Case discussion: How would you treat this patient? [21 September]

This week we present an interesting case from Dr Kyung Lee (Bruce) featuring a:

  • 77 year-old female patient
  • L lower leg lesion

Please review the clinical and dermoscopy images. What is your evaluation, and what would you do next (if anything)?

Case discussion

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The treating doctor applied liquid nitrogen, and the lesion now looks like these. What would you do next?

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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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41 comments on “Case discussion: How would you treat this patient? [21 September]

  1. Age makes it a bit tricky as lower leg biopsies in this age group can heal poorly. I would want to know how long she has has had this lesion – if longstanding stable then observe with repeat photo in 3-6 months. However assume it is new growth so need biopsy. I would do a punch biopsy of 3mm.
    Diff Dx is Seb keratosis / wart cannot rule out e.g. SCC

  2. Normally I’d prefer Punch Bx to get a full thickness sample but on legs I worry about creating ulcers especially in the elderly where there can be some oedema. If I feel I can close it, a punch biopsy is my first choice. Otherwise, I’d do a shave biopsy with cautery to the base.

    A full excision might need need a halo graft and I’d rather know it needs doing rather than do an excision as an initial procedure.

  3. If this has developed suddenly, I would be suspicious of a keratoacanthoma and I would excise with 2 mm clinical margins.

  4. Likely irritated sebk, but we are missing the history especially as to how long it has been there. At 15mm (plus a margin) it is too big for a safe primary excision — lower leg and elderly. Propose 4mm punch biopsy to determine diagnosis, and if sebk the options include reassurance, shave, or your favourite ablation therapy. If not sebk, and not benign, then excision options have to be evaluated. In my practice this gets a referral to surgeon (always easier with diagnosis established), but excision with halo graft could work (well defined edge and confirmation there is no melanoma) provided the awful cosmetic result is not a concern.

  5. Exophytic, hyperkearatosis but with vessels. Clear edges and some benign features.
    I would punch biopsy to exclude SCC .
    I dont see see Seb K’s pop up like that on the lower leg much and I have had “verrucca like SCC” on the lower limb .

  6. This is a well defined lesion; the surrounding skin doesn’t look terribly sun damaged, but there are a few superficial veins (?varicosities); there doesn’t appear to be any induration around the lesion and it looks papillomatous; I’d like to know the history of this lesion, and whether it is tender; on dermoscopy it is a well defined, predominantly pink lesion; the few vessels that I can see are centred in pink clods; there is scale and a dark colour which I think is blood, along with some red, which is blood; I would like to know what her co-morbidities are, in particular risk for biopsy in this area (diabetes, smoking, peripheral vascular disease etc.). The temptation with such a raised lesion is to shave it, but instead I would do a 3mm punch biopsy which would result in a much smaller defect than a shave; this may be a wart, with a differential diagnosis of well differentiated SCC

  7. Likely to be a irritated Seb K. However, I would still be prudent and perform a shave biopsy. If it is a Seb K, the lesion would have already been removed/ treated by the shave. If it is SCC, then I will come back for a full excision.

  8. Would love some history. If it had been there for a decade with no change I may do nothing.
    However in this age group a new nodular lesion needs a biopsy of some kind, either shave or punch but I would lean toward a shave as you could remove the entire lesion and if it comes back as a seb K which is what it looks like then no further treatment is necessary.

  9. irritated seb k , white clods with a comma shaped bv on it. Does not need treatment. If patient requests options are cryotherapy or shave excision

  10. irritated seb K but odd location. looks scaly – i’m suspicious about SCC and need a tissue diagnosis. I’d shave that off but probably not do it myself as might need grafting etc.

  11. Treat the ulcer (andit does heal), allow 4-8 weeks for this. Biopsy if not healing (i.e., possible BCC/SCC). No further action if healing well and no residual lesion (i.e., likely was sebk or wart). Need to wait to allow for resolution of tissue damage from cryotherapy). If not healing, and biopsy is negative, the leg ulcer in this elderly patient may now take months to resolve so a referral to community nurses will be needed.

  12. Some great responses – thanks all. I would definitely want a diagnosis here (pathology) before treating (using cryotherapy). I would have done either a nice big punch, or a shallow shave if the lesion looked like it would “come off easily”. You MUST get a DIAGNOSIS before you treat!! Please! Now that we can see the lesion, I am really worried about the pigmented area – I would want to know what that it. I would probably do a shave of the pigmented area and a big punch in the middle of the pink area.

  13. keep under observation and give the best conditions to heal. If healed and scarred no further management. If ulcer is not healing , need biopsy of the margin and the centre. The leg look like having varicose veins which may be the reason of ulceration of the cryo base . 3 layer compression for a few weeks will aid healing

  14. I have a rule, never to look too hard at a lesion within 3 -4 weeks of freezing . So often they have a border or look sinister. The pathologist must also find it hard to interpret at this stage too.
    SO, my suggestion: it is very close monitoring with photos FROM 6 weeks post procedure.
    DONT lose this patient to follow up. Explain there is some ambiguity.
    Even if it looks good, from the second picture, you will need a tissue diagnosis for reassurance.

  15. It looks like a keratinocytic lesion with a white halo around (coiled) blood vessels.
    If a history of relatively fast growth (months) or tenderness I would assume invasive SCC to be the most likely diagnosis – and do a punch biopsy.
    If none of the above either very slow changes/growth – I would think it may be a SebK – and I would shave it and send to the pathologist – as either way impossible to tell what it is without histology.
    The images post cryo don`t tell me much. I don`t see any obvious pigment – rather a dried up scab !?
    Either way – a biopsy seems preferable to cryo – and if no histology best have good documentation in the notes of a discussion around diagnostic uncertainty in the notes …
    Is there any histology available on this case ???

  16. I have thought it was irritant Seb K, Cryo seems right option.
    however after discussion here , performed two 4mm punched biopsies
    and showed

    1) “Lesion 1 central” – Two cores of skin 4 x 2mm and 4 x 1mm.
    Processed whole. 1 block.
    2) “Lesion 2 lower margin” – A core of skin 4 x 2mm. Bisected, all in.
    1 block. gb

    1) “Lesion 1 central” – This is a biopsy of skin showing benign
    keratosis, with compact surface hyperkeratosis overlying acanthotic
    epidermis with retained stratum granulosum and no evidence of dysplasia
    or malignancy. The lesion is fragmented and inflamed.

    2) “Lesion 2 lower margin” – This is a biopsy of skin showing benign
    keratosis, with compact surface hyperkeratosis overlying acanthotic
    epidermis with retained stratum granulosum and no evidence of dysplasia
    or malignancy. The lesion is inflamed and shows focal spongiosis.



    lesson: clear diagnosis before treat !

    thank you folks

  17. It look like an irritated Seb K. As a new Dr in skin cancer medicine, I am not sure and prefer to perform a shave biopsy.