Case discussion: How would you treat this patient? [29 August]

In this week’s case discussion from Dr David Stewart, a 72-year-old male came in with a lesion on his foot which had been present for one month.

It was initially crusty and the patient had picked the crust off, but it won’t heal. What would you do next?

case discussion

Update

Here is the pathology report. What would you do next?

– Prof David Wilkinson

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23 comments on “Case discussion: How would you treat this patient? [29 August]

  1. Circular pink-white lesion with central red ulcerated area and scale, aborising blood vessels can be seen faintly. Likely BCC.

    Amelanotic melanoma a possibility noting perhaps a ‘regression’ area at 1o’clock.
    Punch biopsy then circular excision with purse-string suture for definitive cure.

  2. Clinically a 72 yr old, if he has poor venous return, could have a non healing ulcer from trauma /scratching . On top of 2 whitish thickened plaques, with moderate keratin. Dermatoscope features = clusters of dotted +/- glomerular blood vessels with white scale and a central ulcer. Benign possibilities= psoriasis or lichen sclerosis or prurigo that has been traumatized. As far as skin cancer differential , the most likely would be Bowens /SCC followed by BCC.
    PLAN= A punch biopsy of both areas, and base management on the result.

    1. Most likely it could be a non healing healing ulcer as it is located on lower limb ankle region .Also it has not healed for past one month . cause of this non healing ulcer could be diabetes or poor blood supply or any other systemic cause .
      To rule skin cancer we have to do biopsy of the lesion.
      Clinically lesion is not present for long duration .There is no growth seen or lump present .it is only a single lesion .Evidence of metastasis have to be ruled .Examining lymph nodes or other organs .

  3. i think because only 1 month ulcer we need more time to heal , many varicose veins seen
    other option if not healing is biopsy

  4. Non healing ulcer lower leg 72 years old. Exclude diabetes and circulation issues. Dermatoscope shows red area with some red dots and ulcer / hemorrhage area. Differentials could be BCC vs BD vs SCC.

  5. CREAMMY-LIKE BACKGROUND, DOTTED AND GLOMERULAR BLOOD VESSELS, AND BLUE GRY LIEAF LIK STRUCTURE
    ?? BASAL AGAINST AMELANOTIC MELANOMA

  6. Scaley, erythematous, thickened, unhealing. with looped vessels are suggestive of SCC, especially if tender.
    My approach would be assume malignancy with those features until proved otherwise.
    My approach is circumferential excision with a bevelled border and application of a matching split skin graft taken from an adjacent area. Apply kaltostat to graft and donor site and tegaderm to keep it moist for three days. Bleeding control with sutures if required, avoiding grafted area. Firm dressing and advise leg elevation till tomorrow to reduce bleeding risk. Review and change dressing and remove sutures on day 3, and review histo to guide further management if required. This technique is fast to perform, safe with very high primary healing rate, heals fast with low infection risk. The main precaution is to ensure enough depth of excision but this is examined histologically.

  7. Short history and appearance consistent with pyogenic or traumatic lesion. Age and skin quality would support this. Are these sticky fires from white socks amongst the serosanguinous discharge.
    I cannot see any specific malignant features to warrant surgery at this stage with expected poor healing.
    So I would treat as infected lesion and cover to protect while healing. Then dermoscopy.
    Possibiliies to exclude would be early scc and less likely bcc and melanoma or even Merkles which if need can biopsy with minimum excision, suture and dressing and a pressure support stocking. His general medical history could be of value.

  8. non healing ulcer always somewhat concerning
    this is a pink lesion with some glomerular vessels and some branching vessels
    I would be concerned about SCC or BCC
    consider biopsy or discuss wound care and review in 2-3 months with a low threshold to biopsy

  9. Approx 10 mm round papular lesion with central ulceration. Dermoscopy not definitive, History suggest BCC or SCC until proven otherwise. Crust/scale would favor SCC.

  10. 2 Ulcerated lesions above the ? medial malleolus of the left foot. Difficult to say if the margins are flat/ soft or raised / firm. Central red / orange ( ulcer with blood/serum ) Perpheral pink and white with coiled or dot vessels with scale. No evidence of definite white circles or looped vessels / radial. Differencial Diagnosis : Varicose ulceration ? is it painful or Non Melanoma skin Cancer ? Squamous Cell Carcinoma. Punch Biopsy of both lesions as management of a Varicose ulcer ( Graduated pressure Bandaging ) would be different from a Squamous Cell Carcinoma ( Excision with margins and Grafting with risk of poor healing due to circulation issues and varicose veins – would need graduated pressure bandaging post Grafting )

  11. I think a case can be made here, to dress the wound and see if it heals. The history – of 1 month – is on the borderline for biopsy and action, versus ‘watchful waiting’. I would be tempted to dress and review in 2 weeks if the skin is really thin and vascular supply is poor. I would only wait 2 weeks and i would book a review. Of course in this case, it wouldn’t heal, we would do a punch biopsy and then need to consider how to treat this BCC. This needs surgical treatment because it is infiltrative

  12. aCCORDING TO THE RESULT OF THE BIOPSY WE WILL APPLY IMIQUIMOL 5% CREAM 1XPER DAY DURING 5 DAYS OF WEEK DURING 6 WEEKS

  13. The skin here looks old & not too healthy. As this is a difficult surgical area & this would be prone to infection.
    I would attempt a freeze thaw freeze technique here . 30 secs:thaw: 30 secs.