Case discussion: How would you treat this patient? [7 November]

Thank you to Dr Ravanjit Singh for contributing this fascinating case. 65 year old male, lesion on neck with history of growth recently. Please review the clinical and dermoscopic pictures.

What are the differential diagnoses here? What would you do next?

161107_dr-ravanjith_1  161107_dr-ravanjith_2

Case submitted by Dr Ravanjit Singh

UPDATE:

Excision showed: SKIN EXCISION LEFT SIDE OF NECK: – INTRAEPIDERMAL CARCINOMA. – MARGINS CLEAR.  What are the treatment options, other than excision, for this condition, and what are 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? [7 November]

  1. Red scaly, flat, keratotic lesion with regressed and brown pigmented areas.
    DDX Lichen planus-like solar keratosis vs solar lentigo
    Observe and review.
    If concerned do punch biopsy

  2. Hi,
    Clinically; sun damaged skin with widespread Actinic Keratoses on the neck. A lesion of concern has recently grown and I am not sure if he means the whole red patch or specific part has grown in thickness! I can see no clear margins even for the dermoscopic picture.
    Dermoscopically: scattered faint lentiginous pigment amid scaly erythematous area with a couple of irregularly pigmented circles. I cannot spot any specific vascular type.
    Dx: Solar keratosis/lentigo with a DDx of pigmented Bowen disease (&/or SCC?!)
    Plan; 1. Punch biopsy of the suspicious area(s)
    2. Offer treatment options e.g Picato, Cryo if there is NO invasive malignancy

  3. Sun damaged skin with surface scales physically which fits AK and which can be associated with SCC…However the dermatoscope for me is not that specific as i do see chaos with central pigmentation and surface scales and nothing else i can see really. So logically can be SCC as too much scales.
    I will take a biopsy to confirm Dg.

  4. Multiple sun damaged skin with Sol K. Area of interest has a small mixed pigmentation with difficult to ascertain clues on dermoscopic pic.
    D/Dx: Sol K, SCC, mixed melanoma,..
    Next: as per guidelines, no monitoring/observation. Leave as benign or proceed. Given recently growing and skin type, inclined to proceed with punched biopsy-wide bore 4-5mm or 2x punched over lesion (ensuring pigmented part included). Then go from there. Not favoured for excisional 2-3mm margin due to large area of erythema avoiding unnecessarily removal of large skin if benign.

  5. I agree here – i think the way to go is 1 or 2 nice and large punch biopsies. I agree that there are a couple of points of pigment but it would be fair to class this lesion as “non pigmented” and as such PB is good. Long list of differentials – inflammatory, neoplastic, etc

  6. “Excision showed: SKIN EXCISION LEFT SIDE OF NECK: – INTRAEPIDERMAL CARCINOMA. – MARGINS CLEAR”

    Was the whole red area excised? It looks like a very large area!