Case discussion: How would you treat this patient? [11 February]

This week we have an interesting case. What do you make of the clinical and dermoscopic images below?

Is there a differential diagnosis? If so, how would you biopsy?

Case discussion      Case discussion

Case discussion       Case discussion

Update:

These are the results from the pathology report. What are the pros and cons of the treatment options here?

Case discussion

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

  1. raised pink lesion with aborising blood vessels. In the centre there is pigment which is a bit blurry ?not chaotic. I would do two 3mm punch, one to get the pigment area and one in the nonpigment area. DDx= BCC, amelanocytic melanoma

  2. The arborizing vessels and pearly sheen suggests a a BCC. The brown area is likely dried blood from minor ulceration. I would do a shave bx.

  3. Dermoscopy very suggestive of nodular BCC. I rarely skip the biopsy but in this case I might.
    Well defined borders.
    Excision w min. 3mm margins – the surgery may be a bit challenging due to the location on the scalp.

  4. Strongly favouring a nodular BCC.
    Clinically: 10-12mm diameter size of raised erythema lesion with central ulceration.
    Dermoscopically: Arborising v/s, white stuff (structure) in the background of erythema and central haemorrhage.
    Biopsy: punched (3-4mm) and go from there.
    Surgery: depending on individual choice- O-Z or O-S flap or others.

  5. Nodular BCC with classic features, can do shave if you are confident on removing it deep, otherwise WLE with 4mm margins

  6. Sorry for the delay in contributing. I have been walking the Overland Track in Tasmania. No phone signal there. As everyone says, this is clearly a nodular BCC – the arborising blood vessels really are diagnostic. I would always do a punch biopsy (3mm) in case like this. A really good treatment option here is to curette. It is very safe to curette a nBCC, and because the scalp bleeds so much and is so tricky to operate on (and beyond the scope of many GPs) a curette often works really well