Case discussion: How would you treat this patient? [8 November]

The topic of this week’s case is pigmented lesions on the face of elderly people. This 82-year-old woman presented to Dr David Stewart with a longstanding lesion on her cheek, possibly slowly growing.

  • 82-year-old female
  • Longstanding lesion on cheek

What is your differential diagnosis, and what would you do next?

case discussion

– Prof David Wilkinson


Here is the pathology. 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.


Learn more about skin cancer medicine in primary care with the HealthCert Skin Cancer Certificate Courses.

Skin Cancer Certificate Courses in Australia

Leave a Reply

Your email address will not be published. Required fields are marked *

23 comments on “Case discussion: How would you treat this patient? [8 November]

  1. flat pigmented lesion on the face with geometrical lines , grey dots
    most probably lentigo maligna , need excision biopsy
    as the lesion is large I might do the most obvious part of the lesion
    after the confirmation of the diagnosis need wide excision

  2. A spread out facial pigmented asymmetrical lesion (an elderly person)
    Presence of grey dots and circles
    Most likely lentigo maligna; a Shave biopsy

  3. Macro – looks like lentigo maligna so probably is
    – large & irregular
    – flat
    – pigmented but variable
    Dermoscopy is consistent with this
    – pigment dots around hair follicles (face/neck) = pseudonetwork
    – colours
    – maybe some regression areas

    Partial shave excision including the most pigmented area. If histology is negative don’t necessarily believe and arrange a further biopsy.

    When proven will need excision – presumably refer to plastics for skin grafting (but I would be interested if others thought it could be handled without plastics referral)

    When diagnosis is proven, arrange

  4. Asymmetrical lesion – colour and shape
    Blue grey veil
    Grey circles
    ? Lentigo maligna
    for shave biopsy / punch biopsy 3-4 mm

  5. A longstanding pigmented lesion on the right cheek of a 82 year old woman.
    Dermatoscopic: Assymmetric in colour and structure and colour. Colours white, tan, brown and grey. Peri-follicular grey and brown pigmentation, circle in a circle, brown and grey dots
    DD: LM, May be Solar Lentigo: but not likely

  6. The lesion is suggestive of a lentigo maligna with areas of grey pigmentation, APFO’s and polygons. I would probably do a complete shave removal initially to confirm the diagnosis. I think that a rhombic flap might be the best definitive surgical option after diagnosis.

  7. Grey features on the face.

    Need to exclude lentigo maligna.

    Either shave or incisional biopsy, directed by dermatoscopy

  8. grey dots around follicles are suggestive of LM
    DDx: SL

    shave biopsy of darker centre
    consider referral as it is likely to need focal microscopy to determine extent of lesion

  9. Flat lesion with irregular margins, milia like cysts in the periphery, grey peppering and circles. Solar keratosis versus lentigo maligna. Shave biopsy.

  10. history and pt age is suspicious of a malignant lesion , dermatosocpy showas asymmetry ,but no abnormal network /abnormal pigment .
    DD= benign melanocytic naevus ,melanoma insitu transformation
    plan-excision biopsy with 2mm margin

  11. peppery pattern,
    several colors.
    tan like structureless areas and chrysalline structures?
    excision biopsy to rule out Lentigo Maligna

  12. I see peppering and blue grey features and I need a biopsy. I dont favour saucerisation / shaves though popular. ( I fear a partially sampled lesion with a shave? ) Macroscopically the pigmented lesion looks pretty well defined. So I would undertake incisional biopsy ( less than ideal) and then consider referral or consider doing with a flap ( aim for 10mm in Lentigo) and I have had some pleasing results but this one is a bit big for me
    Could this a collision lesion with a Seb keratosis?

  13. Macroscopically it is a healthy pigmented lesion that the patient has always worn and which apparently does not change dimension. Dermoscopically we notice the absence of a network, asymmetrical lesion with 3 checklist points of 1. it is a benign lesion that presents the same globule-like structures evoking cobblestones. Conclusion: a congenital nevus
    action to be taken: No specific support.
    The program of regular visits according to the country’s health policy remains to be followed in view of its age and the epidemiological picture of the region.

  14. These lesions are so very common in much of Australia – certainly here in QLD – and the differential is Lentigo / Seb K, or Pigmented AK, or Lentigo. I find that, unless the diagnosis is “obvious” seb k or lentigo (all features classical) then I do a shave biopsy through most of the lesion / the most atypical looking part

  15. Thanks everyone for the comments. In this case there was only one section which looked dermatoscopically suspicious so I only shaved that section. I was happy to leave the rest to avoid shaving a large section off this lady’s face.