Case discussion: How would you treat this patient? [19 October]

In this week’s case discussion from Dr Pearly Cooray we present the following patient:

  • 62 year-old male
  • Lesion noted on forehead during skin check

Please review the clinical and dermoscopy images. What is your differential diagnosis and what would you do next?

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36 comments on “Case discussion: How would you treat this patient? [19 October]

  1. As an RN these are my thoughts…

    Assymetrical
    Border uneven
    Colours – multiple
    Appears evolving – but unsure without a history.
    Given the evidence of AKs on the patients forehead, robust actinic damage.

    Melanoma – superficial spreading query

  2. A bit young for lentigo maligna but certainly has asymmetry and thickened network
    Difficult location – excision Bx would be ideal but could easily just be a flat seborrheic keratosis
    One of the few times I would consider a shave biopsy – will get the dermo-epidermal junction and should allow a definitive diagnosis with minimal cosmetic defect if benign

  3. Pigmented AK
    Lentigo Maligna
    Lentigo Maligna Melanoma

    Consider shave biopsy of the most pigmented area or if pt. doesn’t prefer, follow up and field treatment with imiquimod.

  4. Chaos in structure and colour.
    Clues – thick lines reticular at 1-2 o’clock
    Excisional biopsy with 2 mm margin
    Simple elliptical excision should be okay
    DDx – ?melanoma ?melanoma-in-situ

  5. Some features of AK, looks a bit dry and scaly. ?? Beginnings of polygonal structures. Asymmetrical. Unclear if changing. If in doubt I would probably do a shave biopsy to r/o Lentigo maligna with pigmented AK being my main differential.

  6. it has thick lines reticular on the head, not too much chaos. Unable to rule out melonoma. I would do an excisional biopsy, narrow margin.

  7. Probably benign but has messy features. Main worry are the polygon forms. Lesion has regions and very poorly differentiated (chaotic?) bridge between them. Margins are not well defined. Lesion is just on the margin for my GP skills to excise with 2mm margin but he also has another lesion nearby (at 4o’clock). So I will be sending him to a dermatologist.

  8. collission lesion: actinic keratosis (with follicles, rosettes + keratin) with solar lentigo (structureless)

  9. Diff diagnosis:
    Actinic keratoses, pigmented Bowens disease, solar lentigo, lentigo maligna, melanoma
    Treatment: complete excision with 3mm margins and after that depending on histology

  10. At a glance, pAK or p-Bowen with scales and oval/round circles in the background of pigmented Erythema. But careful look at top-part, disruption of follicles with angulated lines/polygons + thick retics which indicate abnormal proliferation of melanocytes . Thus shaved (saucer) or 2mm margin excisional biopsy and go from there.
    Imp: ?LM or MiS.

  11. Asymmetrical hyperpigmentation in polygonal pattern on the face.needs to rule out lentigo maligna.Circle in circle pattern not seen most areas of the lesion
    WARRANT EX/B WITH 2MM MARGIN

  12. fits the ABCDE: likely Hutchinson’s melanotic freckle/ LENTIGO MALIGNA , I would excise it with 2mm margin

  13. Thanks for all the comments. A small number of colleagues are adamant this is benign, and will leave it alone. Many others propose excision biopsy. Both groups are wrong! In my humble opinion. Let’s do “first principles”: there are benign options here – Seb keratosis can look like this, and so can solar lentigo. Malignant options exist for sure – lentigo maligna melanoma is the obvious one. That is on the clinical view alone. Thus you MUST biopsy – and the best and easiest way is a shave that is deep and wide enough to remove the whole lesion. Easy to do – use the local anaesthetic to elegant the lesion from the surrounding skin and simply shave it off 1-2mm. Dermoscopy is very helpful – but you need to be good at facial lesions dermoscopy: suspicious for melanoma (note the variability in colour across the lesion, with red and brown and the variation in network thickness). Not diagnostic but certainly confirms needs for biopsy

  14. As many of you thought I biopsied that suspecting Lentigo Maligna
    Results came as solar lentigo and solar keratosis. No malignancy.
    Rechecked with pathologist.

  15. Looks like a variegated ugly duckling
    Lots of actnic lesions on lateral left forehead and temple
    Brown structureless punctuated by follicular openings
    Seems to a small amount of grey but no grey circles appreciated
    I would say it was keratinocytic
    DDx incl pigmented AK/IEC and lentigo maligna
    Seems more worrying clinically vs dermatoscopic findings
    I would shave biopsy this