Case discussion: How would you treat this patient? [2 August]

Here is a very nice dermoscopic photograph from Dr David Smith. For some of you this will be a dead easy diagnosis – for the more novice colleagues it won’t be. So, let’s use this photograph to learn some more dermoscopy.

Please describe what you see here. Please do NOT jump to a diagnosis, even if you know it – please just describe the features in the photograph first.

Lesion 25.07.16

Case submitted by Dr. David Smith

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

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12 comments on “Case discussion: How would you treat this patient? [2 August]

  1. Non pigmented skin lesion with white colour in the centre and arborizing blood vessels mainly around the lesion but some in the centre

  2. 1/ fine vessels (Comma vessels, arborising vessels,..)
    2/ concentric pale pink-white areas (pearly appearance)
    3/ scaly or slight brownish elevated area (4′ o clock border)- don’t know honestly in term of clinical significance.
    4/ scaly (10′ o clock)
    no blue or other pigmented dots seen.

  3. A pink skin lesion with a remnant of pigment on the periphery all around, and eccentric white structureless area, white lines, ? some faint polygons on right top, serpentine/ torturous vessels, and 3 areas of too much white (fiber- due to erosion/ ulceration’s) all of which would fit one diagnosis. But u said not to state it.

  4. Non-pigmented lesion with large white structureless area and lots of tortuous vessels around the edge and a few in the middle.

  5. Structureless lesion with white center and crowning blood vessels on the edge of the lesion. The lesion has a core

  6. Nice descriptions – many thanks! I concur. So, what is our provisional diagnosis and how would be confirm (what biopsy technique)?

  7. with given history with no size, site and +/- elevation,…
    1/ provisional diagnosis: BCC (based on vessels pattern).
    2/ how would be confirm (what biopsy technique)? : punched biopsy or shaved biopsy if nodular and less than 1cm in size.
    Then go from histology report.

  8. For me i think its sclerosing BCC based on the dermatoscopic features. Excision with wide margin.

  9. I thought it was a BCC too and I would punch biopsy it, only because I am more familiar/comfortable with punch than shave. Then excise depending on histology.

  10. This was a nodular BCC. 5X5mm. A little unusual with the vessels more peripherally arranged, but typical arbourising pattern. I would describe the central area as demonstrating semi-translucency. That typically pearly colour that you get with some nodular BCCs. With the eye-of-faith I even think that I can identify the surrounding stroma. BCCs are stroma dependent and a reason why they are disinclined to metastasise. They can’t seem to survive without it. It also shows how well defined the edges can be. You don’t need wide margins, except maybe the central face, that has higher recurrence rates.
    This lesion came from the back of a 39 year old female patient and the BCC extended to 1 mm deep.
    These lesions are often excised without biopsy but you may get into trouble with the more aggressive subtypes if you proceed without the biopsy.

  11. Thanks for this case David. I agree that the dermoscopy is pretty typical, but that a punch biopsy is wise, before treatment. This is, as you say, because the histology sometimes shows an aggressive sub type that requires excision with wide margins. I like C&C for nodular BCC, but only after a punch biopsy diagnosis. Thanks again David.