Lumps and Bumps

So, I realize that I have a tendency to call every bump I see on a patient either a lipoma (if it’s squishy) or a sebaceous cyst (if it’s not) and tell them not to worry.  Thought it might be time to refine my diagnostic skills a little.  Thanks to Up to Date and Visual Dx for the pictures, and thanks to Ashley Haddad for inspiring this one…

tumblr_inline_mj9fj8b6pi1qz4rgp

We’ll talk about these “tumors” based onwhere they come from:

Dermal Tumors

Skin Tags (fancy name, Acrochordon) Single or Multiple pedunculated lesions on narrow stalks. Often grow in areas of friction: neckline, axilla, inframammary regions. Easy to remove, but bleed freely.

Acrochordon_close_view

  • Dermatofibromas Firm, hyperpigmented lesions, most commonly on lower extremities.  Made of benign proliferation of fibroblasts. Dimple when the edges are pinched together (nevi don’t do that).  Can recur if removed, sometimes the scar looks worse than the original lesion.

Dermatofibroma_shinDermatofibroma_dimple

  • Neurofibromas We are used to thinking about 100s of lesions in patients with NF, but can occur as sporadic lesions in healthy adults.  Soft, usually flesh colored papules- less than 3cm. Some will retract when pushed (Button-hole sign).

Cutaneous_neurofibromaneurofibroma button hole

Epidermal Tumors

  • Seborrheic Keratosis Hyperpigmented, waxy, “stuck on” papules. Often warty or scaly in appearance. Looks like you could just scrape it off.  Don’t forget the “sign of Leser-Trelat,” which is the sudden appearance of 100s of SKs, acrochordons, and acathosis nigricans.  This is associated with underlying malignancy, often lung or GI.

Seborrheic_keratosis_2

  • Epidermoid Cyst  This is the all too common “sebaceous cyst.”  It is actually a cyst of normal epidermal tissue that has somehow gotten down into the dermis.  The cyst is filled with keratin produced by the epidermis- not sebum.  There is often (but not always) a punctum, and the cyst can drain a thick, cheesy, foul smelling material.  They can become inflamed or infected.

epidermoid cyst 3 epidermoid cyst2 epidermoid cyst

Appendage Tumors (Appendages? Skin appendages include hair, nails, glands, arrector pili muscles)

  • Pilar Cysts These come from the hair follicle, often grow on the scalp.  They are filled with keratin, may not have a punctum.  They tend to calcify and feel very firm, more than epidermoid cysts. They get tender if they rupture.

Pilar_cyst_4

  • Pilomatricoma Probably come from certain cells in the hair follicle.  Smaller than Pilar cysts, often bluish or reddish discoloration.  These can also become calcified and feel quite hard.

pilotrichoma

Vascular Tumors

  • Cherry angioma Capillary proliferation, most commonly found on the trunk.  Dome shaped, blanch with pressure.

Cherry_angiomas

  • Pyogenic granuloma can occur on skin or mucus membranes, grows quickly and has a friable surface that bleeds profusely. Bigger than cherry angiomata.

Pyogenic_gran_chest

Fatty tumors

  • Lipomas collection of mature fat cells. Often looks like a “ball” under the skin. Is soft, not painful, slow growing.  Biopsy if it is painful, restricts movement, or is growing quickly.

Lipoma_trunk

  • Angiolipoma  Looks like a lipoma, but is a collection of fat cells and capillaries. These may occur in groups, and are painful. May occur in HIV patients after starting anti-retroviral therapy.

Angiolipoma

Dermoid Cysts I gave these their own category. They are embryonic remnants of skin formation- with epithelial, glandular, and hair elements, and may communicate with the central nervous system.  They occur along the embryonic lines of cleavage. Most  common spot is on the eyebrow, also on forehead, scalp, floor of the mouth.  As these may communicate with the CNS- don’t attempt to excise scalp lesions without imaging. dermoid cyst

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A case for exercise, continued

So…. the whole commenting thing didn’t work out so well.  I choose to believe that many tried and failed, rather than that I’m talking to myself over here.   So, here’s my take on our case.  Disagree? Something to add?  Speak up on Twitter (follow @ihaterashes)

 Our case..

