Management Plan for Patient with Sebaceous Cyst, Forearm Lumps, and Elevated GGT
The patient should be managed with surgical excision of the sebaceous cyst, referral for ultrasound evaluation of the forearm lumps, and lifestyle modifications to address the elevated GGT levels.
Sebaceous Cyst Management
- Surgical excision is the treatment of choice for the sebaceous cyst on the patient's back, as it provides definitive treatment and prevents recurrence 1
- The procedure should be performed by a surgeon experienced in the treatment of skin lesions to ensure complete removal of the cyst wall 1
- Prior to excision, ultrasound may be used to confirm the diagnosis and rule out more concerning pathology, particularly since the lesion was manipulated and has changed in appearance 1, 2
- Local excision with careful attention to complete removal of the cyst wall is essential to prevent recurrence 1, 3
- The excised specimen should be sent for histopathological examination to confirm diagnosis and rule out malignancy 1, 4
Management of Forearm Lumps
- Urgent direct access ultrasound scan (to be performed within 2 weeks) is recommended to assess the painful forearm lumps, as per NICE guidelines for evaluation of soft tissue masses 1
- The ultrasound will help differentiate between benign conditions (lipomas) and more concerning pathologies that could explain the nerve-like pain 1, 5
- If ultrasound findings are suggestive of soft tissue sarcoma or remain uncertain with persistent clinical concern, consider a suspected cancer pathway referral (for an appointment within 2 weeks) 1
- The presence of pain, particularly the described shock-like radiating pain, warrants careful evaluation as most lipomas are painless 1, 5
- Consider referral to a regional sarcoma service if the ultrasound reveals concerning features, as specialized multidisciplinary evaluation may be required 1
Management of Elevated GGT
- Comprehensive evaluation of other liver function tests and metabolic parameters is necessary to determine the underlying cause of persistently elevated GGT levels 1
- Despite the patient's denial of alcohol consumption, other causes of elevated GGT should be investigated, including:
- Medications that can elevate liver enzymes
- Non-alcoholic fatty liver disease
- Biliary tract disorders
- Metabolic syndrome components
- Serial monitoring of GGT and other liver function tests is recommended to track trends over time 1
- Lifestyle modifications including weight management, regular exercise, and a healthy diet should be recommended regardless of the underlying cause 1
Important Considerations and Pitfalls
- The sebaceous cyst may be infected or inflamed due to previous manipulation attempts, which could complicate surgical excision; consider treating any inflammation before surgical intervention 1, 6
- Beware of atypical presentations - what appears to be a simple sebaceous cyst could occasionally represent a more serious condition, as documented in case reports of malignancies initially misdiagnosed as benign skin lesions 4
- The painful forearm lumps with nerve-like pain could represent lipomas compressing nearby nerves, but other diagnoses such as neuromas or schwannomas should be considered 1, 5
- The coexistence of different skin lesions (sebaceous cyst and possible lipomas) at different sites is common, but the rare coexistence at the same site has been reported and should be considered during evaluation 6
- Persistent elevation of GGT over several years without significant progression suggests a chronic condition rather than acute liver injury 1
Follow-up Recommendations
- After sebaceous cyst removal, monitor the surgical site for signs of infection or recurrence 1
- Based on ultrasound findings of the forearm lumps, determine appropriate follow-up or intervention 1
- For elevated GGT, recommend follow-up liver function tests in 3-6 months to monitor trends 1
- Provide patient education regarding warning signs that would necessitate earlier follow-up for any of these conditions 1