Case discussion: How would you treat this patient? [24 February]

This week, we present a dermoscopy only case from Dr Shiran Fernando. It features a 48-year-old male with actinic facial skin damage, who noticed that his PSL had darkened in the past 6 months.

Please describe what you see, provide a differential diagnosis, and method of biopsy, if you would biopsy.

Case discussion

Update:

Here is the result. What would you do next?

CLINICAL NOTES:
PSL left face, noted by patient 6 months ago ? darker. Peripheral brown clods and thick brown lines – pseudo network.

MACROSCOPIC:
Specimen site not indicated on container. The specimen consists of a shave of skin measuring 8x8x1mm bearing a scaly cream to grey area measuring 8x8mm. Bisected and all embedded. (1 block) SAD SK24

MICROSCOPIC:
Sections of sun damaged skin shows actinic keratosis associated with basal hyperpigmentation. Immunohistochemistry for SOX10 shows no evidence of an atypical melanocytic proliferation.

DIAGNOSIS:
LEFT FACE, SKIN – PIGMENTED ACTINIC KERATOSIS

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11 comments on “Case discussion: How would you treat this patient? [24 February]

  1. Changing, Chaotic lesion 9mm in size, with grey circles (in varying intensity), present above the neck.
    Likely Dx of pAK v Lentigo Maligna

    Mgt: Shave excision / Biopsy for Histological Diagnosis

    1. Need to rule out LM. Ddx pigmented AK, ?Lplk. Not hugely convincing but possibly an annular-granular pattern at 9 o’clock. Regardless changing lesion on an adult face warrants shave bx.

  2. 8mm chaotic pigmented lesion with grey pink and brown colours. Dots and grey peppering at 11 o clock. Ddx includes lentigo maligna, Pigmented Actinic keratosis, lichen planus like keratosis. Would do a shave biopsy to confirm as punch biopsy may miss malignant region.

  3. 7mm pigmented chaotic lesion, 3 point check score 2
    DDX : AK , Lentigo maligna,
    shave or Punch biopsy

  4. it is a pigmented lesion.
    can see pigmentation and erythema with hair follicles. cant see any scale. cant see any real grey circles or grey polygons.
    can see some grey dots but no grey circles as such. the pattern of pigmentation and follicular openings can be seen on normal skin too.
    given all the evidence
    my diagnosis is pigmented AK.
    DD will be LPLK and LM
    shave biopsy if needed.

  5. Dominant pattern is pigmented annular-granular. Red vessels pseudonetwork is inside a pigmented pattern in the center. Over the upper border of red pseudonetwork the white structureles zone is present. Scattered grey dots are not in lines of network.
    Ds: LM
    Tx: excision or shave

  6. 48 yrs old man who noticed a change in his pigmented skin lesion. this is a worrying sign that makes me seriouly consider a biopsy.
    It is a flat and pigmented lesion.
    Dermatoscopy showed Chaos of Pattern, Colour and border abruptness
    There are clues for malignancy, Grey structures at te 10-11 o’clock position as well as the presence of Circles of varying colours in the face is very suspicious
    My primary diagnosis is Lentigo Maligna, However The possibility of Solar lentigo, and Pigmented solar keratosis cannot be ruled out
    Given it is a flat lesion 9-10 mm in size and melanoma is suspected, i would do a whole lesion shave biopsy.

  7. 8 mm chaos – irregular shape and colour. Grey elements. Dots and probably polygons.
    All point to need to exclude malignancy by a shave biopsy. Mark sample orientation if possible so elements can be identified. PD Lentigo Malinga /melanoma in situ. Could be a solar lentigo.
    Doesn’t have the definite border of a seb k and lacks scale of an actinic keratosis.

  8. This looks like pigmented solar keratosis with a collision lesion of solar lentigo but given the polygons I would do a shave biopsy of the lesion for excluding lentigo maligna

  9. thanks everyone. for me, these lesions are very tricky and even for expert dermoscopists, threes often doubt. My. view- just do a shave biopsy and get a diagnosis. I am a pragmatist