Case discussion: How would you treat this patient? [1 August]

This week’s case discussion, submitted by Dr Randa Al-Hajali, features a 63-year-old man with past history of multiple skin cancer excisions. He presented for his routine skin cancer check and a large, pigmented lesion was noted on his right malar bridge. He noticed it is getting darker in colour.

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

case discussion


Here is the result. What next?

case discussion

– 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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26 comments on “Case discussion: How would you treat this patient? [1 August]

  1. Hi !!! The picture is not enought clear to see all the structures, but the tissue is completly actinic damage for time and now appear this a new dark macular lession , I sugest excision biopsia extirpation.


  2. Great example of a pigmented Actinic keratosis. Lovely rosettes, strawberry dipped in chocolate, with wide and white follicular openings.

  3. Pigmented Ak leave alone, Photograph and review once. If no change then leave alone . Rosettes non specific.

  4. PIgmented lesion
    Assymetrical colour and shape
    Atypical network or more than one kind
    Possible regression area 9o’clock
    Suspicious 3/3 Excision biopsy 2mm margins
    Melanoma likely
    DDx SebK

  5. Flat lesion. Pigmented portion is irregular in shape, border and colour.
    Differential includes lentigo maligna melanoma and pigmented superficial BCC.
    It could also be benign such as dysplastic naevus.
    My approach would be either excisional biopsy with about 2 to 3 mm clearance, if the skin has plenty of laxity, or a shave excision with the same border as an alternative.
    Follow up management would then be based on the histology.

  6. definitely elements of concern ,asymmetry 0f colour and shape, variable pigmentation, white whorls, some regression be good to see better picture,but enough to indicate, also with that history, excision biopsy 2mm clearance

  7. Deep shave biopsy or multiple 3 mm punch biopsies as it is asymmetric and has pigmented network with past history of skin cancers.

  8. PSL with various shades of colour and some follicular obliterations. Angulated lines. Rosettes. ?LMM vs PAK.

  9. A solitary changing lesion is a concern. Darker with some asymmetry . It would be good to know if the lesion feels rough with some scale.
    Dermoscopic image fits a Pigmented Actinic Keratosis = actinic sun damage, a strawberry pattern in 2/3 of the lesion. Rosette’s and variable follicular openings with an erythematous back ground. It looks like the also is some scale.
    The other 1/3 to the right his dark brown pigmentation with some blue grey annular granular atypical follicular openings, as well as obliteration of a few of the follicular openings.
    IMPRESSION I would still favor a pigmented actinic keratosis , but a lentigo maligna needs to be excluded with the changes on the right 1/3 of the lesion vs lentigo
    PLAN =a simple shave excision biopsy, with management dependent on the histology.

  10. Scale, Erythema with the darker area having a well defined margin between 12 and 6 O’clock. Clods as Rosettes. I would say this is most likely a combination lesion of a Actinic Keratosis and Solar Lentigo. Consider monitoring in 3 months, shave or incisional biopsy to ensure one is not missing a melanoma.

  11. Likely In situ melanoma 2mm excision wait on pathology for defin management
    Network changes(atypical) regressive features superiorly
    Should have included macro pic and included scale thanks

  12. ? Lentigo maligna. For excision biopsy
    I can see polygons and grey structures to right of the photograph; which makes suspicious

  13. asymmetrical pigmented lesion on face
    chaos – YES
    clues – thick lines, grey circles
    likely lentigo maligna or melanoma
    needs biopsy – preferably excision biopsy
    I would take a photo and arrange urgent appointment with visiting plastic surgeon (or consider shave biopsy to confirm diagnosis if referral is difficult)

  14. Severely sun damaged skin with active solar keratosis and pigmentation
    could be pigmented Bowens disease or pigmented solar keratosis
    multiple biopsies from from different part of the lesion is recommended

  15. Asymmetric pigmented lesion; Thick irregular network; Blue gray patches
    Superficial MM (Lentigo Maligna) until proven otherwise
    Macro photo and size scale would be appreciated to see exact location
    Shave Biopsy

  16. This is a pigmented lesion with a pseudonetwork but i dont see any scales.

    Differential includes AK although a lentigo maligna cannot be ruled out.
    punch biopsy?

  17. I find these lesions quite tricky! I recommend that colleagues become familiar with the “inverse approach” – get on Google and you will find it. Basically, you look for clear features of AK or solar lentigo, and if present make the relevant diagnosis. If they are not present, and clearly present, then it may be LMM and requires a shave biopsy