breslow thickness 3
• Sentinel lymph node biopsy for staging if indicated 1

Cutaneous Lymphoma

• Requires specialized treatment based on type and stage
• May include topical therapies, radiation, or systemic treatments 5

Inflammatory Nodules

Hidradenitis Suppurativa

• Mild disease:
  • Topical clindamycin 1% solution/gel twice daily for 12 weeks or
  • Tetracycline 500mg orally twice daily for 4 months 3
• Moderate-to-severe disease:
  • Clindamycin 300mg orally twice daily with Rifampicin 600mg once daily for 10 weeks
  • If no improvement, Adalimumab 160mg at week 0, 80mg at week 2, then 40mg weekly 3

Treatment Pitfalls to Avoid

1. Inadequate diagnosis: Never treat without proper histological confirmation
2. Insufficient margins: Ensure adequate margins for excision of malignant lesions
3. Inappropriate technique: Avoid shave biopsies for suspicious pigmented lesions as they may underestimate depth 1
4. Delayed treatment: Don't delay evaluation of nodules showing concerning changes 1
5. Incomplete excision: For cysts, ensure complete removal of the cyst wall to prevent recurrence 2

Follow-up Recommendations

• More frequent follow-up (every 3-6 months) for lesions with concerning features 1
• Document with clinical photographs for monitoring changes
• Instruct patients to report concerning changes such as rapid growth, bleeding, pain, or ulceration 1

By following this evidence-based approach to skin nodule treatment, you can ensure appropriate management while minimizing complications and recurrence.