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

In our case this week from Dr Tim Aung, we present a:

  • 20 year-old male patient
  • Mother concerned about lesions

How do you evaluate the below images? What would you do next?










Here is the pathology result. What would you do next?

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

  1. It’s a retricular naevus. Blue grey structures evident,>6mm, asymmetrical. Age is on his side but I’d like some more history and physically examining the lesion helps. I’d do a narrow margin full skin thickness biopsy excision.

  2. It’s a reticular naevus. Blue grey structures evident,>6mm, asymmetrical. Age is on his side but I’d like some more history and physically examining the lesion helps. I’d do a narrow margin full skin thickness biopsy excision.

  3. asymmetrical, blue gray, absence of network in places is it an ugly duckling? excisional biopsy withnarrow margins

  4. history needed: if new lesion I would excise it with 3mm margin if old, watch, looks like dysplastic naevus or junction naevus : can be watched with mole map if one has the equipment

        1. Really , ple1. The Ugly Duckling Sign – New Growths, Moles, Spots or Lesions
          Ugly duckling sign of melanoma
          The most significant sign is a mark, mole or any new growth on the skin that looks different from the other spots on your skin. (An Ugly Duckling – A lesion looking a bit different from the other spots on your skin). With the uniqueness of each person comes the uniqueness of our skin and its moles and marks. But if a mole or mark stands out from the other lesions on your skin you should pay closer attention
          please stick to your diagnosis and leave my comments to the expert

          1. I do agree a “new mole” per se at this age is not a significant history. But CHANGING mole ( size and color) is an important factor especially rapid growth

  5. To me , until proven otherwise , with a dermatoscopic features – 3/3 ( suspicious ) . Hence, pigmented suspicious skin lesion must be excised by a complete excisional elliptical excision with 3 mm margin until subcutaneous tissue .

  6. Reticular borders, but has eccentric pigmented areas, some bottom left clods and pseudopods, a definite grey veil rt lower. This is therefore a malig melanoma and needs excisional biopsy with 5 mm margins.

  7. You can clearly see few black dots left side periphery! A red flag from Dermoscopy point of view! Also atypical network which means two different network in one lesion! ? Grey color! I would excise immediately! Melanoma until proven otherwise

  8. Clue for the diagnosis of this lesion. Check out the file name of the image 🙂
    Probably doesn’t help in real life though.
    The diagnostic answer isn’t important though. More important is how to manage this patient

  9. Chaotic network, blue grey areas and suggestion of some pseudopod patterns in 2 pictures. Needs excision biopsy. Probable melanoma

  10. Evidence of chaos of pattern and colour in a melanocytes lesion which makes a biopsy important. If needed for further impetus to biopsy it has an atypical reticular network as well as grey/blue structures and some peripheral clods. Given the age the overall risk of melanoma is still pretty low as it may be a growing naevus but only a biopsy is going to be reassuring. Given the small size a deep shave biopsy will probably be sufficient to make the diagnosis although a narrow margin excision biopsy is ideal.

  11. AT 20 years he will continue to grow new nevi, so history of duration and the appearance are important here. If the central raised (?polypoid)portion has been present longer term and the flat reticular component changed ,there is more concern.However,it is >6mm, asymmetric with deeper pigmented thick reticular pattern in some areas, black dots (6-8 o clock),some greyness and some structureless flesh coloured areas at the periphery of the thickened component.It is possible that trauma contributes to these colours, but unless there has been molemax monitoring short term with no change, dermoscopy warrants biopsy to exclude “dysplastic” nevus or melanoma .

  12. I agree with David: Blue grey structures evident, >6mm, asymmetrical. Narrow margin full skin thickness excisional biopsy.

  13. chaos of structures, colours and border abruptness
    reticular pattern and structureless, black dots segmental peripheral, multiple colours including grey, border indistinct segmentally
    DDx: melanoma- SSM, dysplastic nevus, congenital nevus

  14. Reticular pattern but some lines are thickened and possibly a few clods within the lesion. Not convinced re blue/white structure.
    New naevi do develop prob until the 40’s. At this age likely to be new. In itself not helpful.
    Skin looks pale so prob Fitzpatrick type 2. FH would help.
    If this is the stand out ugly ducking it appears to be I would do an excisional biopsy.

  15. A challenging one to me. Would be easier to see in reality, see what his other naevi look like, if it is changing. Gut feeling is benign. My opinion is that the purple bit is more likely to be a soft raised area which would be more reassuring. There are some thickened pigment areas centrally so at a push is 2/3 so excise. If maternal (and patient) concern then by all means excise with 2mm margin or deep shave depending on area.

  16. A great case, and it illustrates the challenge of skin cancer medicine in general practice: some colleagues are convinced this is benign and will leave alone, some are convinced it is melanoma and will go straight to 5mm margins, some think it is benign and will excision biopsy anyway, and some think it is suspicious and will do a 2mm excision biopsy!!!

    Let me try and give some guidance:

    1 Benign and suspicious diagnoses are not plausible here. If the patient has multiple lesions that look very similar, you can be more confident this is benign. If this lesion is different from others, it is much more likely to be suspicious.

    2 Some, experienced and well trained dermoscopists will be confident this was benign. (I was). Others, were NOT so confident (I would not have been in my early years of skin cancer medicine).

    3 We each have our own threshold of knowledge and confidence and that is OK. If you are going to biopsy this, 2mm excision biopsy is the way to go. Not 5mm – that is not correct.

    4 Skin cancer medicine is easy, if we follow simple rules. It is ONLY benign if you are sure that you know what it is, or you can score it as 0 or 1 on the 3 point checklist. “If in doubt, cut it out”.