What's beneath skin bumps and lumps?

When a mysterious lump or bump appears on your skin, it’s time to ponder. What could this be? Did you notice it just now or has it been there for a while? Is it painful, itchy or asymptomatic? Is it flesh-colored, brown or black or red, yellowish, or does it have a black dot at the center? Is it localized or all over your body? What was the possible trigger? Is this the first time you have it?

These are all questions that are important, especially if the bumps or lumps are accompanied by other signs and symptoms like fever, night sweats, itching, etc. Infections, tumors, and the body’s response to trauma or injury can all lead to lumps or bumps that appear to be located on or underneath the skin. 

Depending on the cause, skin lumps or bumps may vary in size and be firm or soft to the touch. The overlying skin may be reddened or ulcerated. Skin bumps may or may not be painful or tender, depending upon the cause. But while we tend to think of the worst, most lumps are not a cause for concern. There are a few that are, however.

Case number one: GS, a 30-year-old male who experienced recurring lumps on both legs with accompanying symptoms of severe, throbbing pain with a little itching.  These lumps would resolve spontaneously and heal without scarring, even without medications. This was accompanied by a general feeling of ill health, exhaustion and weakness. Later on ulcerations started to appear over the mouth and genital areas.  

After thorough laboratory tests I came up with a diagnosis of Behcet’s disease. Behcet’s is a rare, chronic, lifelong disease that affects mainly young adults, with men having more severe symptoms than women. Although the exact cause remains unclear, Behcet’s syndrome is thought to arise as the result of an autoimmune response when the body’s defense mechanism malfunctions and begins to attack its own tissues. The syndrome involves inflammation of blood vessels throughout the body.

Symptoms include recurrent oral ulcers, recurrent genital ulcers, and eye inflammation. It may also cause various types of skin lesions, arthritis, bowel inflammation, and meningitis (inflammation of the membranes of the brain and spinal cord). The symptoms usually flare up then go into remission. The time between attacks tends to be unpredictable; it can be as short as a few days, or it can be long as years before a person has another episode.

Behcet’s syndrome affects men five to 10 times more frequently than women. On average, the first symptoms appear between the ages of 10 and 30. GS’s presentation was definitely not a classic one, so what was difficult was arriving at the correct diagnosis.

Case number two: Ellen, a 23-year-old internal medicine resident, went to my clinic. She was worried about the red lumps on the back of her legs that started appearing a month ago. There were no other accompanying symptoms except for the painful lumps. Her history was unremarkable, meaning no disease or illness prior to the appearance of the bumps. So I did several tests and, lo and behold, the tests for pulmonary tuberculosis (PTB) were positive.

I referred her to an internist specializing in infectious diseases for management of her PTB, which she probably got during her rotation at the hospital. She was treated for erythema induratum (EI) of the Bazin type and her lumps disappeared completely. EI is a panniculitis (inflammation of the subcutaneous fat) that occurs mainly in women.

Historically, when it occurs, it‘s often concomitant with cutaneous tuberculosis, and it was formerly thought to be always a reaction to the tubercle bacillus, but they discovered that there are other disease entities (hepatitis, etc.) that might be involved, although physical examination may be very similar to EI. It is characterized by tender nodules underneath the skin, usually located on the back of the legs (calf). Most cases appear between 20 to 40 years of age and it is more common in women.

Case number three: GH, a 25-year-old female, presented with raised tender lesions on the shins that measured one to two centimeters in diameter, together with wrist arthralgia (joint pain). She had no recent history of sore throat, was otherwise healthy, not pregnant, no shortness of breath, no gastrointestinal symptoms and cough. She was not a TB (tuberculosis) risk patient and did not have any fungal exposure or recent travel. She had a history of urinary tract infection a week prior, for which she was given an antibiotic. All laboratory tests were essentially normal.

Diagnosis: Drug-related erythema nodosum. The most common drugs implicated include oral contraceptive pills, iodide/bromide, sulphonamides, saliclyates, and other non-steroidal anti-inflammatory drugs (NSAIDs).

Case number four:  Two years ago, ND, a Filipina, lived in the US for eight years until she developed an unusual skin problem. She was 35 years old when she first saw me. At her visit to my clinic she presented with raised, tender, two- to four-cm. lumps on the shins of four-weeks duration. This was accompanied by pain and redness in both ankles. Otherwise, ND was a healthy woman. Past history was okay: no sore throat, no respiratory and gastrointestinal symptoms, currently not pregnant, no eye-related signs and symptoms, no tubercular or fungal infection.

Laboratory tests were normal except for an elevated erythrocyte sedimentation rate (ESR) and chest X-ray that showed lymph node enlargement.  I treated her for of Lofgren’s syndrome. Oral administration of prednisolone was initiated. The pain resolved within days, and the levels of ESR were normalized after two weeks. The prednisolone dose was lowered a month later. The pain and joint swelling improved, but she sometimes still felt mild pain in her joints, and the lymph node enlargement was still seen on chest radiography after two months. For these reasons, prednisolone administration was continued for eight months then totally stopped. No recurrence has been observed since then.

All four cases presented with red, painful bumps on the lower extremities very typical of erythema nodosum. Erythema nodosum is the most common form of the group of skin conditions called panniculitis (or inflammation of the fatty layer beneath the skin) wherein the skin often develops painful red lumps or plaques and will look darker and feel harder.

The condition may clear up on its own without treatment after some weeks, but for some people the condition will return. Erythema nodosum may occur as an isolated condition or in association with other conditions.

Conditions that are associated with erythema nodosum include medications (sulfa-related drugs, birth control pills, estrogens), sore throat (caused by streptococcus bacteria), cat-scratch fever, fungal diseases, glandular, sarcoidosis, Behçet’s disease, inflammatory bowel diseases (Crohn’s disease and ulcerative colitis) and normal pregnancy.

Erythema nodosum is managed by identifying and treating the underlying condition present. Simultaneously, treatment is directed towards relieving symptoms of inflamed skin.

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For questions or inquiries please call 0917-4976261, 0999-8834802 or 263-4094, or email gc_beltran@yahoo.com.