Reasoning GP · Algorithm · 1-page summary
Subcutaneous lumps (lumps and bumps)
For: adults, children and young people with a palpable soft-tissue lump in primary care. Not for: breast, axillary, neck, thyroid, testicular or skin lesions as a generic lump — they have their own NG12 routes (block 2). Children run on a 48-hour clock.
Core rule: growth is the trigger and imaging comes before the knife. An unexplained lump increasing in size → consider urgent ultrasound; never excise or "shell out" a lump you have not characterised.
0Stop — emergency first — infection and vascular lumps
- Signs of sepsis with high-risk features (abscess, cellulitis, deep infection) → 999 (NICE NG253).
- Pulsatile or expansile mass with haemodynamic instability or uncontrolled bleeding → 999. Never aspirate or biopsy it.
- Rapidly spreading cellulitis, expanding painful vascular mass, active bleeding, distal ischaemia or neurovascular compromise, irreducible tender hernia, suspected deep infection or joint involvement → Same-day
- Stable pulsatile mass → Urgent vascular or radiology advice and Doppler imaging. No office drainage of a possible deep abscess, vascular lesion, or hand, face or joint lump.
1Triage — sarcoma — NICE NG12 (updated April 2026)
| Who | Unexplained lump increasing in size |
|---|---|
| Adult | Consider direct-access ultrasound ≤2 weeks. Suggests sarcoma, or uncertain and concern persists → consider suspected cancer referral |
| Child / YP | Consider very urgent ultrasound ≤48 h. Suggestive or uncertain → consider very urgent referral (48 h) via paediatrics |
| Bone | Child/YP swelling or pain → consider very urgent X-ray (48 h). Adult X-ray suggests sarcoma → consider suspected cancer referral |
2Screen — any one row changes the route
- >5 cm, deep to fascia, painful, fixed, rapid growth, recurrence after excision, indeterminate scan → image or discuss. Do not wait for 5 cm.
- Unexplained breast lump ≥30 y → suspected cancer referral; axillary lump ≥30 y → consider it.
- Neck lump unexplained ≥45 y, or persistent at any age; unexplained thyroid lump → consider suspected cancer referral.
- Testis painless enlargement or change in shape/texture → consider suspected cancer referral; unexplained or persistent symptoms → consider urgent ultrasound.
- Nodes persistent, enlarging, hard, fixed, supraclavicular, generalised or systemic features → bloods, urgent tests, consider lymphoma referral.
- Skin lesion suggesting SCC or nodular melanoma → consider suspected cancer referral.
3Assess — history, the lump, then imaging
☐ Growth (old photos), pain, previous excision and histology, systemic symptoms, known cancer, NF1, radiotherapy ☐ Size in cm, depth (tense the muscle), mobility, skin, pulsatility, cough impulse, nodes, distal neurovascular status. Uncertain → ultrasound first, "?sarcoma" on the request. Targeted bloods only.
4Classify — only if blocks 0–2 are negative
- Lipoma — small, soft, mobile, superficial, stable → reassure if secure. Deep, large, painful, enlarging or recurrent → image first.
- Cyst — punctum (epidermoid) or smooth on the scalp (pilar) → leave, or excise when quiet.
- Ganglion — firm, by a joint or tendon sheath → observe if symptoms are minimal.
- Reactive node — tender, mobile, local infection → treat the cause and re-examine.
- Abscess — hot, fluctuant. Hernia — cough impulse; irreducible and tender → same-day.
- Uncertain — say so → ultrasound, not excision.
5Treat today — only these
- Fluctuant abscess (not deep or vascular): incise and drain. Antibiotics only for cellulitis, systemic upset or immunocompromise (local guideline; doses: NICE/SPC, BNF, local formulary).
- Inflamed cyst: often sterile inflammation; antibiotics only with a clear indication; excise with its wall once settled.
- Growth unclear: record size in cm; book a dated re-measure by the same method.
- Anything excised → histology, labelled with site and differential; result reviewed and acted on.
6Refer routinely
- Symptomatic, clearly benign lumps → Routine surgery or dermatology, per local Evidence-Based Interventions policy.
- Ganglion painful, limiting or with nerve symptoms → discuss hand/orthopaedic options.
- Recurrent abscesses → HbA1c; assess for hidradenitis, PVL Staphylococcus aureus or immunodeficiency.
7Never reassure by
- A lump that is painless, under 5 cm or mobile.
- An old "lipoma" label — recurrence at an excision site is suspicious.
- A slip sign or transillumination.
- A normal FBC or LDH when lymphoma is possible.
- A normal X-ray when bone pain or swelling persists.
- A benign look — every excised lump goes for histology.
8Safety-net — say it, then document it
999 “Call 999 if you feel very unwell — new confusion, very fast breathing, mottled or ashen skin, or not passing urine.” Same-day “Spreading redness, fever, or the lump quickly becoming bigger and tender — contact us today.”
Benign label: “Come back if it grows, becomes painful or fixed, the skin changes or it comes back — don't wait for it to reach 5 cm. Photograph it beside a ruler every few weeks.”
✓Safe to leave primary care only if — all five, documented
No block 0 trigger
Size in cm, depth, mobility and nodes recorded
No growth or sarcoma feature, or imaging arranged
Breast, neck, testis and node routes checked
Safety-net given; dated review or histology owner set
Summary of the full Reasoning GP lumps and bumps algorithm, which holds the history, examination, differential and evidence. Sources: NICE NG12 (updated April 2026); UK guidelines for the management of soft tissue sarcomas (2024); NICE NG253; NHS England Evidence-Based Interventions programme; local antimicrobial guidelines. Clinical reference — follow local lump, breast, node and sarcoma pathways and check doses: NICE/SPC, BNF.