Case discussion: How would you treat this patient? [21 November]

This week we have a great case from Dr Kerry Lowe. A 49-year-old female presents with a lesion on her left forearm. It has been present for a couple of years but as she has kept catching it with her handbag it increased in size over the past few months, especially the “horn” component due to plenty of sun exposure. She has no family history of melanomas.

Lesion measured ~ 1 x 1 cm with idurated region at lesion base plus a 1 to 1.5 cm horn in its centre. What is your evaluation and what would you do next?


Case submitted by Dr Kerry Lowe


Performed 4mm punch biopsy over indurated region at a base of lesion (3 O clock position) and the patient had already knocked off most of the horn on the previous day. Having knocked it, shave biopsy was done after Punch biopsy. Both specimens were sent to pathology as outlined below:

The sections show a hyperkeratotic well differentiated squamoproliferative lesion. The pattern of keratinisation favours a keratoacanthoma; however, the deep aspect of the lesion is not present for assessment and therefore a squamous cell carcinoma cannot be excluded.


What would you do next?

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 this patient? [21 November]

  1. Agreed with those above. It does look tick but too long for 2 yrs duration!!!
    Possibilities are KA, nodular SCC or BCC, based on info and pic presented. Biopsy first and then +/- 2-3mm margin excision.

  2. I favour the diagnosis of SCC in this patient since the history of a 2 years presence. The size of the lesion would have me contemplate a shave biopsy. I find that the healing processes [fibroses] of the shave biopsy tends to shrink the defect size which in this case may lead to a more acceptable cosmetic result given where on the body the lesion is situated. More so if it proves to be a benign lesion allowing for even lesser margins, effectively only having to remove the biopsy scar should it prove necessary.

  3. I agree a number of possibilities Keratin horn, with underlying solar keratosis or SCC. I think a Shave biopsy would be simple, although healing time a little slow. Further definitive treatment can be completed as a secondary procedure if the lesion is malignant.

  4. Hi everyone;
    A couple of years growing lump can be any of the following possibilities including solar keratosis, verrucas, seborrheic keratosis, trichilemmoma, SCC and even melanoma. A cutaneous horn with KA is rare but possible. I should ask if she has shown that to any practitioner previously because a couple of years for such a big lesion is not usual to wait for. I should check for axillary LNs and other possible skin lesions. I should use dermoscopy to get more clues. Such a lesion can be biopsied by excision and 2mm margin. It is possibly a SCC.