Case discussion: How would you treat this patient? [12 February]

This week we have an engaging case from Dr Dave Stewart. An 76-year-old female with 2 week history of rapidly growing tender nodule (R) forearm.

Please review and describe the clinical and dermoscopic image. What is your evaluation, and differential diagnosis?

Case discussion Dave_Stewart     Case discussion Dave_Stewart


This is the pathology result. What is your conclusion and what are the next steps you would take to treat this patient?

case discussion

We encourage you to participate in the case discussions and submit your own clinical images and questions, so we can all learn together.


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

  1. Clinically I would say this is most likely a keratoacanthoma. Dermatoscopically it is chaotic, but I`m not able to find sufficient arguments/clues to decide what it is – some blue clods centrally and serpignious vessels at 11o`clock + few small superficial ulcerations – ?BCC possibly . Some white circles at 10 oclock – ?SCC. Could be anything really, including amelanotic melanoma.
    I would do a shave biopsy of the entire lesion before deciding on further management.

  2. Dermoscopic White,pink,polarising white lines with some greyish regression. Needs excision- shave. D/D- Nodular melanoma/ Poorly Differentiated SCC / Dermatofibrosarcoma/ Atypical Fibroxanthoma

  3. Macroscopically it resembles a nodular BCC. DD includes, amelanotic melanoma . I would do an excision biopsy with a 3mm margin.

  4. Interesting Dermoscopic appearance. Clinically a raised (nodular) erythema lesion.
    CHAOS- present in term of structure (asymmetric) and colour (>one)
    CLUES: shiny white blotches & strands, 2-3 brown pigmented clods with no network, blue-white, polymorph v/s with underlying erythema/milky pink, which span several D/Dx. However in order:
    1/ nBCC or pBCC (n=nodular, p=pigmented) { white blotches and strands are quite specific for BCC as per Navarrete-Dechent C, et al. JAMA Dermatol. 2016 May 1;152(5):546-52. doi: 10.1001/jamadermatol.2015.5731}
    2/ DF (Dermatofibroma)
    3/ MM (Hypomelanotic or aMM) (in view of milky-pink, polymorph v/s,….)
    4/ Secondary metastasis (in view of rapidly growing and tender)
    5/ MCC (Merkel cell …) (in view of rapidly growing and tender)

    Nevertheless, it certainly warrants excisional biopsy (2-3mm margin) instead of shaved or punched, and go from there! If over face or lower legs, I would weight excisional biopsy vs shaved/punch, but here in forearm.

  5. 76-year-old female with 2 week history of rapidly growing tender nodule most commonly keratoacanthoma but SCC possible ant rest etc etc, The best is excision biopsy ( always mine choice) and start from there. I would like to be 100 % sure on dermoscopy but that is impossible, ( or 80%) My moto : excise and than talk about possibilities as if you do not like it follow your gut instinct, ” excise as with good explanation to patient they will agree to be safe than sorry. Only pathologist can tell us what is there. (photo is blurred so it is hard to say, but history points to ” excision only , no observation)
    sorry to make it simple

  6. This is a rapidly growing lesion that appears to be firm, and is elevated. Dermatoscopy shows an amelanotoc lesion with a lot of white scar like areas, and perpendicular white lines. It appears to have polymorphous dot and serpentine blood vessels at 10-11 o’clock. There do not appear to be any white circles or keratin scale. This is a suspicious lesion, possibly an amelanotic melanoma, and it needs to be completely excised with a 2mm margin.

  7. Would love to say I picked this at the time but I was thinking poorly differentiated SCC or amelanotic melanoma.
    There was no history of injury to the site, and I wanted to do an excision there and then, but the patient declined. After much persuasion she agreed to a shave biopsy, but she clearly thought I was over-reacting! Even when I got the pathology back, she denied any injury at this site.
    She did say something along the lines of “just as well I didn’t let you chop it out, eh Doc?” but I thought that was probably reasonable 🙂

  8. Not everything that looks like a skin cancer is a skin cancer! Thanks Dave for such a great case. As I always say “I don’t care what it is, what I do with it is what counts”. This case clearly needed biopsy – so we can find out what it is, right? I don’t think the biopsy technique really matters here – big punch, shave or indeed excision. The important thing is – 1) we don’t know what it is and 2) it needs a tissue diagnosis. So, Dave did absolutely the right thing!

  9. Rapid growing then remove I always think. Keratoacanthoma is most likely for these or SCC, but life is full of surprises.