Case discussion: How would you treat this patient? [25 June]

This week we have an engaging case from Dr Tim Aung. An 70-year-old male with two distinct pigmented skin lesions were found on the face, as shown.

What is your evaluation of the clinical and dermoscopic images? What would you do next?

Case discussion    Case discussion

Case discussion

Update:

These are the results from the pathology report. What is your conclusion and what are the next steps you would take to treat this patient?

Case discussion      Case discussion

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11 comments on “Case discussion: How would you treat this patient? [25 June]

  1. the first lesion where arrow pointed – appears to be seb K. very mild regression, but not convincing to need an excision, recehck in 4 months time

    2nd lesion- has features of central regression and polygons with dermoscopic grey, needs shave. possible lentigo maligna

  2. The lesion on the left has irregular border with dark blotches and grey areas in the follicular areas. Also some probably thick line reticular. Looks like maybe MM vs LM. The arrow one I am not very certain though.

  3. Both these lesions appear to be part of a lentigo, and both look suspicious. Both have darkly pigmented circles, and one has a blue white veil. I would sample both of these lesions with an excisional biopsy rather than a shave as I am concerned that there is invasion, particularly in the one with the blue white veil.

  4. Top one looks like Solar Lentigo . Bottom one either Solar Lentigo or regressing Seb K
    Shave excise to exclude LM

  5. the 1st lesion like i predicted has come back seb k which is good

    why wasn’t the 2nd lesion biopsied ? the 2nd one below the pointed arrow is the one that looks regressed with central polygons possible highly dysplastic nevi or SSM

  6. For those who concerned of lower lesion (w/out arrow), I might look into again at his next visit. Although patient was not sure of duration, both look SebK to me. However different intensity of pigmentation, being more darker in the upper one with dark-gray, grey-white and thick reticular in contrast to lower) led me a biopsy to r/o LM/LMM.
    I felt the lower lesion has typical features of SebK: demarcated border, white/orange clods. BTW, patient was a low risk in term of Fitzpatrick skin types 3 and nil PHx of cutaneous cancer. There is a good article to differentiate between SebK vs MM (4 important clues). https://jamanetwork.com/journals/jamadermatology/fullarticle/2612723; https://www.australiandoctor.com.au/news/4-clues-unmask-hidden-melanoma.

  7. The lower anterior lesion appears more `worry-some` with the blue white veil and slightly greyish colour + the light brown macula connecting the 2 more obvious pigmented lesions has quite a few pigmented brown circles, particularly in the upper half – ?this might be worthwhile a (shave) biopsy as well – lentigo maligna!?

  8. really great case I think. for me, the clinical is very suspicious – 2 obvious and lonely pigmented lesions. they look like they could easily be lentigo / Seb k. Dermoscopy does not make a definitive diagnosis for me – more likely benign that not, but not definite. I would do a shave biopsy on both of these. I do note also that there is a lot of solar damage between these 2 lesions. thanks Tim – great case