Case discussion: How would you treat this patient? [4 January]

The first case discussion of the year features an interesting submission from Dr Terry Harvey.

  • 56-year-old female patient
  • Lesion on leg

Please review these images. Any issues of concern? How would you biopsy the indicated lesion?

 

Update:

Here are the results. What next?

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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29 comments on “Case discussion: How would you treat this patient? [4 January]

  1. The lesion shows atypical features- asymmetrical, irregular borders, blue veil, strcuturless area and dots suggesting melanoma.
    Excision biopsy or deep and wide shave biopsy is ideal depending on the size. It is important to advice the patient that there may be need for further excision in future and she MUST return for review in 3-5 days.

  2. Clinically a white lesion adjacent to or part of a pink lesion. Background on leg of other white spots – guttate hypomelanosis. On dermoscopy not too sure where pink part of lesion is? Maybe at the top at 9-12? The white part can be reviewed against other white lesions on leg and if same can leave. The white has one grey ovoid nest at 9pm and many bright white lines. The “pink” area adjacent has pinpoint vessels and also white lesions. I would biopsy this part

  3. I’d like to know if it felt rocky, if there was a recent inflammatory response in the area.
    ?dermatofibroma

  4. The lesion is irregular with white blotchy centre, peripheral pigmented network between 1 & 2 O’Clock and linear pigmentation or haemorrhage at 5 O’Clock and various type of blood vessels seen peripherally
    All is suggustive of amelanocytic melanoma

  5. Looks like benign hypopigmentation or dermatofibroma

    Biopsy probably not required

    Requires more clinical information

  6. Appearances suggest either dermatofibroma or melanoma in site with large area of white regression. Would do save biopsy of whole lesion.

  7. looks like a dermatofibroma – some atypical pigment network seen with asymmetry
    excision biopsy with 2mm margin

  8. History of chronicity ,previous infection at site
    Looks benign condition
    if she is concerned,do excision biopsy

  9. The lesion appears to lack much pigmentation. There’s what appears to be central scarring with slight pigmentation to the peripheries. Abscence of vascular presence. Based on the photos alone the lesion looks like a dermatofibroma. As others have mentioned, palpation of the lesion with reveal a firmness to it 🙂

  10. Guttate hypomelanosis a consideration due to the flatness of the lesion and near uniform whiteness.Amelanotic melanoma possible but vessels and shapes etc lacking on dermoscopy. I would punch biopsy at 12 and 3 review histology and be guided by that

  11. Does the lady have any history at all. When this lesion noticed snd it the lady had any relevant history of injury or insect bite. Having that said, from the physical image i can see a white flat skin lesion with a tiny red pink area. However on dermatoscope i can only see a white area full of short white lines. I would also like to have a feel. If feel was positive I could think of DF provided it’s a short history and probably had history of local trivial injury. Does the lady had any previous history of skin cancer at all. Also any history of sun exposure or sunbed tans or taking immunosuppressive or chronic ailments to rule out AMM. If the lady is kind of alarmed as myself I would excise snd subject to biopsy to put her at ease. Awaiting the HP for this case. It’s challenging and interesting. Thank you for sharing.

  12. The lesion looks suspicious due to asymmetrical colour and shape. Central regression, abnormal pigmentation, and networking. Also the patient is 56 yo. I believe it is a Malignant Melanoma and needs a punch biopsy ASAP.

  13. The dermatoscopic picture of the lesion is suggestive of dermatofibroma. I would simply reassure the patient.

  14. Area of hypopigmentation which has irregular outline with telangiectasia. For excision biopsy and histopathology. Surrounding skin reveals sun damage,

  15. Interesting. At first glance I was sure this was a dermatofibroma. Is there a dimple sign? It’s largely structureless, central white lines. , brown lines at 9 oclock and vessels at 11 oclock. If there is no dimple sign it requires excisional biopsy to exclude amelanotic melanoma.

  16. A hypopigmented area in the center with solar damage on the periphery .Polarised white lines in the center
    Differential – Dermatofibroma, Scar of the previous biopsy, Amelanotic melanoma
    Plan- More clinical information required eg duration, changes, previous biopsy history
    If no reliable information available, An excision biopsy with 2 mm margins

  17. Naked eye exam shows almost circular lesion , depigmented with an irregularity at 2 o clock position with fleshy appearance. Dermoscopy shows irregular borders, scar like regression pattern, shiny white streaks and irregular
    network / fibrillar pattern with ? peppering. Melanoma needs to be ruled out. Dermatofibroma or benign scarring can be in differentials. Excision biopsy with 3 mm margins is recommended.

  18. The lesion seen on this case discussion is likely a dermatofibroma. DD: dermatofibrosarcoma, melanoma mimic. Excision bx is preferable but bigger punch bx can be considered. Dermatofibroma itself is a benign lesion . It is a good clinical scenario. Thank you.

  19. suspicious lesion , irregular margins , central area of depigmentation , ? white lines. and blakc dots over one side .? Amelanotic melanoma. Excision biopsy.