Case discussion: How would you treat this patient? [4 March]

This week we have an engaging case from Dr Tim Aung. A 55-year-old female with 1-2 years history of slow growth of an asymptomatic, non tender lesion on the upper chest. Please review the images.

What is your impression, what is the differential diagnosis, and (if you would biopsy) what technique would you use?

Case discussion      Case discussion

Case discussion      Case discussion

Case submitted by Dr Tim Aung

Update:

These are the results from the pathology report. What do you think now? How would you treat further?

Case discussion     Case discussion

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11 comments on “Case discussion: How would you treat this patient? [4 March]

  1. Agree it looks like a dermatofibroma both macroscopically(maybe ?)and dermatoscopically,but against this diagnosis are atypical site,stated non tender, age—-and I doubt whether Tim would post such a simple benign lesion for us.
    This is likely to to be something unusual.
    I would therefore do a small(3 mm)punch biopsy
    including the edge of the lesion,given that the upper chest is a well known site for hypertrophic scarring.If benign,that’s it. If malignant ,treat appropriately surgically,and hope for a good cosmetic result.
    Women hate ugly surgical scarring on the upper chest—it severely limits what they can wear,and there are medicolegal implications.

  2. Dermatofibroma vs hypertrophied scar. Location could represent prev biopsy site ? Excise at request.

  3. needed some more history other than a raised lesion, i thought of a scar. leave it alone and reassure the patient that there will be another hypertrophic scar which will form in a few months after excision which he can get treated by kenacort A10

  4. So how the doctor will proceed with this case which proved to be DF/ scar like structure. Bearing in mind, the tendency to form
    Another scar like lesion as it’s one of the susceptible sites.

  5. The dermoscopic picture was not much helpful. Please be aware, blurred pink photo was non-contact and white-straw was contact with dermatoscope plate (moving away of blood from overlying skin).
    Given clinically and dermoscopically, the possibility of Dx could be DF, MM (amelanotic), nBCC, secondary cutaneous tumour, etc. In this case, EFG (Elevated, Firm, Growing) rule was applied, not to miss sinister.

    If there are multiple similar lesions and patient can recall how it started, it is reasonable to suspect abnormal scar. But this is an only single lesion patient had and unable to recall how started to develop. She wanted to get rid of due to irritation with bra string. Unfortunately ending up with hypertrophic scar which is consistent with follow-up 6/52. Punched biopsy would be non-specific report in this similar cases.

    Now to learn, Hypertrophic scar can present with smooth doom shaped with overlying intact skin which can mimic several cutaneous neoplasms. They probably develop from a small folliculitis/furuncle or scratch with spontaneous healing resulting in difficult to notice by patient. Also to be aware of contact and non-contact DERMOSCOPIC features and “EFG” rule (aka NFG= nodular,firm, growing).

  6. What a great case, and many thanks to Tim for sharing. I think the discussion above covers all the issues. When I first saw the case I thought it was a scar / DF, and the history and appearance are consistent with this. However, if there is doubt then biopsy is needed. As we can see, with excision it all just gets worse, with more scaring. I do like David C’s suggestion for a punch biopsy to minimise the impact. Thanks Tim!!