Case discussion: How would you treat this patient? [26 April]

A suspicious lesion is marked by the yellow arrow. Do you see any other suspicious lesions on this man’s face, and if so, where? With regard to the lesion marked by the yellow arrow what is your differential diagnosis on this clinical image? How would you biopsy this lesion and why?

Clinical picture

UPDATE

Dermatoscopic picture

Questions:

Here is the dermoscopic image. How does this help you in your diagnosis?

What options are there for the management of this lesion? Pros and cons?

 

Please share your thoughts in the comment section below. Professor David Wilkinson will provide his opinion and advice.


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6 comments on “Case discussion: How would you treat this patient? [26 April]

  1. i think it’s a nodular BCC which warrants a 3 mm punch biopsy.A shave biopsy may be too large and excision prior to a firm diagnosis is not mic choice here. There is a PSL on l zygoma area that may be of interest.Generally he has badly sun damaged skin with scattered ak on forehead. There is also an indurated area root of anti helix area?? morphed BCC.

  2. I think it is a BCC and there are two ways of treating. 1- to perform a punch biopsy removing the full lesion ideally or if able to an excision biopsy with 2mm margin and if it is nodular BCC it is already treated . DD would be amelanotic melanoma and therefore I would not do a shave biopsy.
    there is a pigmented skin lesion on L temporal area most likely see keratosis but I would need to put the dermatoscopy for better diagnosis
    Forehead sun damage lesions suggestive of solar keratosis .
    L ear helix -superior part some deformity and declaration needs dermoscopy ? BCC also on the inferior part of the helix there is a pigmented skin lesion that needs dermatosocopic assessment.

  3. Pink dome shaped exophytic lesion on the left ala groove.
    From the macro shot it looks like a nodular BCC.
    I’d like a closer look but obviously the dermoscopic view will help with a definitive diagnosis.
    I’d probably go for a punch biopsy. Even though it looks nodular you would like to be sure of the sub-type looking for histological signs of deeper invasion.
    I agree with Solange that a big enough punch with 2mm margin would be diagnostic and therapeutic, assuming it is a nodular BCC.

  4. Nasal lesion likely nodular BCC, DDx nodular melanoma, would also do PBx (4mm rather than 3), ultimate surgery depending on Dx. Lesion over left temple possibly sebK (will depend on dermoscopic appearance); sun-damaged skin, telangiectasia, AKs over forehead & scalp (might benefit from field Tx w/ efudix), scaly lesion over superior left helix and pigmented macule over proximal ear lobe warrant closer look w/ dermatoscope; pale lesion superior to pigmented macule over ear lobe could be scar from previous use of liquid N2 or, as Charlie suggested ?? morphaeic BCC

  5. dermscopic views are classical of nBCC with very defined , in focus vessels.
    process
    1 ] pb , 3 mm for diagnosis.
    2 ] excise in the round with healing by secondary intention . Being in the concavity makes healing by secondary intent a great option with good cosmesis.
    one could do a modified rhomboid rotating skin from higher up the nose . Topicals are inappropriate due it’s histological type and site.

  6. Thanks to everyone for the input so far. Well this was indeed a nodular BCC. There were no other suspicious lesion on close examination, but I agree with the concerns raised about the temple and ear; in real life all was OK. So, for me, a lesion like this clinically is a pink lesion and is suspicious. I would then do a punch biopsy (3 or 4mm is great) for diagnostic confirmation. Important differential diagnosis certainly is nodular melanoma. Remember the EFG – elevated, form and growing = must exclude nodular melanoma! Dermoscopy is certainly typical for nBCC. In terms of treatment excision in the round, or curette, would be really good and certainly healing by secondary intent would work very well here. I think as this is such a small lesion, secondary intent is the “closure” of choice!