What are the most common types of lumps on the head?

Most Common Types of Lumps on the Head

The most common lumps on the head/scalp are benign lesions, with epidermoid/dermoid cysts, lipomas, and pilar (trichilemmal) cysts representing the majority of cases, followed by vascular lesions and post-traumatic masses in children.

Age-Specific Patterns

Children and Young Adults

• Dermoid and epidermoid cysts are the most frequently reported extracranial scalp masses in pediatric populations, though the actual spectrum is broader than commonly recognized 1
• Post-traumatic lesions including calcified cephalhematomas and pseudocysts account for approximately 20% of pediatric scalp masses 1
• Vascular lesions (capillary hemangiomas, venous angiomas, lymphangiomas) represent another significant category, comprising roughly 17% of cases in children 1
• Pilomatricomas occur across a wide age range (2-93 years, mean 29.5 years) but are most common in the first and second decades, with the cheek (23%), neck (22%), eyebrow (18%), and scalp (14%) being the most affected sites 2

Adults

• Trichilemmal (pilar) cysts are extremely common on the scalp in adults, presenting as painless, slowly enlarging subcutaneous masses that are more cystic and fluctuant than lipomas 3
• Lipomas remain a frequent benign diagnosis, though they are often confused with other lesions clinically 3

Key Diagnostic Considerations

Clinical Presentation Patterns

• Most scalp lumps present as slowly enlarging, asymptomatic subcutaneous masses 2
• Approximately 25% of pilomatricomas are symptomatic, and 12% demonstrate reddish-blue skin discoloration 2
• The majority of lesions are solitary (95% in pilomatricoma series), with multiple lesions being uncommon 2

Diagnostic Accuracy Challenges

• Preoperative diagnosis is notoriously difficult, with correct identification made in only 28% of pilomatricoma cases before excision 2
• Preoperative investigations are performed infrequently and often provide limited diagnostic value 2
• Clinical examination alone is usually sufficient for diagnosis in most cases, with further investigations often unnecessary 4

Important Differential Diagnoses to Consider

Benign Lesions (Most Common)

• Epidermoid and dermoid cysts 1
• Trichilemmal (pilar) cysts 3
• Lipomas 3
• Vascular lesions (hemangiomas, lymphangiomas) 1
• Pilomatricomas 2
• Post-traumatic masses (cephalhematomas, pseudocysts) 1

Less Common but Important Entities

• Cranial fasciitis and other reactive/inflammatory lesions 1
• Congenital cystic lesions in children (thyroglossal duct cysts, branchial cysts) 5
• Reactive lymphadenopathy when involving the neck/posterior scalp regions 4

Rare but Serious Considerations

• Skull base tumors including leiomyomas and angioleiomyomas can present as head masses, though these typically involve deeper structures 6
• Malignancy is uncommon in scalp lumps, particularly in younger patients, and is largely restricted to older children and adolescents when it does occur 4

Management Approach

Initial Assessment

• Focus on patient age, as this is the single most important demographic factor influencing the differential diagnosis 6
• Determine if the mass is superficial (scalp) versus deep (involving skull), as deep masses require neurosurgical evaluation 7
• Assess for multiplicity of lesions, which may suggest systemic conditions or metastatic disease 6

Treatment

• Conservative excision is the most appropriate treatment for the vast majority of scalp masses 2
• Complete excision is ideal, though incomplete excision carries only a 1% recurrence rate in pilomatricomas 2
• Deep masses involving or adjacent to the skull require neurosurgical consultation, particularly if there is potential intracranial extension 7

Critical Pitfalls to Avoid

• Do not assume all scalp lumps are simple cysts or lipomas – the differential is much broader and includes vascular lesions, post-traumatic masses, and rare entities 1
• Do not over-investigate – most benign scalp lumps can be diagnosed clinically and do not require extensive preoperative imaging 2, 4
• Do not miss deep involvement – always assess whether the mass involves the skull, as this changes surgical planning and requires specialized expertise 7
• Consider vascular lesions – these may require preoperative embolization to reduce bleeding risk if excision is planned 7