Case discussion: How would you treat this patient? [26 September]

In this week’s case discussion, we look at a pigmented lesion that Dr Ovida Vipulaguna found on his hand, and he is concerned it may be suspicious.

What do you think of the lesion and what would you do?

case discussion

Update

The result is below. What next?

case discussion

 

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

  1. It’s a pigmented lesion to be sure but its only 1mm in size.
    So I don’t think it is possible to pass judgement on ‘suspicious’ or not.
    However because it is a doctor’s hand I would take it off with a 4mm punch and be done with it.

  2. Small asymmetrical pigmented lesion that crosses over both ridges and furrows of the palm.
    Using the BRAAF algorithm I’d say it’s a 4-5?
    Excision biopsy

  3. From what I can the lesion is irregular and appears to have crossed the reit lines I would excise with a small margin

  4. It’s most likely a lentigo with pigmentation incontinence.
    Serial observation would be the best approach.
    Excision biopsy if patient highly anxious.

  5. Interpretation of 8 Kb image is fraught with hazard. Reliable distinction of PFP and PRP is not possible in this case.
    A positive note, of all sites melanoma are recorded , those from the palmar aspect of hand have a very very low incidence.

  6. Not very clear however it’s one colour but I could see a two lines in ridge with a cross. So the best to rule out any sinister is to biopsy 4 mm.

  7. while small pigmented lesions on glaborous skin do cause concern.
    the pigment does seem to be concentrated in dermal furrows – less concerning, but detail magnification is lacking.
    If smudging of the palmar pigmented skin ridges is seen / evolves, I would advise narrow excision Bx.

  8. Clinically = a new small acral pigmented lesion on the hand
    Dermatoscopic image = hard to say much re the size of the lesion and the image. A brown structureless lesion that crosses furrows and ridges with an irregular margin
    Impression= Because the lesion is so small and the dermatoscopic image gives no alarming clues for an acral melanoma, this is most likely an acral lentiginous lesion. The clinical presentation trumps the Dermatoscopic image. That is a new acral pigmented lesion, hence an excision biopsy with a 3-4mm punch to exclude an early acral melanoma. Equally one could do another dermatoscopic image in 4-6 months, if no change then just monitor the lesion.

  9. Suggest looking hard for similiar lesions elsewhere : it could be reassuring
    Its simple enough to photograph and watch.
    I dont find the image compelling for immediate removal .
    I like that your asking other doctors opinions: how often do we manage our own health with out checking.
    You could someone non medical …” Sir, I am reading your palm ….and I see surgery in the near future “

  10. Well done for removing this. This must be one of the smallest detected acral lentiginous melanomas. This melanoma will need a 5mm re excision re it is insitu. An elliptical excision should be possible re the lesion is so small.

  11. Refer on to hand/plastic surgeon for excision with 5mm margins. Suggest full skin check in light of the above lesion.

  12. Maybe I am late in expressing an opinion but there are some salient points I would like o make.
    Thick skin does not shave well nor is it very malleable hence an elliptic 2mm biopsy I would consider would give the best cosmetic result and biopsy excision for histopathology. This could simply be done here in line with her natural creases.
    Thick skin normally is not pigmented so any new pigmentated lesion needs to be considered highly suspicious.
    This lesion has a dermoscopic polygon.

    All these factors make the first to be considered differential diagnosis to be a melanoma. Excision biopsy therefore required.