Case discussion: How would you treat this patient? [14 March]

This week’s case discussion, submitted by Dr David Stewart, features a 53-year-old lady with a previous BCC on her chest which was treated with Aldara, leaving a keloid scar.

At her routine skin check, this lesion was noted on her upper chest. The patient reported “it has been there for ages” with no change noted. The patient was reluctant to have anything done due to previous keloid scarring.

What is your differential? Does the dermoscopy image change your thinking?

case discussion

Update

Here is the pathology report. What next?

– Prof David Wilkinson

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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18 comments on “Case discussion: How would you treat this patient? [14 March]

  1. We need to exclude a melanoma. I would give her the option of me excising it or to do a plastics referral and reiterate the risk of keloid scarring.

  2. Likely BCC
    Arborising vessels, pigment blotches, no network, irregular white areas, maybe some ulceration.

    Convince to have punch biopsy.
    When confirmed consideri ellipse excision with Kenacort infiltrations shortly after sutures removed.

  3. structureless lesion
    Brown globules/area
    Hypopigmentation- regression?
    Multiple grey colour
    radial lines
    suspicous for BCC
    request for a punch biopsy
    The result will determine the therapeutic management

  4. It does not appear to be a melanocytic lesion and pigmentation pattern most consistent with a pigmented BCC. I would ask her to allow me the smallest punch biopsy (2mm) to confirm the diagnosis. Once she knows it is a skin cancer, then she may well change her mind about intervention. Realistic expectations about scar outcome would need to be plainly spelled out.

  5. annular granular pattern with greyish regression and black dots on the right hand side- this lesion needs to be shaved to exclude in situ melanoma – explain that to the patient. keloid scar can be injected with kenacort with lignocaine if she is concerned

  6. Quite possible original lesion possibly not a keloid ,rather recurrent BCC– that needs biopsy ? –then discussion depending on result for excision biopsy ?– the new lesion needs full discussion for biopsy, and if the original keloid then kenacort

  7. Granular grey. Need to exclude melanoma. History of keloid with Aldara sounds a little odd. Was it the biopsy site? What procedure and materials were used? Is it keloidal or hypertrophic? Is there a history of other abnormal scarring? Monitor post biopsy for abnormal scarring and consider early or prophylactic intralesional/scar corticosteroid. Stratamed gel post op, then follow with Strataderm or similar. Consider plastics referral.

  8. 1. Incisional biopsy marked carefully to include the peppery like pigmented dots and the hazy grey area . Alternatively multiple punches , less preferred. melanoma is certainly a possible differential .
    2. As for scarring : multiple preventative measures can be employed to reduce the risk , however , scarring is an acceptable complication to diagnosing / treating or excluding a a melanoma .

  9. 1. Incisional biopsy planned carefully to include the pigmented dots and part of the hazy grey area . Melanoma is certainly in the differential .
    2. Different types of scarring are certainly seen with Aldabra , dented and hypertrophic/ keloid depending on genetics and the area treated . Unless genetically prone , she may be less likely to scar with surgical excision . However , many preventative measures can be employed to reduce scarring risk . Worst possibilities, a keloid is an acceptable risk to take to exclude or diagnose & treat a melanoma .

  10. How aldara caused keloid. Strange. Was it injured before on the area. The area of concern showed peppering with different colours options of brown, black along white area of regression in a sun damaged skin. I can’t see any features of bcc but the peppering and different shades warrant a biopsy to exclude malignancy.

  11. We have different pigmented lesions located near each other. When I consider all the sites as one lesion. It is seen as irregular in shape and color lesion with white scar sites, asymmetric. The 3 point checklist is 2. The Lesions take a large surface with normal tissues and abnormal ones. I propose to do excision biopsy on lightly pigmented lesions ( 11:00 and 1:00) and large deep excision biopsy on darkly pigmented lesions ( at 5:00 and 7:00). The visible lesion is not bleeding and but it is pigmented ( no BCC ) but has taken a long time but not since she was born. I think about a superficial melanoma in local extension.

  12. I think the key message is – this lesion needs a biopsy, irrespective of prior scaring / risk. We need to exclude melanoma, on skin like this. Here in Queensland, we see lots of patients like this, and (in my experience) dermoscopy is rarely very helpful. Surprises are common. My ‘go-to’ is a shave biopsy, sometimes supplemented with 1-2 punch biopsies, depending on the lesion.

  13. Thanks everyone. Couple of follow up points for those interested:
    (1) Due to the site and previous scarring, I referred this lady off to plastics for a wider local excision – surgeon was worried about underlying structures so is going to admit her as a day case for the procedure
    (2) some comments about the degree of scarring after Aldara. The lesion was biopsied/debulked with a shave excision prior to using Aldara so possibly the shave was a factor. She also had a very vigorous reaction to the Aldara which may also have affected the scarring seen (and mean she had no interest in using Aldara as a possible treatment for the lentigo maliga!)