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

This week we have an interesting case from Dr Slavko Doslo. Elderly male, reports non healing ulcer being there for several weeks.

Please review and describe the clinical and dermoscopic images. What is your evaluation, and differential diagnosis? What would you do?

Case discussion Slavko Doslo     Case discussion Slavko Doslo

Update:

This is the pathology result (there was a past history of melanoma excision). What is your conclusion and what are the next steps you would take to treat this patient?

Case discussion Dr Slavko Doslo Case discussion Dr Slavko Doslo

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

  1. This lesion is clinically ulcerated with pearly raised edges, non healing. Dermoscopically has serum crusting, sticky fiber sign and central erythematous changes with no specific vessel pattern. Possibly a nodulo-ulcerated BCC. will need shave excision done for confirmation

    1. Another D/D is Poorly differentiated SCC which is a high possibility given the dermoscopic pink and non specific vessel patterns

  2. Layers of keratin surrounding the lesion which is erythematous with an amorphous background. Suggested serpentine vessels especially at 3 O’clock and glomerular vessels in places. Likely to be a bcc, ddx scc. will do a wide excisional biopsy with 4mm margins.

    1. Sorry Tari, that means that he will need grafting due to circumference of finger and proximity of joint
      location is important in this case, I would not do it ( I am not so confident)

        1. I wanted diagnosis, for me the choice is biopsy, I needed diagnosis as the size and location was what will prompt me for referral is it cancer

          1. Patient was referred to plastic surgeon and had finger amputated, seen by oncologist PET scan clear of any mets,
            follow up every 3/12 for skin check

  3. great case from Slavko – again Slavko. Nobody would expect melanoma here; BCC or more likely SCC is the differential. So, as Slavko says, key next step is a biopsy – punch or shave would do the trick, and give the diagnosis. As we have heard, amputation is the treatment.

  4. I wonder if there was still a possibility of saving the digit with some localised radio/chemo ? amputation seemed an extreme strategy