Clinical Challenge: Enlarged, Ulcerated Lesion on the Face - MPR

Clinical Challenge: Enlarged, Ulcerated Lesion on the Face

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A patient, aged 67 years, presented complaining of a lesion on the face that had enlarged and ulcerated over a four-year period.

Pigmented basal cell carcinoma is a subtype of basal cell carcinoma (BCC). BCC is the most common type of cancer. However, it usually does not metastasize and is rarely fatal. It appears as a shiny or waxy nodule with telangiectasias, and may...

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Pigmented basal cell carcinoma is a subtype of basal cell carcinoma (BCC). BCC is the most common type of cancer. However, it usually does not metastasize and is rarely fatal. It appears as a shiny or waxy nodule with telangiectasias, and may present with a central ulceration as the lesion grows.

The risk factors for developing a BCC include prior blistering sunburns, family history of BCC, radiation therapy, and having a fair complexion. They are treated with surgical excision with adequate margins, Mohs surgery if the location demands smaller margins, topical chemotherapy, or with electrodessication and curettage (EDC). 

The major subtypes of BCC include nodular (or classic), morpheaform, cystic, infiltrative, superficial, and pigmented.

Pigmented BCC is like a classical BCC but also has a brown, blue, or black appearance. It is the most common subtype of BCC seen in people with darker skin color, and is uncommon in caucasians. These lesions may have a similar appearance to melanoma. 

Lentigo maligna

Also known as a melanoma in-situ, lentigo maligna is a type of in-situ melanoma that grows slowly. It is commonly found on sun-damaged skin at the face and cheek. It appears as a brown-to-black macule and can progress to a patch or even an invasive melanoma if left unchecked for years.

Seborrheic keratosis

This common lesion is a benign growth that appears as a raised brown-to-black “stuck on” lesion. They can appear anywhere on the body except for the palms and soles, and they favor sun-damaged skin. These lesions are found more commonly as patients age.

Apocrine hidrocystoma

These translucent, skin-to-blue colored lesions are cysts that appear almost exclusively on the face. These lesions may resemble a BCC, cystic type, and biopsy is warranted if BCC is suspected. Excision is the preferred treatment.

Jason Preissig, MD, is a graduate of Baylor College of Medicine.

Adam Rees, MD, a graduate of the David Geffen School of Medicine at UCLA, practices dermatology in Los Angeles.

References

  1. William J, Berger T, Elston D. 2011. “Chapter 29 – Epidermal Nevi, Neoplasms, and Cysts.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunder Elsevier. Print.
  2. William J, Berger T, Elston D. 2011. “Chapter 30 – Melanocytic Nevi and Neoplasms.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunder Elsevier. Print.
  3. Bolognia J, Jorizzo J, Rapini R. 2008. “Section 18 – Neoplasms of the Skin” Dermatology. St. Louis, MO: Mosby/Elsevier. Print