An 87-year-old woman came to the office for evaluation of a lesion above her lip (FIGURE 1) that had “been there a while” and had intermittently been bleeding and crusting for the last few months. On examination, there was a distinct, firm (but not hard) papule with some adjacent erythema. No distinct telangiectasias, ulceration, blood, or crusts were visible with handheld magnification or upon dermoscopy. (see “The digital camera: Another stethoscope for the skin,”)
FIGURE 1
Lesion above lip
An evaluation of the remainder of the woman’s face revealed 3 more lesions that the patient termed “age spots.” They had been present for quite some time, had not had any notable rapid change, and had not caused her (or a physician in the family) any concern. These “age spots” are depicted in (FIGURE 2A) (left temple), (FIGURE 2B) (forehead), and (FIGURE 2C) (left cheek). Digital photographs were taken through the dermatoscope of the temple, forehead, and cheek lesions (FIGURE 3A, B, AND C).
FIGURE 2A
Digital photos
FIGURE 2B
Digital photos
FIGURE 2C
Digital photos
The 4 lesions are easily identified as worrisome, given that they were pigmented and asymmetric, with a variety of bizarre colors.
The lip. In particular, the lesion above the upper lip (FIGURE 1) clinically presented a wide range of possibilities, including basal cell carcinoma (BCC), milial cyst, nevus, trichoepithelioma, fibrous papule, or any of a variety of adnexal skin neoplasms. Knowing that the lesion was relatively new and had bled and crusted was sufficient to warrant biopsy.
The temple. Dermoscopically, the temple lesion (FIGURE 3A) had blue and brown ovoid structures (also called “blebs” or “blobs”), white areas within the lesion (whiter than normal surrounding skin), a high degree of asymmetry, and distinct telangiectatic vessels. The pink color on dermoscopy was also a cause for concern. The blue ovoid structures plus telangiectasias were highly suggestive of basal cell carcinoma.
FIGURE 3A
Dermoscopy images
The forehead. Dermoscopy of the forehead lesion (FIGURE 3B) showed leaf-like structures (12 o’clock) and maple-leaf structures (6 o’clock). These alone were highly suggestive of pigmented basal cell carcinoma—but in the absence of distinct telangiectasias, we decided to do a deep incisional biopsy rather than risk potentially “shaving a melanoma.” (If a melanoma is biopsied via a shave technique, the ability to histologically measure its thickness and to stage it according to Clark and Breslow staging is lost.)
FIGURE 3B
Dermoscopy images
The cheek. Dermoscopically, the lesion on the cheek (FIGURE 3C) also had no obvious telangiectasias but had a “spoke-wheel” structure (6 o’clock) highly suggestive of basal cell carcinoma.
FIGURE 3C
Dermoscopy images
All the lesions—except for the temple lesion, which was biopsied via a shave technique—were biopsied via generous incisional ellipses.
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