Case discussion: How would you treat this patient? [27 August]

This week we have an engaging case from Dr Dorothy Dowd. A lesion – reported as new – on an older woman’s forearm. Here are 2 images, one with the very recent scab on, and one with it removed. 

From the shown dermoscopy images, please evaluate, indicate your likely diagnosis, and method of biopsy.

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?

Case discussion

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14 comments on “Case discussion: How would you treat this patient? [27 August]

  1. I thought the lesion looked like a seb K with the scab on. Without the scab, i though it might be a bit hard to tell with all the inflammation and irritation going on. I might just observe it for now and review again in 1-2 months. If i were to biopsy this lesion, I would use shave biospy method.

  2. Raised,papillary pink vascular lesion in a sun exposed skin area in an older patient.Possibly grown quickly and ulcerated.The deeper peripheral vessels and lack of keratin crust raise the possibility of poorly differentiated SCC,so at only 4 mm diameter I would excise with 2 mm margins and be prepared to do a WLE with 5 mm surgical margins if dermatopath. revealed the above.

  3. This is an ill defined pink, nodular lesion with polymorphous vessels; needs an excisional biopsy with 2mm margins for a pathological diagnosis; AM is on the differential list

  4. A lesion with thick crust and when it’s off, showing an ulcerated skin lesion with some tiny vessels. I was thinking of bcc however the thick surface scale doesn’t fit. I think it’s well differentiated scc. Excise with 4 mm margin and review pathology.

  5. A raised pink lesion that apparently has bled and formed a scab. I don`t think dermoscopy gives me answers , but such a lesion in an older lady would need a biopsy to decide on further management – I would do a 4 or 5mm punch that fits more or less the whole lesion in it.

  6. Isolated lesion on arm of middle-aged female
    Relatively normal surrounding skin
    The lesion;
    Pink- No pigment
    Small non-descript vessels
    Defects in dermis

    ? Infection ?Other
    Swab for MCS
    Wait for result- if no pathogens proceed to biopsy
    6 mm Punch of the whole lesion for histo
    Absorptive dressing till histo result , then proceed on merits

  7. Hyperkeratotic non melanocytic.Not the crust you see in a seb k.PD well diff SCC.Would shave biopsy.

  8. The top lesion has raised edges and the bottom lesion is ulcerated and those vessels are chaotic , I reckon I can call one a hairpin vessel .
    Poorly differentiated SCC ? Needs 2mm margin

  9. New lesion fairly small. Excisional biopsy/punch with adequate margins and wait for HPE – ? Scc vs keratocanthoma

  10. This is a very non specific lesion. What is meant by a new lesion? presence of a scab does not mean anything & I can’t see any significant BV. Could just be an insect bite reaction . I would wait & see if it settles on its own & r/v in 4 weeks

  11. benign path, good for the patient; in retrospect the lesion still had to come out for histological diagnosis

  12. A great case, and some great inputs here. Thank you, all. My input here is to urge all of us to “almost never” monitor a suspicious lesion, and certainly never monitor a pink lump. AMM is on the list here, and most of you considered SCC (rightly in my view). “Monitoring” can only cause trouble – if it serious, it will be getting worse. If the patient doesn’t come back……you may be in real trouble. So, if your decision is “this is benign” then no follow up. If your decision is “this is suspicious” then do a biopsy. Shave or punch can be done on the spot and you will get a diagnosis from a good biopsy.