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

This week we have an interesting case. No clinical image or history.

What do you make of the dermoscopic image below? How would you biopsy?

Case discussion


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

Case discussion

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

  1. Chaos and clue of black dots peripheral on dermatoscopy, also possible grey colour at 12 o’clock . I would opt for excision biopsy with 2mm margins.

  2. its hard to say without seeing a non magnified image of the area on scalp. looks like a pigmented BCC with globules of black amongst a structureless brown lesion

  3. It is asymmetrical skin lesion with abrupt borderline and islands of pigmentation with blue-grey discoloration on right lateral border making it suspicious for melanoma. I would go for an excision biopsy under local anaesthesia with 2 mm margin.

  4. Too much blue for a shave – will muck up the Breslow. Excise w 2 mm margin for suspected invasive melanoma.

  5. Looks like a BCC on Dermoscopy ( blue clods. Peripheral brown lines, serpentine vessel, structureless area).
    Biospy?/ excision confirms
    I’d excise further aiming for clear margins ( 4mm). I find Dermoscopy can assist to check placing of edges. Spec to histology. This way can confirm all out.

  6. Thanks David and Ashwin . This highlights a perennial question for me.
    I worry about shaving a pigmented lesion, but there are times it would be handy for say ? lentigo maligna .
    I notice it is often recommened in this forum for pigmented lesions.
    I did once take a shave too shallowly for a pigmented lesion and want never to repeat that.
    Is it the technique,? how do you know how deep to shave and margins?
    I shave allot of Seb K ‘s ( for free) so I have little practice in full depth shaves.
    The technique does not really come up at in the procedures meetings, they seem always to be shallow.

    1. Don`t take my word for it as I`m not in a position to teach ( I sometimes get mistaken for Prof. David who started this blog – that`s not me) . Anyway – to my understanding a shave for diagnosing a melanoma is appropriate when you suspect melanoma in situ or a flat thin melanoma – and in that case you expect to see mostly irregular brown network – you shouldn’t see blue, lots of grey or regression … in those cases an excision is usually more appropriate if you don`t want to `mess up` the Breslow. I recently saw a webinar by Dr Robyn Shaw oncologist-surgeon, and her opinion is that a deep shave should basically be down to the subcut fat tissue. Personally I`ve never done shaves this deep- must heal slowly and be quite unpleasant for the patient!?

  7. Thanks everyone. This is a tricky case. Clearly an asymmetric pigmented lesion, and needs a biopsy as it is suspicious. Following the rules, we would do a 2mm excision biopsy to be safe as melanoma is clearly in the differential. A shave is definitely an option for a small, flat pigmented lesion – this is quite a safe approach, because usually you will get the full thickness, and if you don’t (but it is a melanoma) you can move to full excision anyway. how deep to go? just 1-2mm will do the trick and they heal nicely.