You have a 58 year old white male patient who you’ve seen 4-5 times in your continuity clinic.  He has diabetes (uncontrolled, with HbA1c 9.5%), HTN (typically reads low 150s/90s in clinic), and hyperlipidemia (guess what?  He refuses medicines).  Oh, and his BMI is 36.

You’ve been harping on the miraculous benefits of diet and exercise all this time, and he’s finally decided to give it a try. He tells you that he’s joined Crossfit and is ready to start exercising, once you give the OK.

Does he need some testing before you give the “OK”?  The commercials say, “Talk to your doctor before starting an exercise program.”  So what are we supposed to say or do?

For low/average risk patients there is no benefit to screening for asymptomatic coronary disease. The ACC has added stress testing in asymptomatic individuals to their list of tests to avoid in the ABIM’s Choosing Wisely Initiative. 

But our patient has diabetes, so he’s not low risk.  Not only that, but he has uncontrolled hypertension and hyperlipidemia, so he most certainly has as much risk for a cardiac event as someone who has had an MI.   In fact, if you follow the Choosing Wisely link above, you note there is a caveat for patients with diabetes over age 40.  So, should we screen him?

Some guideline writers, including the American College of Cardiology, recommend stress testing in asymptomatic diabetics over 40.   The ADA says that EKG exercise testing may be indicated for those diabetics starting an exercise program if: they are over 40, over 30 with signs of advanced diabetes (nephropathy, retinopathy), smokers, or have renal failure due to their diabetes.  

So the guideline writers would screen our patient.  Here’s my concern though, what are we going to do with the information?  He already needs aggressive medical therapy (which he’s not really getting). Perhaps we would do best to just focus on that. Should we revascularize if significant ischemia is found?  

There was one trial, DIAD, which randomized 1123 asymptomatic diabetic patients to screening with adenosine MIBI vs no screening. These patients were largely well controlled with aggressive medical management, and the overall cardiac event rate was only 3% for the whole group. There was no difference in the screened and unscreened groups, however, our patient is so uncontrolled on all risk factors, I’m not sure he fits in.  Our pre-test probability of coronary disease is likely higher than 3%, even without symptoms. 

What about the exercise itself?  I’ve not done CrossFit myself, but it looks fairly intense, with a lot of callisthenic type exercises done fast enough to get an aerobic benefit.  I would be afraid that if he jumped right into an intense “boot camp” like experience like CrossFit, that he might injure himself and then quit exercise all together. It is a tricky thing to encourage exercise, but in such a way that it is more likely to stick as a lifestyle change, rather than a month or so of intermittent involvement that quickly fades away.   

So, I would probably applaud him for his initiative, but ask him to take it a little easy and work on a simple paced exercise program to start.  I would ask a lot of questions to convince myself that he really is asymptomatic, and have a very low threshold for getting stress testing (ideally with exercise MIBI).  You could refer him to cardiopulmonary rehab, so that he could get close monitoring of his HR and BP during exercise (assuming he could pay for it- insurance likely will not).  At the same time, he needs to get his risk factors under control– start a statin, titrate his HTN and diabetic medicines. Certainly give him clear warnings of angina or even anginal equivalents that he might experience, with direction to stop if he does.

Thanks to all for the patience with my blog issues.  New site is coming soon, hopefully with fewer technical difficulties!

Oops

Well, nothing like trying an interactive post when your blog is not accepting comments. Not sure what is happening there, but I’m working on it.
I am choosing to believe that many have made comments that have been lost into the internet ether. So, until I can get comments back, please let’s try that a different way.
Recall our obese, diabetic patient who wants to start an exercise program.
-Does he need a stress test before starting?  Does he need anything before starting?
-Can he jump right in to Crossfit? What is your advice for beginning an exercise plan?
-other thoughts, frustrations, successes?

Please share, I’ll compile the most interesting comments and share back with the rest of the readers (lurkers).  You can deliver your thoughts via email (Erin Snyder UAB Email is fine), page, tweet (just let me know by including @ihaterashes, or you can DM), or this google docs form.
Have at it!