Case discussion: How would you treat this patient? [22 May]

Colleagues – a different case this week, submitted by Dr Mike Inskip. Here is a pigmented lesion on a finger. This is an elderly man who gives a history that the lesion has been present for 20 years, but has increased in size recently.

1

Question:

Does this history concern you? Why / why not?

UPDATE

Here is the dermoscopy picture. How would you interpret this?

2

UPDATE

What would you do next? Why? How?

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


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13 comments on “Case discussion: How would you treat this patient? [22 May]

  1. History of a long-standing lesion that has changed recently, warrants further assessment. Further history is also required – including any recent trauma-accident/ pain/ bleeding/ fever/ joint stiffness and to check joint ROM/ circulation. Would like to see the dermoscopic view.

  2. unusual looking lesion. Blood as the pigment seems unlikely on a long standing lesion. There seems to be at least 2 dissimilar areas within the pigmented lesion.
    If this turns out to be a pigmented lesion on an acral surface, the dermoscopy will be helpfully diagnostically as to whether the pigmentation is on the ridges or furrows of the dermoglyphs.

  3. A long standing history with a recent change mandates further assessment work up- I would like to see the dermatoscope picture to asses. Patients some time exaggerate things, however we need to take that into an account.

  4. The history definitely concerns me because a recent change in a pigmented skin lesion is worth further investigation to exclude malignant change. On the other hand having a pigmented lesion in this area for 20 years rather since childhood make me think of an accidental tattooing because of injury. This are is prone to injuries especially in handy men. Further hx is essential. Also dermatoscopi examination is important.

  5. Change warrants close dermatoscopy assessment.
    If any doubt,I reckon a targeted small core biopsy to an area of doubt in this pulp area may be reasonable option.

  6. On a simple analysis. The patient says it has enlarged, which is correct until proved otherwise. The lesion needs dermoscopic evaluation, before a course of action can be undertaken.

  7. Dermoscopy: chaos? Slightly thicker reticular lines on right. Central gray-white scarring area. Radial thick lines peripheral at 5 o’clock. Suspicious lesion both clinically and dermoscopically. It needs biopsy.

  8. History of the change is paramount. The location on the pulp of the digit presents challenges. The meaning of recent changes needs clarification since could even be a pre-existing melanoma that has been ignored until recent trauma caused some “change”. Which is the dominant hand ? since the possibility exist of losing part of the digit. The dremoscopic picture is very suspicious of malignancy there is chaos, grey structure at the centre and focusing on the periphery there is pigmentation of the ridges where pigment surrounds sweat gland openings. In some parts the acral pattern is blurred almost featureless. My approach: 1) discuss with patient implications in detail & obtain written consent 2) do a shave biopsy under digital nerve block and tourniquet (a surgical glove cutting that fingertip and rolling back the rubber is excellent) making sure I obtain the whole lesion. If histology shows melanoma I would refer to a hand surgeon. The cancer needs excision but the best functional result is essential. If it is benign the slice in the pulp of the digit will heal well by second intention with appropriate dressings. And ! before I go; check the axilla and neck for nodes this lesion is 20 years old.

  9. Great input from everyone this week – many thanks! I agree with the approach here. To summarise:

    1 Elderly male with a longstanding pigmented skin lesion = melanoma until proven otherwise

    2 Yes, could be trauma / haemorrhage, but very unlikely with that history

    3 Dermoscopy – doesn’t need anything complex here; the lesion is clearly chaotic and so needs a biopsy (benign nevi on the fingers look very regular and organised)

    4 Like Jorge, I would do a ring block and shave biopsy.

  10. Melanoma , I had similar case, and has all features of melanoma as do not follow the pattern of skin lines of fingerprint,

    1. Dr Doslo, DO you have any images of the case that you can share with us? Thanks, David

      1. Prof Wilkinson, I have as many as you would like , 29 melanomas, plenty SCC BCC, as I am passionate about skin lesions and I have large collection more than 500 patients, melanomas cases are interesting as the way how I did came across them during routine examination of chest for SOB and cough.
        Thanks,
        Slavko

  11. I was late to comment
    I guess I can learn from suggestions made so far. Thanks to you all

    With a lesion like as presented (the long history and photo-image), even with a recent history of trauma, melanoma would be my working diagnosis.
    I would not really wait for dermoscopic exam report (which as posted suggests melanocytic changes – varying pigmented areas, areas of regression and margins) before considering excision biopsy.
    I initially considered elliptical excision under digital block but it is too big to achieve adequate closure. However between shave biopsy and some close to complete closure this may a reasonable approach too – histology wise.
    I would do a thorough skin evaluation including nodal assessment at this visit.