Case discussion: How would you treat this patient? [8 June]

This week’s case from Dr Tim Aung features a:

  • 55 year-old male patient
  • Pigmented lesion in front of left ear
  • Unknown duration

What is your assessment? What would you do next?

Case discussion      Case discussion

Update:

Here is the result. What next?

Case discussion

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32 comments on “Case discussion: How would you treat this patient? [8 June]

  1. An oval lesion on 8 mm in front of left ear, regular margins, some surface scales and a dark spot at left border.
    Dermoscopy shows regular borders, uniform colour with regular reticular pattern except a darker color at one edge. This corresponds to the dark spot on naked eye. No vascular lesions seen . Sun damaged skin in the back ground.
    DD is irritated SK, Solar lentigo,
    Management is observation for any symptoms like pain, itch, bleeding.
    If symptoms are there then consider biopsy.

  2. S keratosis
    AK
    Benign Nevis
    Bowen diseases
    Superficial melanoma
    Punch biopsy and the review

  3. Most of the lesion resembles a solar lentigo. However, at 6 o’clock mark there is chaotic colour and pattern. I would be keen to exclude a melanoma in situ arising in a solar lentigo. Hence, excision biopsy with 2mm margin would be wise. However, it’s tiger territory, so be careful.

  4. The differentials would be as mentioned in the previous comments. Is this an ugly duckling?
    Possibility of melanoma arising in solar lentigo.
    Excision biopsy would be ideal.
    Would it be alright to perform shave biopsy on such lesions?

  5. I will do excisional biopsy for this lesion and DDx will include MIS, Pigmented Bowen’s or AK, LPLK SebK or solar lentigo.

  6. I would be concerned for the dark lesion at 6 o’clock. Rest of pattern seems to be reticular with white spots like a seb K. I would be concerned about possible melanoma within. Excise.

  7. The lesion has irrgeular network and irregular outline , As it is on the trgaus I would refer to a plastic surgeon.

  8. This looks like pigmented sebborreic keratosis with clear cut margins and thick surface on gross anatomy. Can give him the option of cryo to reduce the appearance and see if it does responds to the treatment

  9. clear border with scalloped areas. Seborheic keratosis vs pigmented AK. I would destroy lesion with cryotherapy or effudix. Close follow up to ensure treated and gone

  10. Sharply demarkated lesion on ear. Moth eaten borders. Possible diagnosis solar lentigo.

  11. Solar lentigo, Seb K?
    Asymmetrical lesion, darker area has atypical pigment network? Melanoma.
    Needs excision.

  12. The pigment pattern is most consistent with Bowen’s disease (SCC in situ), but the dark section at 6 o’clock appears to have some black clods. I would examine this area directly with my hand held dermatoscope which provides a sharper image than a camera.
    The darker area does suggests that something more is going on and melanoma would be on the differential diagnosis.
    I would explain the differential diagnosis and encourage excision with 2mm margin. If he refused, I would try ALA with natural light PDT for SCC in situ and follow up in 6 weeks.

  13. Assymetrical pigmentation marked at 7 o clock and suggestion of radial streaming . Superficial spreading melanoma possibleWould go for 2 mm margin excision Closing a defect in this position and size should be feasible

  14. Pseudonetwork with scalloped edges – solar lentigo with some irregular hyperpigmentation at 6 -8 O” clock position?lentigo maligna developing in solar lentigo
    Plan- Either review in 3 months or excision biopsy with 2 mm margins

  15. Skin lesion – DDx will include seborrhoiec keratosis; solar lentigo; melanoma…
    Most likely diagnosis with naked eye is melanoma in situ with solar lentigo. Chaotic features seen at approximately 6 o’clock position. Need dermatoscopic examination which may confirm thick lines and structureless areas!

  16. Chaotic lesion. grey color and atypical clods at the periphery. This is a likely lentigo maligna. biopsy with 2 mm margin recommended.

  17. I think this a pigmented actinic keratosis colliding with lentigo benigna considering keratin clods over a structureless brom pattern with scalloped border Surrouned by sun damaged skin!

  18. the black colour at the edge has made the lesion suspicious for melanoma or lentigo maligna/
    biopsy recommended

  19. pre-auricular irregular lesion with island of pigmented cell, looks like Bowen’s but to be sure need excision biopsy 3mm margin
    dont’t think any role of punch biopsy in pigmented lesion suspected of MM: only excision biopsy as per teaching

  20. It is really suspicious to me.
    I will go for shave biopsy given the area. MM must be excluded given difference in 6 O’clock area and somehow not very even borders.

  21. Most likely solar lentigo or perhaps lichen planus like keratosis given the change at the edge. Unless there is a definitive history that this has not changed over years then there is still some uncertainty for melanoma. I would excise with 2mm margins.

  22. This presentation can go several Dx such as Solar lentigo, Seb K, pAK, MM. Only a proper histology will solve this dilemma. It was Chaotic (asymmetric, > 1 colour) with several clues, more concerning- heavily pigmented dark clods in one side. Ideal biopsy was 2mm margin excisional to rule out a MM. The report was pIEC /pBD. Even I didn’t get right and has to learn in retrospect with Features of pIEC are:
    (1) GLOMERULUS (COILED V/S), IF YOU ZOOMED THE RED DOTS INSIDE.
    (2) PRESENCE OF SCALES.
    (3) WHITE HALO CIRCLES/OVAL.
    Let’s learn at Prof David Wilkinson comments as well.

  23. Thanks everyone, and what a fascinating case! May I suggest that they key here is not worrying about the diagnosis initially, but just focussing on whether to biopsy or not. If we make that the primary decision to make, I think it makes all this much easier. So, is this benign (and you leave it alone) OR is it suspicious and needs a biopsy? That is the key decision to consider. So – could this be benign? Yes, it could. And – could this be malignant and so, is it suspicious? Yes it could be. OK, then we MUST do a biopsy – that is the only way to get a diagnosis. And only then can we treat. And so, how to biopsy? I think a shave is ideal here – easy to do. If you can’t so that, then a large punch biopsy is OK too. You have to be pragmatic – it is a big ask to do an ellipse excision biopsy in this location.