Case discussion: How would you treat this patient? [5 July]
This week’s case discussion, submitted by Dr Saad Raheem Abed, features a 54-year-old man who presents to clinic with a nodule on his skin. It has been present for over 12 months and has been asymptomatic. It has grown a little over that time but his GP has reassured him on a number of occasions. Concerned, the patient has checked out ‘a mole checking service’ which analysed the picture and recommended that he be seen by a dermatologist.
- 54-year-old male patient
- 12-month growing lesion
What is your differential diagnosis, and what would you do next?
Here is the update from Dr Saad Raheem Abed:
The outcome of dermatoscopy:
After dermoscopy, dotted and comma vessels on the upper left corner are visible, hairpin vessels on the right side of the lesion and linear vessels all through pointing towards polymorphic vessel morphology in an irregular distribution and mostly central. Lesion is a partially pigmented melanoma due to the presence of some pigment in the periphery of the lesion. There is also blue-white veil at the top right part of the lesion. The vessels most likely disappeared in the top right image due to compression via dermatoscope and the fluid medium. There are also milky-red areas with multiple shades of pink.
So briefly, the dermatoscopic features are:
- Irregular pigmentation
- Irregular dots/globules
- Polymorphous vascular
- Reticular depigmentation
- Dotted irregular vessels, linear irregular vessels, or combination of dotted and linear irregular vessels
- White lines
Thus, combining the clinical features with the dermatoscopic features, the diagnosis is nodular melanoma (amelanotic nodular melanoma).
We encourage you to participate in the case discussions and submit your own clinical images and questions, so we can all learn together.