Case discussion: How would you treat this patient? [20 January]

This week, we discuss another interesting case from Dr Mokesh Raj. A 60+ year-old female presented with an “irritated lesion on the hip”. Please examine the dermoscopic image below.

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.
TISSUE RIGHT HIP

Gross Description.
The specimen consists of two irregular pieces of tan tissue 9 x 5 x 3 mm and 7 x 4 x 4 mm.  The tissue is friable. X NR 3L 

Microscopy.
The skin biopsies show an inflamed seborrheic keratosis of acanthotic type.  There is no naevomelanocytic proliferation, dysplasia or malignancy.

 INFLAMED SEBORRHEIC KERATOSIS

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17 comments on “Case discussion: How would you treat this patient? [20 January]

  1. Raised non pigmented lesion with surface keratin clods and coiled vessels. Mild erythema surrounding.
    DDx SCC, KA, Seb K
    ? Location on hip being traumatized by underwear or clothing.
    Dx Seb K
    Shave biopsy to eliminate trauma.

  2. Elevated,pink,? firm and growing.
    Scale and vascular pattern suggests squamoproliferative lesion( well diff SCC
    Some features of Seb K also.
    I would do a deep shave excision to differentiate, & also because it deals with the whole lesion immediately.

  3. This looks like an irritated Seborrheic keratosis, leave it alone or use cryotherapy to treat. no need for biopsy

  4. This is a raised nodular keratotic lesion, with multiple looped vessels indicative of fairly rapid growth.
    probable SCC.

    I would excise, 2mm margin.

  5. My initial impression was of an irritated S.K but closer exam makes me wonder if this is a BCC. It would be helpful to know if this was a longstanding lesion recently irritated or a new lesion.

  6. loop (coiled) v/s and keratin in the background of milky-pink erythema > likely SCC (Keratinocyte t/m).
    If BCC: branched or serpentine (tortuous) v/s, but this seemingly raised (nodular) type is rare for SCC and thus there is a possibility of BCC.
    If Seb K: usually hairpin v/s (but still possible d/t variety of pattern are seen in Seb K).
    Melanoma: usually dotted or polymorphic v/s with no keratin.
    4mm punched biopsy and go from there.

  7. Most likely irritated seb K, scales look more yellowish/orange than white, also not a typical heavily sun exposed area. Would deep shave to remove the nuisance factor and reassure us that it’s not an (unlikely) SCC.

  8. erythematous lesion with scaling
    looped blood vessels, excoriation visible
    Ddx: unpigmented Bowen’s disease (scaling, [?clusters] of coiled vessels, , SCC (but no white circles visible)
    Plan: shave biopsy

  9. thanks everyone – to me this is a very typical Seb k, and I would shave excise it to both confirm this and remove it