Case discussion: How would you treat this patient? [13 January]

This week, we discuss an interesting case from Dr Mokesh Raj. There are no clinical details for this patient, so please evaluate the case based on the dermoscopic image presented.

How would you evaluate this? If you were to do anything next, what would you do?

Case discussion

Update:

These are the results from the pathology report. What would you do next?

Anatomical Pathology:

Specimen.
SKIN LESION RIGHT FOREHEAD

 

Gross Description.
The specimen consists of a tear-drop shaped piece of skin 12 x 8 x 2 mm with a variegated slightly raised pigmented lesion 7 x 5 mm approaching to one of the margins.  The apex is designated as 12 o’clock.  The 3 o’clock margin is inked green and 9 o’clock margin is inked black. 5 NR
 

Microscopy.
Sections show skin with an irritated pigmented seborrhoeic keratosis. There is no evidence of malignancy.


Diagnosis:
SEBORRHOEIC KERATOSIS

 

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15 comments on “Case discussion: How would you treat this patient? [13 January]

  1. Chaos, peripheral structureless, gray (regression), pink, some lentigo like border but others very indistinct.
    Melanoma
    Excise with 2mm margins, comfirm whether invasive or not then 5mm or 10mm margins as appropriate

  2. This is a chaotic melanocytic lesion with possible grey pigmentation at 1 o clock. There are some features of solar lentigo with a well defined moth eaten border and indeed of seborrheic keratosis with the milia like cysts but given the chaos and clues, melanoma cannot be excluded. I would refer for excisional biopsy with 2mm margins.

  3. First impression: chaotic, multiple colours
    Pattern analysis: clods and structureless
    Colours: white, brown, purple
    Clues for benign lesion: white clods, moth eaten border. Clues for malignancy: chaos and multipele colours

    I would act depending on clinical context such as age , previous history and macroscopic image as well. In case of a high risk patient I would excise and otherwise follow-up in 6-12 weeks

  4. chaotic lesion, non uniform, structureless, thick lines reticular, key point is multiple grey areas, looks like invasive melanoma over melanoma in situ, would do a excision biopsy with 2mm border

  5. the lesion is chaotic pigmented lesion several colours, light brown to dark brown and at 12 o’clock , 1o’clock and 4o’clock,areas of blue grey.
    eccentric otherwise structureless area contains possible milia like cysts,the border is indistinct.
    Has enough features to consider biopsy,depending onsite initially deep shave , or excision 2mm margins.

  6. Probably lesion on face with pseudopattern, miliary cyst, moth eaton border suggestive of pigmented Seb. K or solar lentigo. Irregular pigementation around some follicular opening but no rhomboid structure or granular pattern. Review in 3 months for any changes

  7. First time at this. It is chaotic and border is vaguely defined. Suspicious pigmented, so excise with 2mm borders.
    The problem is working out where the lesion borders are and therefore where to place the 2mm line.i would like to see the slide with some superimposed markings for excision…..

  8. chaotic lesion
    grey colour centre at at 1:00
    eccentric tan structureless area
    border in some parts is distinct, in other areas gradually fades away; moth eaten border in some areas
    milia like cysts like a SK
    but worrisome; appears like an SK or solar lentigo but with worrisome features, would excise with at least 2 mm margins

    Polymorphous vessels
    Polygons

  9. thanks for all the above comments, very helpful and insightful. Clearly some of us are confident that this is a Seb k and would leave. Others are convinced its a melanoma and would do an excision biopsy. This reflects reality and the spectrum of experience and expertise among GPs. Nothing bad or wrong here. I think this is a lesion that could easily be benign (Seb k) and is more likely to be benign than not. However, it definitely could be malignant. So, for me that means biopsy. If it is small and flat I would do a shave biopsy – because I am comfortable with that technique. If you prefer an excision with 2mm margins, that is great also