Case discussion: How would you treat this patient? [3 January]

This week’s case discussion, submitted by Dr Bronwyn Edmunds, features a 64-year-old female with a scaly macule on her forearm, with a past history of BCC.

No clinical picture is available here but the dermoscopy is shown.

  • 64-year-old female
  • History of BCC
  • Scaly macule identified

What is your approach here? What would you do?

case discussion

– Prof David Wilkinson


Here is the pathology report. What next?

case discussion

Below is a macro photo taken after the punch biopsy and before the excision of the lesion, as well as the pathology report from the excision.

case discussion

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23 comments on “Case discussion: How would you treat this patient? [3 January]

  1. If its a solitary pink lesion ddx would be a amelanotic melanoma and poorly differentiated SCC. It’s unlikely to be a BCC.
    Dermoscopoc image is very poor

  2. I agree difficult to have any certainty from that image ,but it has the appearance of new tissue and with that history and treat with imiquinod or effudix and if any doubt after that treatment would do 4mm biopsies in 3 regions

  3. No clear clues, except presence of some amount of scales, unable to find vascular pattern to help with differential diagnosis.

    No erosions noted. It certainly needs further evaluation, may do a punch biopsy at most atypical site, or a large area of shave biopsy will be my decision

  4. Scale on a pink lesion with some area showing pink dots. Although dermoscopy is not great i would have in ddx actinic keratosis and superficial scc both of which may be present here. Depending on size and location a shave Bx may be a good option for histopathology.

  5. Pinkish lesion + scaly macules: differential diagnosis is ;
    – Rosacea and further tests must be performed to identify any underlying causes such as Actinic keratosis or the return of BCC . or a microbial lesion.
    Paraclinic is punch biopsie , the skin examination, culture plus antibiogram , …
    the symptomatic treatment will be undergo while the patient will wait the result

  6. Because of the age of the pacient, I do punch biopsy.
    I think it may be superficial SCC or amelanotic melanoma.

  7. Lesion is pink and non-pigmented. Irregular structure. The blood vessels are indistinct and vary in shape and size but are not sharply focussed as in a BCC which means they are deep in the lesion. Structureless areas between. This lesion is a possible amelanotic melanoma which should have an excisional biopsy to exclude.

  8. Pink lesion with no definate vascular markings. Some white lines are present
    DD 1 BCC 2 Melanoma I would excise if it is a persistant lesion

  9. A great case to start the new year – thanks Bronwyn. Pink lesion (suspicious) leads to a punch biopsy (for me). Amelanotic melanoma diagnosis is a surprise, and very unusual compared to the much more likely BCC, SCC, Bowens, and many other benign lesions. But, all good – AM it is, and so now do a full excision biopsy, as was done here. We are now faced with an invasive melanoma (1.1mm Breslow) which requires discussion regarding benefits of SLNB. At this patient’s age I would be encouraging SLNB as it is the route into highly effective adjuvant therapy, as well as valuable prognostic information. SLNB is best done (in a specialist setting) at the same time as wide local excision for melanoma.