Case discussion: How would you treat this patient? [30 November]

This week we present another case from Dr Tim Aung, whose patient came in for a skin check:

  • 70-year-old male
  • Lesion noted behind right ear

Please review the clinical and dermoscopic images below. What are your differential diagnoses, and what would you do next?

Case discussion    Case discussion

Update:

Here is the pathology result. What 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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23 comments on “Case discussion: How would you treat this patient? [30 November]

  1. Clinical: Pigmented lesion, appears slightly raised, Irregular shape with well demarcated margin. Colour Asymmetry +
    Dermoscopy: Pattern asymmetry. Clue +, Color asymmetry +, Grey colour at 11 and 4 O’Clock site. Curved vessels

  2. Ugly duckling in that area
    chaos of structure and colour
    black clods
    grey structure
    eccentric structureless area
    2 tiny peripheral dots suggesting active growth
    – excise with a 2mm margin for possible melanoma

  3. Asymmetry of shape and colour with grey area at 5 o’clock adn structureless area at 6-7 o’clock. Borwn and black dots. Probable Melanoma. Excisional biosy with 2mm margin.

  4. Fairly classic ,asymmetry, reticulation, irregular pigmentation .Melanoma or melanoma in situ .Fortunately lots of lacks skin in that area –excision biopsy 5mm margin

  5. Suspect new lesion? Peripheral blue grey clods. Melanoma vs BCC. Pigmented Seborheic keratosis.
    Biopsy with 2mm margin.

  6. Not in focused however it shows different colours and taken the account of the patient age I would be very alarmed. Thus a biopsy is mandatory to rule out any suspicious growth.

  7. Highly likely to be a melanoma,chaotic pattern, radial streaming, pale areas.
    On assumption that an 8mm punch biopsy would include a >2mm margin, I would use 8mm punch biopsy. And if histology confirms , then a wide excision as per guidelines.

  8. Pretty compelling for seborrhoeic keratosis but given he’s almost certainly going to be repeatedly asked about it by every person moving behind him I’d do a shave removal to confirm

  9. I would like to know how long he has had this lesion for/?change/?irritates
    Looking at the pictures sveral networks ,area of dipgmentation and irregular outline -for excision

  10. Possible melanoma. I would do a punch excision with an 8mm PB, closed with a Mirini absorbable suture, and see in 2 weeks for ROS and review.

  11. Appears to be a benign well demarcated “moth eaten border” macule / low papule lesion – pigmented Seb Ker.

    I 1st see clues to benign SK.

    Not enough chaos or clues to malignancy for me. I dont identify any radial steaming. I dont see lentiginous spread
    Lesion has some “veiling” of orthokeratosis. No network seen. Darkish brown possibly pigmented keratin filled crypts if a pig SK . No vessels seen.
    A pigmented BCC unlikely on a usually known glabrous area mastoid area
    I dont see a larger area to call this an ugly duckling.
    I would like a lot more history taken 1st before deciding ANY definitive management

  12. Great comments re. MM vs Seb K.
    To reiterate the principle again (as Prof Wilkinson usual say), to BIOPY if you are suspicious for MM and aren’t confident enough to leave as it is a benign. Either shaved or 2 mm marginal excisional will do. Given scar is not a issue in old man of location behind the ear, 2 mm margin is decent one. Retrospectively, this Australia map like is characterised by well demarcated border with brown dots and dark clods inside but no network. Cheers!