Case discussion: How would you treat these patients? [18 July]

Today we have two images from 2 different patients, from Dr David Smith.

No history in these cases, but both lesions caught David’s eye and warranted dermoscopic view.

Please evaluate both lesions, as best you can.


Lesion 2


Lesion 1

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

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11 comments on “Case discussion: How would you treat these patients? [18 July]

  1. lesion 1 -is differently a chaos with eccentric white grey brown structureless area and brown clods/ dots, with a dark thick black blotch at top (cant see any clear network, however some thick line reticular at lower part of the blotch with brown black clods can be appreciated)….all of which are clues to perhaps malignancy…so needs to be excised and send for HP. PD” MM.

    lesion 2 -shows structureless pale brownish area with thin branching vessels on the periphery and most of the lesion….it warrant to be excised i guess….PD: aMM.

  2. Lesion I. non-polarised.
    A. Chaos (+) in structure and colour.
    B. Clues (+) : grey and black dots, Eccentric structure-less (slight pinkish) in central and inferior. Unable to visualise thick reticular, pods,.. in the given picture.
    Overall, pattern breaker and warrants excisional biopsy, or shaved biopsy with deep dermal if size <5mm, and then go from there.

    Lesion II. seemingly polarised – mostly pinkish erythema with mixed mild pigmentation.
    Chaos + , but unable to apply any clues dermocsopically for melanoma. If small / polymorph vessels, would fall into suspicion of BCC. Depending upon history- size, location,..etc, will apply biopsy (shaved or punched) or watchful wait.

  3. Hi all. Lesion 1: It is a chaotic structure with dark brown clod in the upper half, pseudopods in the upper pole and a blue structureless region in the centre. A shall do an excision biopsy with a 2mm healthy skin margin and warn the patient that may require wider operation pending biopsy result. The chance of a melanoma is fairly high.
    Lesion 2: An oval shaped lesion with reasonably regular edges a fairly uniform pink background peppered with faintly brown pigmented dots. There are serpentine and coiled vessels especially in the periphery. I would lean towards Bowen’s disease or even a very thin seborrheic keratosis; BCC ranks a bit lower in my list. In any case I would take one or (depending on the lesion’s size) two 3mm punch biopsies and proceed from there. If SK cryotherapy; if Bowen’s or BCC excise, most likely with a 4 mm healthy skin margin. If this lesion is in the leg of an elderly/ diabetic/oedematous/ smoker/ varicose veins patient I would plan for possible difficulties.

  4. Interesting comments! Let me be provocative, as a way to stimulate discussion. Case 1 – isn’t this an “obvious” seborrheic keratosis? Case 2 – non-pigmented lesion, can’t name it, so do a punch biopsy? Yes/no? What do colleagues think?

  5. Lesion 1
    Shades of brown irreg shaped pig patch?macule
    Multi focal: irreg areas of hypo pig with overlying blue grey and a pink background
    Brown irreg blotch. Irreg dots
    Asymmetry of colour/ structure
    Highly suspicious and therefore warrants an excision all or deep shave biopsy

    Lesion 2
    Irreg shaped shades of brown with pink background macule.patch
    Atypical network, irreg dots and polymorphic blood vessels
    Highly suspicious that warrants an excision all biopsy

  6. Case 1 was just within the hairline of the frontal scalp which is a classic situation for sebKs. I had quite a few looks and then took the photo and became even less certain. The lesion didn’t feel raised and there was enough variety of structure there for me to biopsy. SebKs have acanthotic thickening of the epidermis and sometimes some extension into the dermis, so its not uncommon to get some blues and greys. This was quite a large lesion and an excisional biopsy probably wouldn’t be appreciated for a sebK.
    Case 2 I couldn’t give a diagnosis to it dermoscopically, and that is a worry. Amelanotic lesions are out there and a more difficult diagnostic proposition. More usually the melanoma will be hypomelanotic with at least some remnant pigmentation to give you a clue. Again I biopsied it through uncertainty.

  7. Lesion one I had a couple of looks at, took some photos and was even less sure. This lesion was just within the hairline of the frontal scalp a typical site of sebKs but this lesion seemed quite flat with variety of patterns. SebKs are acanthotic, sometimes with extension into the dermis, so shade of blue and grey are not uncommon.
    Excisional biopsy for sebKs, particularly in the scalp, would probably make you unpopular.
    Lesion 2. I was unable to give this lesion a diagnosis, so that is always a worry. I worry about missing the amelanotic lesion but generally the melanoma will by hypomelanotic with, at least some remnant of pigmentation, which helps.

  8. Lesion 1 was just within the hairline of the frontal scalp, a typical site of sebKs. They are acanthotic, sometimes with extension into the dermis so blues and greys are not uncommon. Excisional biopsy of scalp sebKs would probably make you unpopular.
    lesion2. I couldn’t give a diagnosis to, so that is a worry. You don’t want to miss the melanotic lesion but generally the melanomas are hypomelanotic with some remnant pigmentation.

  9. In response to Professor Wilkinson at the given picture without history:

    Lesion I. pretty much falling into likely melanoma in view of pattern-breaker with dots through out, pale & pinkish structureless areas, and pseudopods (12′ o clock). There is a tiny bleeding area at 10′ o clock which might point to recent evolving and invasive.

    Lesion II. Yes for biopsy 3-4mm punched whether BCC or IEC (BD) or none. Can’t imagine for amelanotic but who know w/out biopsy!!!

  10. Lesion 1 I had quite a few looks at and photographed but was still unsure. Positioned just within the hairline on the frontal scalp, a really typical site for sebKs but felt macular and still atypical enough to warrant a biopsy. The epidermal hyperplasia, sometimes with extension into the dermis can give blue/grey colour.
    Lesion 2. I couldn’t give this lesion a diagnosis, which is always a worry. Not wanting to miss the melanotic lesion is also a worry. The melanotic melanomas tend to be hypomelanotic, often with a remnant of pigmentation, which is helpful.

  11. lesion 1. sebK. It shows how well these lesions can mimic melanoma, not always so obvious.
    Lesion 2. LPLK on the chest of a 53 year old female with type 1-2 skin. It fits with complete regression a solar lentigo but not what I was expecting.