Case discussion: How would you treat this patient? [9 March]

In this week’s case from Dr David Stewart, we present a 41-year old female with a painless lesion on her ear. Please review the below clinical and dermoscopic images.

• What is your preferred and differential diagnoses?
• How would you biopsy?

Case discussion      Case discussion

Update:

Here is the result. What would you do next?

Case discussion

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17 comments on “Case discussion: How would you treat this patient? [9 March]

  1. Circular central ulcerating lesion on at risk location, dermatoscope demonstrates arborising blood vessels, white crystalline streaking and white areas.
    Suspicious for BCC.
    Punch biopsy then wedge resection.

  2. Non-healing skin lesion on the helix of the ear. Pink lesion – non-melanocytic. The Peripheral area of structureless pink wit the periphery showing pseudo reticulations. Centre of the lesion shows an erosion.
    Vascularity: Irregular random vessels in the centre of the lesion, at five o clock position and at 11 o clock position.
    Clinical Impression:
    Peripheral actinic keratosis( strawberry appearance)
    lesion is suspicious.
    ? Squamous Cell Carcinoma.

  3. Non healing lesion should be shave biopsied on this ear. Women have much less skin cancer on their ears due to hair protection from the sun. Older patients have continued cartilage growth and often develop helicus chronicus which is chronic skin irritations from chronic trauma. The growing cartilage will sometimes create a protrusion which acts as an internal foreign body causing skin irritations and erosions from night friction against the pillow.
    These lesions are rarely cancer but often look and behave locally as non-melanoma skin cancer. The only effective treatment it to excise the inflamed skin and then shave down or excise the excess cartilage. This takes a bit of plastic surgery skill, but ears are extremely forgiving to surgical trauma.
    Alternatively, the patients can be asked to cover the ear nightly with an adhesive bandage and sometimes that will alleviate the erosion problem, but more often the irritation will remain until the anatomy is altered by excision of the protruding cartilage. Wm. Jackson Epperson, MD , MBA

  4. This is grade 3 solar keratosis, can be treated with cryotherapy in 2 weekly cycles. Does not need biopsy at this stage. The arborisation on the lesion is not typical of a nodular BCC and I haven’t yet seen a nodular BCC on outer helix before

  5. This lesion most like is a BCC – due to the relatively long linear vessels, the orange scab suggestive of ulceration … but I wouldn’t jump to any conclusions without a biopsy – I would perform a 3 mm punch biopsy either a shave. In this location (upper 1/3 of the helix) I was tricked before by a lesion looking like a classic invasive SCC with a central white-grey keratotic scab and around this radially arranged loop vessels and white circles. However it turned out to be chondrodermatitis nodularis helicis — if anyone knows any (dermoscopic or other) tricks to distinguish this condition from an SCC … ?

  6. The orange scale is unusual for BCC but I still think microscopically and dermatoscopically that’s the provisional diagnosis. Ddx SCC, benign irritation. Shave biopsy.

  7. Thanks to everyone for the really interesting comments. The dersmoscopy here is very supportive of nBCC – the barbarising blood vessels are almost diagnostic. I would do a punch biopsy here – 4 or 5mm. From the images I suspect that the best surgical treatment here would be an H-plasty. Thanks everyone