Case discussion: How would you treat this patient? [5 September]

This week we have another real life, apparently simple case from Dr David Smith. A small, apparently innocuous pink lesion on the nose.

What is the differential diagnosis?

How would you confirm diagnosis here?

Pink Lesion in the Nose  Pink Lesion in teh nose_Closer Look

Case submitted by Dr David Smith

UPDATE:

Diagnosis is confirmed as a multifocal BCC – what are your treatment options?

 

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


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9 comments on “Case discussion: How would you treat this patient? [5 September]

  1. 3mm punch biopsy to confirm its a BCC. Then excise with clear margins. Probably would do a small graft with the promise she may need more excised if the margins were to close. This may require a bilobed flap after MOHS.

  2. Punch bx. If infiltrative BCC, I’d refer for MOHS. Any other type of BCC I’d do a slow mohs. Repair likely to require a flap ?bilobe ?island (V-Y). Last option would be a FTSG.

  3. A pink skin lesion on the nose tip, showing some white circles, branched vessels, and a surface scales, DD: SCC VS BCC

    Diagnosis: punch or shave biopsy.

  4. stretch the surrounding skin to rule out morphoeic BCC
    3 mm punch to confirm the diagnosis
    morphoeic BCC require MOH’s surgery

  5. Hi;
    NPSL with white clues and polymorphous vessels. DD:
    1. BCC,
    2. Amelanotic Melanoma
    3. ?SCC

    An excisional biopsy with 2mm margin or (a 5mm punch biopsy) to confirm the diagnosis. Repair should be delayed pending diagnosis as Moh’s surgery might be needed.

  6. I. D/Dx: BCC (in view of v/s + site); SCC (in view of tiny scaly); Rosacea,..

    II. Punched biopsy to confirm diagnosis.

  7. I. D/Dx: BCC (in view of v/s + site); Sol K or SCC (in view of tiny scaly); Rosacea,..

    II. Punched biopsy to confirm Dx.

    Management: Depending upon Histopathology- type, thickness,….. etc.

  8. Thanks for all the inputs here – nice and consistent responses. I would do a nice and big punch biopsy here; there are high levels of discordance between biopsy results and excision results with BCC. That is, often the BCC is actually aggressive even when it is reported as not aggressive on biopsy. Clinically, this does not look like a superficial BCC, and it certainly is not nodular. So, I am very suspicious of an aggressive BCC.

    Histology confirms this – multifocal BCC is aggressive. So surgery is the only option here. Slow MOHS is certainly a good option. Remember – excision is easy! It is the repair that is the hard part. So, if you can’t do a good repair – refer!

  9. Many thanks David for good learning point “Clinically, this does not look like a superficial BCC, and it certainly is not nodular. So, I am very suspicious of an aggressive BCC.”