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June 21, 2012 / molehunter

Traumatised bleeding wart

Seborrhoiec keratoses (otherwise known as seborrhoiec warts or basal cell papillomas) are usually easy to diagnose. However, they come in a wide range of colours from pale pink to black, and can have mixed colour and irregular outline etc. When traumatised, for example by scratching or catching on clothing, they can take on an alarming appearance. It is widely recognised that a high proportion of urgent referrals are for these harmless lesions. Dermoscopy can be very helpful here to reduce avoidable referrals.

This is a case of a traumatised seborrhoic keratosis that looked very alarming initially.

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Dermoscopy reveals blood clot on the right, some warty features in the centre (looped vessels in halos), and on the left many of what I call ‘charcoal flecks’ which I associate with thrombosed capillaries. This sign is not very well recognised in the books I have seen, but I often see it in resolving traumatised seborrhoiec warts. There are no features here pointing to a melanocytic lesion or BCC.

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In cases like this, it is excusable, arguably mandatory, for a beginner to seek advice, but if there is a short history of recent change, features of bleeding and of a warty lesion are seen and there are no features pointing to a dangerous skin cancer, a policy of photograph and measurement and review in 2 weeks is IMO more reasonable than urgent referral. Treat any obvious inflammation and infection as appropriate.

Many lesions like this will drop off between seeing the primary care physician (GP) and being seen by the specialist to whom the patient is urgently referred. This is a story I hear all the time in clinic ‘Sorry to waste your time doctor, it looked terrible a week ago but fell off yesterday.’ Often some redness (erythema) and charcoal flecks are all that remain of a lesion which had appeared worrying enough to trigger urgent referral when seen a week earlier. I will try to post some more images of traumatised seb warts. They can be challenging for beginners.

Be careful though, sometimes there will be a cancer underneath a mess of blood and pus. Don’t just leave things like this, but don’t necessarily refer all urgently. And thoroughly cleanse the dermoscope plate with alcohol gel, preferably use a no-touch dermoscope.

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