Case discussion: How would you treat this patient? [20 August]

This week we have an interesting case from Dr Slavko Doslo. From the shown clinical and dermoscopy images, please evaluate, indicate your likely diagnosis, and method of biopsy.

Case discussion      Case discussion

Case discussion



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?

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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12 comments on “Case discussion: How would you treat this patient? [20 August]

  1. This lesion is a concern both on macro and dermatoscopy – irregular pigmentation with pigmented circles, grey dots, grey dots around a hair follicle/annular granular pattern, radial streaming, peripheral structureless zones and looks like polymorphous vessels; PDx melanoma; I would excise with 2mm margin, or shave biopsy if couldn’t excise.

  2. This is a collision lesion between a Solar lentigo and Actinic keratosis, if I am correct, i can actually see the ROSETTE Pattern on polarisation consistent with grade 2 Actinic keratosis. Advise is to leave this lesion alone and reassure the patient

  3. Middle-aged man
    multiple actinic lesions on “bald” scalp
    Lesion without pigment
    Ulceration and white structures
    No white lines
    No vessels to rely on
    Unlikely to be KA because ulcerated and no radial vessels etc
    Dx : SCC
    Biopsy 1st to confirm
    Then definitive surgical removal and mindful of where it is


  4. White circles and rosettes on red background. Brown lines like pseudonetwork. Ulceration present.
    DD pigmented AK, scc
    Biopsy required. Shave biopsy would sample larger area although multiple targeted punch biopsies may be better at differentiating scc in situ from invasive scc.
    If proven to be AK or scc in situ treat with cryotherapy and follow up.
    If scc will need excision, likely with graft.

  5. Great set of thoughts and responses here – thanks to everyone. When I first saw the clinical and dermoscopic images (before I saw the pathology) the only conclusion I came to was “needs a biopsy”. Shave or (large) punch would work here. That is, a partial biopsy is fine – here, I discount the apparent pigment in and around the lesion as being consistent with his heavy solar damage. While I do believe the biopsy result, I think it is quite a small (2x1mm) biopsy and I would wonder if there is SCC also. Because of this, I would actually treat this with Currette (so I get more tissue off and can check if there is SCC) and Cautery. Any SCC requires formal excision of course.

  6. Glad i got the solar keratosis right ! cant go wrong with the rosette pattern. this can be treated with efudix & avoid a scar without excision

  7. Given the path results I would use Imiqimod or wider excison.
    Is Efudix OK for Bowens disease?
    Can I ask ? i still use the Aldara sachets and not the pump pack. They say single use but I get patients to use the sachets sometimes for 3-5 days for small leisons on the face . IS that OK.
    I have found it hard to find how people actually prescribe and use ALDARA
    I know it is 5 times a week and so on, but I seem to be able to get an adequate response and use less product.
    Would appreciate your comments

  8. The histo findings fits with dermoscopy _ BUT;
    limited (2mm) bopsy
    Also large lesion +- 10mm -by the time margins are added this will blow out 15 – 20 mm

    I lean more towards 5FU and then follow up with proof of
    histological clearance in 3months.

    Will also treat other AKs